tag:theconversation.com,2011:/au/topics/brain-injury-942/articlesBrain injury – The Conversation2024-02-28T12:34:47Ztag:theconversation.com,2011:article/2202672024-02-28T12:34:47Z2024-02-28T12:34:47ZLow-level blasts from heavy weapons can cause traumatic brain injury − 2 engineers explain the physics of invisible cell death<figure><img src="https://images.theconversation.com/files/574230/original/file-20240207-24-4417vk.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3500%2C2331&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Low-level blasts can cause physical changes in the brain.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/RussiaUkraineWarFrenchWeapons/0b650af49a654704a4bef82ae8a4bc93">Libkos/AP Photo</a></span></figcaption></figure><p>When the force of a blast shoots a round out of a large-caliber rifle, howitzer or M1 Abrams tank gun, the teams of people operating these weapons are exposed to <a href="https://health.mil/Reference-Center/Fact-Sheets/2023/07/18/Low-Level-Blast-Service-Members-Fact-Sheet">low-level blasts</a> that can cause <a href="https://www.brainline.org/qa/what-do-blast-injuries-do-your-brain">traumatic brain injuries</a>.</p>
<p>Low-level blasts do not cause visible trauma, such as bleeding from ruptured eardrums, and they don’t cause injury through violent head motion, such as a concussion. Yet, these blasts can cause <a href="https://pubmed.ncbi.nlm.nih.gov/27291520/">physical changes in the brain</a> that lead to a host of neuropsychiatric symptoms.</p>
<p>The link between the force of a blast and the resulting changes in the brain is not completely understood. So our team of <a href="https://scholar.google.com/citations?user=VlzdxcEAAAAJ&hl=en">engineers and</a> <a href="https://scholar.google.com/citations?user=aIl1GHoAAAAJ&hl=en">scientists in</a> the <a href="https://www.panther.engr.wisc.edu/">PANTHER program</a>, funded by the Department of Defense, is using physics to elucidate how blasts cause traumatic brain injury.</p>
<h2>What is a blast?</h2>
<p>When a weapon like a rifle <a href="https://www.hunter-ed.com/national/studyGuide/Video-How-a-Cartridge-Is-Fired/201099_92813/">is fired</a>, the round is initially in its barrel. Pulling the trigger engages a primer that produces a flame, igniting the propellant. This chemical reaction releases stored energy and creates high-pressure, rapidly expanding gas. This is the blast.</p>
<p>The rate and magnitude of gas expansion are often so extreme that they <a href="https://www.americanscientist.org/article/high-speed-imaging-of-shock-waves-explosions-and-gunshots">create a shock wave</a>, where high-pressure air molecules travel outward faster than the speed of sound. This invisible pulse of high pressure carries a tremendous amount of energy. It’s the same force that can propel a 24-pound warhead out of the muzzle of a howitzer to hit a target 19 miles (30.6 kilometers) away. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/574231/original/file-20240207-29-yowd6.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Cross-section of a cartridge" src="https://images.theconversation.com/files/574231/original/file-20240207-29-yowd6.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/574231/original/file-20240207-29-yowd6.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/574231/original/file-20240207-29-yowd6.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/574231/original/file-20240207-29-yowd6.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/574231/original/file-20240207-29-yowd6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/574231/original/file-20240207-29-yowd6.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/574231/original/file-20240207-29-yowd6.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">This cross-section shows: 1. bullet; 2. case; 3. gunpowder; 4. rim; and 5. primer.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/File:Cartridge_cross_section.svg">Glrx/Quadrell via Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
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<p>After the blast leaves the gun’s muzzle, it dissipates quickly because it is free to expand in the open air. This is when the high pressure washes over the bodies of nearby people. </p>
<p>The blast from the muzzle of a large gun like the <a href="https://youtu.be/1anCHKq6ESg?feature=shared">M777 howitzer</a> does not pulverize rocks or knock someone off their feet. But some of the blast pressure enters the body, passing through the skin and rigid skull bone and into the soft tissue of the brain. </p>
<h2>Linking blast to brain injury</h2>
<p>As blast pressure enters the brain, it is initially compressive, meaning it squeezes the tissue equally from all sides. Because brain tissue is <a href="https://doi.org/10.1007/s11831-019-09352-w">largely composed of water molecules</a>, which are difficult to compress, this type of pressure <a href="https://link.springer.com/article/10.1007/s10439-019-02437-4">tends to cause little known harm</a> to cells. </p>
<p>An initially compressive wave, or positive pressure wave, that squeezes brain tissue changes when it bounces off the inside of the skull. It is reflected as a tensile wave, or negative pressure wave, which tends to pull brain tissue apart. With low enough pressures, <a href="https://doi.org/10.2217/cnc-2017-0011">micron-sized bubbles can form</a> in a process called cavitation. These bubbles can grow 10 to 50 times their initial size over the course of less than a tenth of a millisecond, rapidly stretching the adjacent brain tissue.</p>
<p>Experiments from our lab have shown that the deformation caused by cavitation bubbles happens so rapidly – like the speed of a bullet – that cells tend to <a href="https://www.sciencedirect.com/science/article/pii/S2666522021000149">get torn apart</a>. The extreme speed of stretching and squeezing causes nearby brain cells to die immediately. Afterward, we see only fragments where healthy cells used to be.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/577687/original/file-20240223-20-xi71p2.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Diagram showing blast pressure creating microbubbles in the brain after reflecting off surfaces, stretching and destroying cells in a process called cavitation." src="https://images.theconversation.com/files/577687/original/file-20240223-20-xi71p2.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/577687/original/file-20240223-20-xi71p2.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=361&fit=crop&dpr=1 600w, https://images.theconversation.com/files/577687/original/file-20240223-20-xi71p2.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=361&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/577687/original/file-20240223-20-xi71p2.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=361&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/577687/original/file-20240223-20-xi71p2.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=454&fit=crop&dpr=1 754w, https://images.theconversation.com/files/577687/original/file-20240223-20-xi71p2.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=454&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/577687/original/file-20240223-20-xi71p2.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=454&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This diagram depicts how blast pressure from a gun can result in brain trauma.</span>
<span class="attribution"><span class="source">Alice Lux Fawzi and Manik Bansal</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
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<p>Cell death is the physical root cause of brain injury. In the lab, when the cells that make up brain tissue are deformed at a magnitude and rate beyond what they can withstand, they die – either immediately, as in the case of blast-induced cavitation, or slowly over six to 24 hours, as in most brain injuries from blunt impacts such as concussions. </p>
<p>In low-level blast exposure, the cavitation bubbles are very small, and the trauma is contained to the small area around them. However, repeated exposure to blasts can lead to an accumulation of these microtraumas, eventually reaching a volume large enough to cause significant and irreversible neurological symptoms. </p>
<p>Although evidence is mounting, it has yet to be fully proven that cavitation directly causes blast-induced traumatic brain injury. The hypothesis fits with <a href="https://pubmed.ncbi.nlm.nih.gov/27291520/">post-mortem analyses</a> of the brains of service members with a history of blast exposure. It also fits with the physics that link blast exposure to injury from tissue deformation. </p>
<p>Understanding the connection between blasts and cellular damage in the brain will help researchers develop better ways to protect against repetitive blast-induced traumatic brain injury.</p><img src="https://counter.theconversation.com/content/220267/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alice Lux Fawzi receives funding from the U. S. Office of Naval Research under the PANTHER Program.</span></em></p><p class="fine-print"><em><span>Christian Franck receives funding from the U.S. Office of Naval Research under the PANTHER program. </span></em></p>The people manning the guns are also at risk of injury from the force of the weapon.Alice Lux Fawzi, PANTHER Engineering Project Manager and Associate Director of the Center for Traumatic Brain Injury, University of Wisconsin-MadisonChristian Franck, Bjorn Borgen Professor of Mechanical Engineering and Director of the Center for Traumatic Brain Injury, University of Wisconsin-Madison, University of Wisconsin-MadisonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2142162023-11-14T13:25:01Z2023-11-14T13:25:01ZBrains have a remarkable ability to rewire themselves following injury − a concussion specialist explains the science behind rehabilitation and recovery<figure><img src="https://images.theconversation.com/files/558408/original/file-20231108-15-h36ch4.jpg?ixlib=rb-1.1.0&rect=0%2C5%2C3594%2C2387&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Every brain injury is unique, as is every person's path to recovery. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/surgery-medical-team-surgical-doctor-teamwork-royalty-free-image/1218284504?phrase=concussion&adppopup=true">Chinnapong/iStock via Getty Images Plus</a></span></figcaption></figure><p>High-profile sports like football and soccer have <a href="https://theconversation.com/concussions-can-cause-disruptions-to-everyday-life-in-both-the-short-and-long-term-a-neurophysiologist-explains-what-to-watch-for-192390">brought greater attention in recent years</a> to concussions – the mildest form of <a href="https://www.cdc.gov/traumaticbraininjury/index.html">traumatic brain injury</a>. </p>
<p>Yet people often do not realize how common concussions are in everyday life, and seldom does the public hear about what happens in the aftermath of concussions – how long the road to recovery can be and what supports healing. Concussions are important to understand, not only for recovery, but also for the insights that the science of recovery can bring to brain health.</p>
<p>I am a speech language pathologist and an <a href="https://som.cuanschutz.edu/Profiles/Faculty/Profile/28113">instructor in physical medicine and rehabilitation</a>. I specialize in brain injury rehabilitation, with experience ranging from coma recovery to concussion care. </p>
<p>Treating problems tied to head injuries is complex. This is, in part, because it is not possible to directly examine the brain of a living person and because every brain injury is unique. Many aspects of health, both pre- and post-injury, affect recovery. In treating brain injuries, I work to translate this specialized science for each patient and their unique situation.</p>
<h2>Brain injury can take many forms</h2>
<p>While people commonly think of athletes when it comes to concussions, <a href="https://theconversation.com/the-risk-of-concussion-lurks-at-the-super-bowl-and-in-all-other-sports-176541">sports-related concussions</a> are just one type of mild brain injury seen in health care practice. Concussions can also result from <a href="https://ninds.nih.gov/health-information/disorders/traumatic-brain-injury-tbi">abusive head trauma, blast exposure, car accidents and falls</a>. </p>
<p>The severity of a brain injury is diagnosed based on symptoms, brain imaging and a neurologic exam. Concussions are characterized by a lack of clear tissue damage seen on <a href="https://my.clevelandclinic.org/health/diagnostics/22966-brain-mri">brain images like an MRI</a> and by the length of time that a person loses consciousness – defined as between zero to 30 minutes. </p>
<p>In addition, a significant portion of concussions <a href="https://doi.org/10.1136/bjsports-2012-091941">may not be identified or formally diagnosed at all</a>. Even if you do not lose consciousness at the time of an injury, you could still have a concussion. Confusion, sensitivity to noise and lights and even changes to sleep and mood are common symptoms. But often, these signs <a href="https://www.youtube.com/watch?v=P2wrNGrVHLk&t=11s">may be misunderstood as signs of stress or shock during traumatic events</a>, such as a car accident. Some people mistakenly assume that if they don’t lose consciousness, they haven’t experienced a concussion.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/P2wrNGrVHLk?wmode=transparent&start=11" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Some people mistakenly assume that if they don’t lose consciousness, they haven’t experienced a concussion.</span></figcaption>
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<p>People who don’t feel that they have returned to normal after a concussion may need further treatment. Many report chronic symptoms that linger beyond the typical three-month recovery – a condition known as <a href="https://www.mayoclinic.org/diseases-conditions/post-concussion-syndrome/symptoms-causes/syc-20353352#">post-concussive syndrome</a>. Around 10% of those who suffer a concussion experience post-concussive syndrome, although differences in how this problem is defined and recorded leads to <a href="https://doi.org/10.3171/2015.6.JNS15664">highly variable estimates across studies</a>.</p>
<p>So how does having a concussion affect the brain over time? </p>
<p>The links between concussion and dementias such as chronic traumatic encephalopathy, or, more generally, the relationship between a brain injury early in life and later brain diseases, are <a href="https://doi.org/10.1093/brain/awz286">not yet clear</a>. </p>
<p>This uncertainty should not stop people from <a href="https://doi.org/10.1002%2Fana.26566">finding a path forward</a> and taking strides to support their own brain health. </p>
<h2>The brain’s mode of repair</h2>
<p>After recovering from a brain injury, patients want to understand how to minimize further risk to their brain, which is all the more important since prior injury puts the brain at <a href="https://pubmed.ncbi.nlm.nih.gov/14625331/">greater risk for further injuries</a>.</p>
<p>Researchers and medical providers have learned that after injury the brain can change and “rewire” itself at a cellular level over the life span – a process called <a href="https://www.ncbi.nlm.nih.gov/books/NBK557811/#">neuroplasticity</a>. Brain cells, called neurons, join to form electrical pathways that power activity within the brain. In addition to other repair processes, neuroplasticity supports damaged brain areas to reconnect injured routes or find “detours” to restore brain function. This means that in recovery, the brain can literally find a new way – or make one – to regain critical abilities.</p>
<p>Neuroplasticity also offers insight into why each brain injury is unique. </p>
<p>Following a concussion, therapists focus on <a href="https://doi.org/10.46747%2Fcfp.6803175">detailed evaluations and patient interviews</a> to identify affected areas and to design an intervention. While the general map of <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/anatomy-of-the-brain">brain regions and their associated functions is standard</a>, individual variability is common. Brain injuries from the same cause of injury, via similar force and intensity of impact and affecting the same location of the brain, can lead to very different symptoms in different people. </p>
<p>While the brain is fully developed by the time people reach their early 20s, neuroplasticity continues well beyond this point. Researchers have seen neuroplastic change during the life span in both <a href="https://theconversation.com/youve-likely-heard-of-the-brains-gray-matter-heres-why-the-white-matter-is-important-too-180945">the white</a> and <a href="https://doi.org/10.1038/nn.3045">gray matter</a> that form brain tissue. The remapping of brain pathways that occurs in <a href="https://doi.org/10.1016/j.apmr.2011.03.036">late-life injuries, such as a stroke</a>, is one strong piece of evidence to suggest there may be no specific “end date” to the brain’s capacity to restore its internal connections. </p>
<p>Importantly, fuller density of brain cells is thought to create a buffer that is protective against damage due to injury and aging. This extra “bandwidth” is referred to as <a href="https://doi.org/10.1016/j.neuropsychologia.2009.03.004">cognitive reserve</a>. Broadly speaking, higher levels of baseline cognitive reserve have been linked to <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002259">genetics, educational attainment and health factors</a>.</p>
<p>Neuroplasticity is one process that research shows is critical to maintaining these reserves throughout life.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/-akOXNcuql8?wmode=transparent&start=51" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">One high-profile study found that nearly half of all people who experienced a concussion were still experiencing symptoms half a year later.</span></figcaption>
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<h2>Building and maintaining your cognitive reserves</h2>
<p>Cognitive reserve is crucial to brain health both before and after a concussion. </p>
<p>Studies show that <a href="https://doi.org/10.1016/j.apmr.2019.08.477">higher levels of cognitive reserve</a> may lessen your risk for prolonged problems after a concussion. In addition, injuries that occur <a href="https://doi.org/10.1177/1941738112473059">during childhood</a> and <a href="https://doi.org/10.1016/j.ajem.2021.11.005">late life</a> may present different challenges in recovery linked to the brain’s cognitive reserves and overall health.</p>
<p>For this reason, <a href="https://www.ncbi.nlm.nih.gov/books/NBK185341/">screening tools for concussion</a> often probe a person’s medical history prior to the event.</p>
<p>Keeping up cognitive reserves likely maintains healthy brain connections that can help us age better. <a href="https://doi.org/10.1002/hbm.25605">Bilingualism</a>, maintaining an <a href="https://www.aan.com/PressRoom/Home/PressRelease/5006">active social life</a> and even <a href="https://www.aan.com/PressRoom/Home/PressRelease/5006">going to museums</a> are linked with lower rates of dementia. These studies support that brain activity is good for brain health and it is triggered by many things, including thinking, learning and engaging with the world around us. </p>
<h2>How daily activity rewires the brain</h2>
<p>Just as there is no one-size-fits-all brain injury, there is also no single path toward brain health. </p>
<p>Advanced <a href="https://doi.org/10.3389%2Ffneur.2021.639179">brain imaging to detect concussions</a> is not available in standard clinical settings, so clinicians rarely have clear road maps for rehabilitation. But getting optimal sleep, avoiding excessive drinking or other toxic substances and leading a physically and mentally active life are core tenets of brain health. </p>
<p>Finally, the brain does not exist in isolation. Its health is connected to other parts of the body in many ways. Therefore, doctors recommend treating medical conditions that <a href="https://doi.org/10.1001/jamaneurol.2022.0976">directly affect our brain health and that reduce brain aging</a>, such as <a href="https://doi.org/10.1161/HYPERTENSIONAHA.110.163055">high blood pressure</a>,<a href="https://doi.org/10.1002/alz.057893">sleep apnea</a>,<a href="https://doi.org/10.1186/s10194-020-01166-7">migraines</a> and even <a href="https://doi.org/10.1016/S2468-2667(23)00058-0">hearing loss</a>.</p>
<p>Brain health is unique to each person, and brain injury treatment depends on your individual lifestyle and health risks. Strategies to treat <a href="https://doi.org/10.1093%2Fneuros%2Fnyz332">specific symptoms vary</a> and should be designed with the help of medical specialists. But brain health and cognitive reserve provide a common direction for everyone. Living an active lifestyle – physically, mentally and socially – can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7586385/">drive neuroplasticity and maintain the brain</a>.</p>
<p>Studies of healthy people offer insights into how individual brains are shaped through everyday activities. For instance, research finds that <a href="https://doi.org/10.3410%2FB1-78">expert musicians</a> have denser sound-processing regions in their brains. The brains of cab drivers have <a href="https://doi.org/10.1073/pnas.070039597">greater development of spatial memory areas</a>. Even military fighter pilots have been shown to have <a href="https://doi.org/10.3389/fphys.2023.1082166">denser tissue in regions connected to strategic thinking</a>. </p>
<p>These startling discoveries teach us that what we do every day truly matters to brain health. For all of these reasons, brain researchers commonly use the phrase <a href="https://doi.org/10.1098%2Frstb.2013.0175">“neurons that fire together, wire together”</a> to describe how the brain’s connections change shape associated with repeated patterns of the electrical firing of brain activity. </p>
<p>While many questions remain to be answered, it is well established that the brain can be shaped throughout life. With this knowledge in mind, we can tend to it with greater care.</p><img src="https://counter.theconversation.com/content/214216/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hilary works in brain rehabilitation and references her clinic in this article. The arguments provided in this article may lead readers to seek brain-related healthcare. Hilary has a professional relationship with two of the authors who works are included in cited research. </span></em></p>Concussions can teach researchers a great deal about how the brain recovers after injury and offer insights into how people can promote brain health throughout their lives.Hilary A. Diefenbach, Speech Language Pathologist and Cognitive Rehabilitation Specialist, Marcus Institute for Brain Health; Instructor, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2045282023-06-19T20:00:41Z2023-06-19T20:00:41ZGenetics and concussion – why a minor knock can be devastating for some people<figure><img src="https://images.theconversation.com/files/528968/original/file-20230530-38788-uxzrwj.jpg?ixlib=rb-1.1.0&rect=30%2C7%2C5081%2C2682&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-young-caucasian-sports-athlete-having-471119147">Shutterstock</a></span></figcaption></figure><p>Concussion and head trauma is a real and serious risk for many Australians. While most people suffer acute and relatively short-lived effects, such as dizziness and headache, in some cases symptoms persist for weeks, months or years. It can result in long-term and debilitating neurological impairment. </p>
<p>Concussion in sport – from the junior to the elite level – is being prioritised as a public health concern in Australia. A <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Headtraumainsport">Senate inquiry</a> into concussions and repeated head trauma in contact sport is due to report in August. Of note in the hearings has been the AFL’s <a href="https://parlinfo.aph.gov.au/parlInfo/download/committees/commsen/26756/toc_pdf/Community%20Affairs%20References%20Committee_2023_04_26.pdf;fileType=application%2Fpdf#search=%22committees/commsen/26756/0000%22">acknowledgement</a> of an association between head trauma and chronic traumatic encephalopathy, a neurodegenerative disease <a href="https://www.abc.net.au/news/2023-04-26/danny-frawley-family-urges-afl-to-act-on-cte-concussion/102269648">found</a> in several deceased players. </p>
<p>The <a href="https://www.aihw.gov.au/reports/sports-injury/sports-injury-in-australia/contents/sports-injury-hospitalisations">latest data</a> show concussion can happen in nearly every sport, not just contact sports, with almost 3,100 hospitalisations for concussion caused by sports in 2020–21.</p>
<p>But not everyone responds the same way to concussion. At present, there are <a href="http://dx.doi.org/10.1136/bjsports-2017-097729">few reliable indicators</a> of who will suffer specific or long-term effects. We do know the number and severity of <a href="http://dx.doi.org/10.1136/bjsports-2017-097729">symptoms</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/23508730/">multiple concussions</a> are important. And we are developing understanding of how a person’s genes play a role. </p>
<h2>Traumatic brain injury</h2>
<p>Concussion is a form of traumatic brain injury that can result in <a href="https://theconversation.com/concussions-can-cause-disruptions-to-everyday-life-in-both-the-short-and-long-term-a-neurophysiologist-explains-what-to-watch-for-192390">neurological dysfunction</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/27889010/">including</a> migraine, cognitive deficit, confusion, slowed reaction times, personality changes, drowsiness and emotional changes. Some people also suffer long-term problems with memory, thinking and other symptoms, such as anxiety and mood disturbances. </p>
<p>After brain injury there is a cascade of events that impacts the health of neurons and affects the flow of chemical ions, such as calcium, in the brain. Mutations in genes that affect the transport of neuronal ions (atoms or molecules with a positive or negative electrical charge), termed <a href="https://www.frontiersin.org/articles/10.3389/fphar.2016.00121/full#:%7E:text=Ion%20channels%20are%20membrane%20proteins,or%20physical%20and%20chemical%20stimuli.">ion channel genes</a>, can also affect how the brain works. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1606923959370502145"}"></div></p>
<p>The strongest evidence of a connection between concussion response and ion channel gene function is from patients with a family history of a rare type of migraine (hemiplegic migraine, which causes the sufferer to experience severe migraine associated with motor impairment and muscle weakness) and <a href="https://rarediseases.info.nih.gov/diseases/10975/familial-hemiplegic-migraine">episodic ataxia</a> (which causes bouts of movement incoordination). </p>
<p>Specific types of these severe neurogenetic disorders are caused by mutations in the calcium channel gene <a href="https://pubmed.ncbi.nlm.nih.gov/8898206/">CACNA1A</a>. Patients with these mutations can be highly sensitive to head impacts. Some <a href="https://doi.org/10.1002/ana.1031">specific mutations</a> can see very minor head trauma lead to concussion, seizures, cerebral oedema (swelling), coma and <a href="https://onlinelibrary.wiley.com/doi/full/10.1016/j.pmrj.2017.07.081">sometimes death</a>. </p>
<p>Research has also shown 35% of patients with <a href="https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-021-01309-4#:%7E:text=Most%20ATP1A2%20mutations%20cause%20familial,disability%20%5B4%2C%2027%5D.">mutations</a> in a second hemiplegic migraine ion channel gene, ATP1A2 – which is linked to hemiplegic migraine, ataxia, epilepsy and other seizures and controls brain sodium and potassium levels, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7693486/">report</a> concussion symptoms following mild head trauma. </p>
<p>Focusing on all ion channel genes, our genomics lab (<a href="https://www.qut.edu.au/research/centre-for-genomics-and-personalised-health">Griffiths Centre for Genomics and Personalised Health</a>) recently studied 117 concussion-affected people. We found mutations in 21 ion channel genes, 14 of which could have an impact on concussion susceptibility or outcomes.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/concussion-almost-half-of-people-still-show-signs-of-brain-injury-after-six-months-204702">Concussion: almost half of people still show signs of brain injury after six months</a>
</strong>
</em>
</p>
<hr>
<h2>Other types of genes</h2>
<p>Apart from a role for ion channel genes, there have been a number of additional genes linked by research to concussion. </p>
<p>One of the most studied is the <a href="https://www.nia.nih.gov/health/alzheimers-disease-genetics-fact-sheet">ApoE gene</a>, which is involved in transporting cholesterol in the body and has long been recognised as a risk factor for Alzheimer’s disease. Studies have indicated a variant of this gene (ApoE4) is linked with <a href="https://pubmed.ncbi.nlm.nih.gov/30848161/">poorer</a> and more <a href="https://pubmed.ncbi.nlm.nih.gov/34333069/">long-term concussion outcomes</a>. Those who carry this variant are also more likely to have significant <a href="https://scholars.mssm.edu/en/publications/association-of-apoe-genotypes-and-chronic-traumatic-encephalopath">signs</a> of brain degeneration after concussion. </p>
<p>Another genetic variation in the ApoE gene that makes it less productive has been <a href="https://pubmed.ncbi.nlm.nih.gov/18185033/">linked</a> to a higher likelihood of concussion.</p>
<p>Beyond ApoE, genes that help control a variety of brain functions have been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910946/">suggested</a> as factors in concussion – including some <a href="https://pubmed.ncbi.nlm.nih.gov/28100103/">involved</a> in neuronal growth, dopamine receptors and, <a href="https://pubmed.ncbi.nlm.nih.gov/33017352/">most recently</a>, brain axon (nerve fibre) development. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/hit-your-head-while-playing-sport-heres-what-just-happened-to-your-brain-203038">Hit your head while playing sport? Here's what just happened to your brain</a>
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<h2>A predisposition for injury</h2>
<p>Questions concerning the link between genetic predisposition to injury in sport are not new. Twenty years ago, the Australian Law Reform Commission <a href="https://www.alrc.gov.au/publication/essentially-yours-the-protection-of-human-genetic-information-in-australia-alrc-report-96/">referred</a> to research showing </p>
<blockquote>
<p>[…] a milder form of this condition [CTE or punch-drunk syndrome] could occur in players of rugby, soccer and other sports associated with repetitive blows to the head.</p>
</blockquote>
<p>In 2016, the Australian Institute of Sport (AIS) released a <a href="https://pubmed.ncbi.nlm.nih.gov/27899345/">position statement</a> on the ethics of genetic testing and research in sport. But the <a href="https://www.concussioninsport.gov.au/__data/assets/pdf_file/0006/1090680/concussion-and-brain-health-position-statement-2023.pdf">latest</a> AIS Concussion and Brain Health Position Statement does not mention the use of genetic information concerning concussion-related susceptibility.</p>
<p>Currently, there is available DNA diagnostic testing for the two ion channel genes already implicated in concussion, because this testing is used for the diagnosis of familial hemiplegic migraine and episodic ataxia. But genetic testing is not currently undertaken for concussion.</p>
<p>In Australia, it is difficult to find information on whether genetic testing occurs in elite sport. In the United Kingdom, genetic testing <a href="https://doi.org/10.5114/biolsport.2018.70747">does take place</a>, although it is not common. Athletes and support staff there are <a href="https://theconversation.com/genetic-testing-is-being-used-in-sport-but-what-are-the-consequences-88604">open to the idea</a> of genetic information being used to improve sport performance and reduce injury risk.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/uncharted-brain-decoding-dementia-a-three-part-series-to-read-and-listen-to-193162">Uncharted Brain: Decoding Dementia – a three-part series to read and listen to</a>
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<h2>What’s next?</h2>
<p>It is vital there is more careful consideration of genetic factors involved in concussion development and response. Clarification of the role of ion channel gene mutations and other gene variants, along with information from additional biomarkers and imaging, will be important in developing better concussion management and treatment approaches. </p>
<p>Before introducing genetic testing, regulatory and governance frameworks would also need careful consideration. Wider ethical and legal implications will need to be fully examined including health privacy laws, privacy of genetic samples, anti-discrimination laws and employment-related laws, especially in professional sport. </p>
<p>With the growing awareness of concussion-related injury risks highlighted by the Senate inquiry, further research in Australia could also investigate attitudes toward the use of genetic testing and predisposition to injury risk in sport.</p><img src="https://counter.theconversation.com/content/204528/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lyn Griffiths has received migraine and concussion research funding from the Australian National Health and Medical Research Council, US Migraine Research Foundation, US Dept of Defence and Teva, and in addition receives research funding for a Defence Innovation Hub from Australian Defence and from VariantBio for her Norfolk Island genetics studies. She is a member of the Human Genetics Society of Australasia and Chair of the Board of Censors for Diagnostic Genomics.</span></em></p><p class="fine-print"><em><span>Annette Greenhow receives funding from the Government of Canada Social Sciences and Humanities Research Council and previously received funding from Australian Catholic University and the City of Gold Coast Ambassador Program. She is affiliated with the Australia and New Zealand Sports Law Association as a board member (views are her own). </span></em></p>The genetic evidence behind why some people suffer longer term concussion effects is growing. But what are the ethical considerations that flow from that knowledge when it comes to sport?Lyn Griffiths, Professor, Queensland University of TechnologyAnnette Greenhow, Assistant Professor, Faculty of Law, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2060842023-06-14T20:10:13Z2023-06-14T20:10:13ZFirst Nations women don’t always access health care after head injuries from family violence. Here’s why<figure><img src="https://images.theconversation.com/files/531828/original/file-20230614-21-zf11ko.jpg?ixlib=rb-1.1.0&rect=24%2C12%2C3989%2C2106&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/silhouette-woman-sitting-on-bed-beside-1439614217">Shutterstock</a></span></figcaption></figure><p><em>Please be advised this article contains details of family violence.</em></p>
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<p>Aboriginal and Torres Strait Islander women are <a href="https://www.mja.com.au/journal/2008/188/10/hospitalisation-head-injury-due-assault-among-indigenous-and-non-indigenous">69 times</a> more likely than non-Indigenous women to be hospitalised with head injuries due to assaults. </p>
<p>But some Aboriginal and Torres Strait Islander women <a href="https://www.tandfonline.com/doi/full/10.1080/14461242.2023.2173018">don’t access</a> health care and support services after head injuries from family violence. Our <a href="https://www.tandfonline.com/doi/full/10.1080/0312407X.2023.2210115?src=">research</a>, published this week, explored some of the reasons why – and how these barriers can be overcome. </p>
<p>We found fear of child removal, poverty, coercive control and low awareness of traumatic brain injury related to <a href="https://www.indigenousmhspc.gov.au/publications/dfv">family violence</a> can all impact on when and how Aboriginal and Torres Strait Islander women <a href="https://www.anrows.org.au/project/improving-family-violence-legal-and-support-services-for-indigenous-women/">access health care and support services</a>.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/first-nations-women-are-69-times-more-likely-to-have-a-head-injury-after-being-assaulted-we-show-how-hard-it-is-to-get-help-194249">First Nations women are 69 times more likely to have a head injury after being assaulted. We show how hard it is to get help</a>
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<h2>What is traumatic brain injury?</h2>
<p>Traumatic brain injury is <a href="https://www.archives-pmr.org/article/S0003-9993(10)00650-7/pdf">caused by</a> a blow, jolt or bump to the head. <a href="https://doi.org/10.1080/10926771.2019.1591562">Non-fatal strangulation</a> can also lead to brain injury as the brain is deprived of oxygen. </p>
<p>Traumatic brain injuries vary from mild to severe, and can cause a range of behavioural, emotional, physical and psychological symptoms, <a href="https://pubmed.ncbi.nlm.nih.gov/12924684/">including</a>:</p>
<ul>
<li>poor memory</li>
<li>dizziness</li>
<li>headaches</li>
<li>lack of concentration</li>
<li>slowness to process information or make decisions</li>
<li>emotional dysregulation, such as inability to control anger</li>
<li>anxiety and depression</li>
<li>lack of insight, where the person with the injury does not realise the effect of their injury.</li>
</ul>
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<p>The <a href="https://synapse.org.au/understanding-brain-injury/effects-of-brain-injury/">experience of brain injury</a> is unique to each person.</p>
<p>The degree of recovery is largely determined by the nature and extent of the injury as well as the level of engagement in rehabilitation. For <a href="https://www.braininjuryaustralia.org.au/download-bias-report-on-australias-first-research-into-family-violence-and-brain-injury/">moderate to severe</a> traumatic brain injury, recovery is most rapid in the first six months after the injury. </p>
<p>Even mild traumatic brain injury can have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8773525/">long-term impacts</a> on wellbeing, parenting capacity, relationships and day-to-day living. </p>
<p>Recovery can be maximised by providing education about the short- and long-term management of symptoms as well as the involvement of family in the rehabilitation and recovery phase. </p>
<h2>Listening to First Nations women</h2>
<p>To find out why Aboriginal and Torres Strait Islander women don’t always <a href="https://www.tandfonline.com/doi/full/10.1080/14461242.2023.2173018">access services</a>, we completed interviews and focus discussion groups with 28 women and 90 service provider professionals in Queensland and the Northern Territory.</p>
<p>Our study focused on Aboriginal and Torres Strait Islander women, as their voices are often <a href="https://theconversation.com/she-was-the-most-important-person-to-us-r-rubuntjas-story-shows-society-is-still-failing-first-nations-women-180857">silenced</a> when it comes to women’s safety.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/she-was-the-most-important-person-to-us-r-rubuntjas-story-shows-society-is-still-failing-first-nations-women-180857">'She was the most important person to us' – R. Rubuntja's story shows society is still failing First Nations women</a>
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<h2>Fear of child removal</h2>
<p>In results similar to those from family violence studies, women told us they avoided health care or minimised the amount of information they shared with health professionals to reduce the risk of contact with child protection authorities. One woman told us:</p>
<blockquote>
<p>We won’t report when there is domestic violence. If there is any words that come from the woman that [her] children were there, children are considered at risk and so they are taken. </p>
</blockquote>
<p>Some women told us their children had been removed following reporting and seeking support following family violence.</p>
<h2>Risks of further violence</h2>
<p>Sometimes women were prevented from accessing health care by manipulation and coercive control. This included partners preventing them accessing a working phone or transport. </p>
<p>One service provider said:</p>
<blockquote>
<p>A lot of users of violence I guess employ such a level of control and coercion that sometimes women are prevented from seeking medical treatment, or attempts to seek medical treatment, or disclose violence, including assaults to the head. It might actually make the situation worse. </p>
</blockquote>
<h2>Women prioritise competing demands</h2>
<p>Community-based service providers recognised the strength and resilience of women in continuing their roles caring for children and other family members after experiencing family violence.</p>
<p>Service providers told us their clients were often also managing financial and housing worries. One service provider told us:</p>
<blockquote>
<p>When a woman arrives here, the most important thing is rest, food, and finding that space to just sit with what’s happened, and then medical attention. I don’t always hear women prioritising medical attention in the first instance. I think that rest definitely, and even hunger, on a real, basic survival level. </p>
</blockquote>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-traumatic-brain-injury-75546">Explainer: what is traumatic brain injury?</a>
</strong>
</em>
</p>
<hr>
<h2>Awareness of brain injury</h2>
<p>Community members and leaders we spoke to had low levels of awareness, knowledge and recognition of the long-term damage violence can have on the brain. One community member said:</p>
<blockquote>
<p>We didn’t know about this brain injury. </p>
</blockquote>
<p>Another participant said:</p>
<blockquote>
<p>I didn’t go to the hospital. I had a bit of [a] headache, didn’t think it was serious enough to [go] and get checked, it [headache] went away. It happened many times. One time I black out, wasn’t aware of the lasting harm that can cause.</p>
</blockquote>
<h2>So what are the solutions?</h2>
<p>There are a range of opportunities to address several of these barriers. </p>
<p>First, service providers (including <a href="https://doi.org/10.1002/ajs4.200">within child protection systems</a>) need to ensure women receive compassionate care, referrals and links to support services for traumatic brain injury in a meaningful, timely and appropriate way.</p>
<p>There are <a href="https://www.familymatters.org.au/wp-content/uploads/2022/11/20221123-Family-Matters-Report-2022-1.pdf">strong calls</a> to have community-controlled organisations deliver child protection services – with many potential benefits to families and communities. </p>
<p>We also need to resource communities to design, implement and evaluate traumatic brain injury prevention and early intervention solutions. </p>
<p>Community-wide and school-based education were among some of the recommendations from community members to help people recognise the signs of traumatic brain injury and the importance of seeking help.</p>
<p>Other strategies to improve access to services include placing supports such as social workers outside of acute, hospital settings – for example, in <a href="https://www.tandfonline.com/doi/full/10.1080/26408066.2023.2202665?src=">GP clinics</a> and Aboriginal Community Controlled Health Services. </p>
<p>Finally, front-line staff and university students need high-quality training and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6645196/">education about traumatic brain injury and family violence</a>, how it presents in parental behaviour, case management and referral pathways. </p>
<p>Any practical solutions must be implemented through local partnerships with Aboriginal and Torres Strait Islander peoples to ensure the measures are community-led, culturally safe and provide an overall benefit, without doing further harm.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/new-research-reveals-harrowing-stories-of-murdered-indigenous-women-and-the-failure-of-police-to-act-205655">New research reveals harrowing stories of murdered Indigenous women and the failure of police to act</a>
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</p>
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<p><em>If this article raises issues for you or someone you know, contact <a href="https://1800respect.org.au/">1800 RESPECT</a> (1800 737 732) or <a href="https://www.13yarn.org.au/">13YARN</a> (13 92 76). In an emergency, call 000.</em></p>
<p><em>Jody Barney is a co-author on the journal paper on which this article is based. The authors thank the project team, advisory group and participants who shared their time and knowledge.</em></p><img src="https://counter.theconversation.com/content/206084/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michelle Fitts receives funding from the Australian Research Council. </span></em></p><p class="fine-print"><em><span>Jennifer Cullen receives funding from the Department of Social Services and the NDIS. She is the CEO of Synapse Australia.</span></em></p>Some First Nations women who sustain head injuries from family violence don’t access health care and support. We studied why and found one reason is a fear their children will be taken away.Michelle Fitts, ARC DECRA Fellow, Institute for Culture and Society, Western Sydney UniversityJennifer Cullen, Adjunct Associate Professor, College of Healthcare Sciences, James Cook UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2030942023-05-22T17:13:35Z2023-05-22T17:13:35ZWhy surfing can be beneficial for people with brain injuries<figure><img src="https://images.theconversation.com/files/525093/original/file-20230509-17-idwc3m.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6596%2C3298&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Surfing has a range of health benefits. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/unrecognizable-surfer-waling-into-ocean-focul-2274501199">BART SADOWSKI PL/Shutterstock</a></span></figcaption></figure><p>Nothing quite beats riding a wave for the first time. And our research suggests you don’t have to be a pro to benefit from the power of the sea. <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0266388">We have found</a> that surfing can help people with brain injuries live more engaged and meaningful lives. </p>
<p>In addition to physical impairments, acquired brain injury can cause difficulties with processing information, regulating emotions and socialising. Many people with brain injuries can struggle to return to work or engage in exercise and can start to feel isolated. Critically, they don’t always have the confidence or connections required to engage with their local communities. </p>
<p><a href="https://doi.org/10.3389/fpsyg.2021.642093">We have been working</a> with a team of psychologists across different Welsh health boards to help survivors overcome these barriers and have studied the effects. </p>
<p>During our research, we teamed up with <a href="https://surfabilityukcic.org/">Surfability UK</a>, which is a surf school that aims to make the activity as inclusive as possible to disabled people. It offers adapted wetsuits, longer boards, beach buggies and developed the world’s first tandem seated surfboard to support those with mobility issues, including people with acquired brain injuries. </p>
<p>Accessing such opportunities can still be a challenge if you have a brain injury. So, to overcome this, psychologists join patients for a dip in the sea and provide them with therapeutic support in their wetsuits. </p>
<figure class="align-center ">
<img alt="Two people stand on a surfboard and ride a small wave." src="https://images.theconversation.com/files/520525/original/file-20230412-16-o440sw.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1597%2C1058&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/520525/original/file-20230412-16-o440sw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/520525/original/file-20230412-16-o440sw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/520525/original/file-20230412-16-o440sw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/520525/original/file-20230412-16-o440sw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/520525/original/file-20230412-16-o440sw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/520525/original/file-20230412-16-o440sw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A team of experts deliver rehabilitation sessions on the south Wales coast.</span>
<span class="attribution"><span class="source">Swansea University</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>We followed up by interviewing 15 patients who have undertaken surfing sessions as part of the neuro-rehabilitation programme run by the Swansea Bay and Hywel Dda university health boards to learn more about their experiences.</p>
<p>We found that providing brain injury survivors with an opportunity to immerse themselves in the dynamic elements of the tide, wind and sea can have a huge impact on their mental health and wellbeing. It enabled participants to reconnect with the outside world and feel respite from the everyday stressors of modern life. </p>
<p>Connecting people to nature <a href="https://www.sciencedirect.com/science/article/abs/pii/S0272494419301185?via%3Dihub">has previously been shown</a> to improve wellbeing and promote an appreciation of the environment. But our patients reported some particular benefits to surfing. </p>
<p>In contrast to gardening, for example, one of the participants who shared their experiences described surf therapy as something which “doesn’t stay still”. It’s something which is constantly evolving – falling off the board is a part of the learning process. This can be uncomfortable and distressing at first, but persevering can often lead to feeling a sense of achievement.</p>
<p>Some of our participants reported that surfing had taught them that all types of emotions – whether positive or negative – are an important part of the human experience. Instead of trying to control them, accepting them can help people find meaning in their lives. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-learning-to-surf-can-be-great-for-your-mental-health-according-to-a-psychologist-196946">Why learning to surf can be great for your mental health, according to a psychologist</a>
</strong>
</em>
</p>
<hr>
<p>Making room for difficult thoughts enabled some of our brain injury survivors to reconnect with their values and hobbies too. Surfing gave them meaning and a “valid reason for being alive”. It also showed them that “despite being a bit broken in some places,” they were still capable people. This helped them to renegotiate their identity.</p>
<p>Connecting with people in similar situations can also be crucial after brain injury. Many report that they don’t feel understood by family and friends. Yet <a href="https://www.semanticscholar.org/paper/Sense-of-belonging-and-indicators-of-social-and-Hagerty-Williams/ac5ed15e943e8ef0d09905a07e047b96ccf66611">belonging</a> is a basic psychological need. </p>
<p>Being part of a group enabled our brain injury survivors to learn there were other people with similar experiences. They were able to create a network where they could share resources and experiences to help each other.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/il9wB7siD-Y?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The seated tandem surfboard allows people who cannot sit unaided to participate in surfing.</span></figcaption>
</figure>
<p>The purpose of therapy is to induce sustained and meaningful change after brain injury. Along with immediate improvements in fitness, balance and coordination, <a href="https://www.mdpi.com/2071-1050/14/15/9605">our follow-up research</a> found patients continued engaging in outdoor physical activity for up to ten months later. </p>
<p>Some stuck with surfing, while others took up paddleboarding or cold-water swimming. Research suggetss taking part in <a href="https://doi.org/10.1093/heapro/day103">purposefully designed water-based activities</a> can generate a similar sense of wellbeing as surfing. </p>
<p>Our research underlines how the power of the sea can offer patients benefits which typical clinical settings do not provide.</p><img src="https://counter.theconversation.com/content/203094/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew H Kemp receives funding from Health and Care Research Wales. </span></em></p><p class="fine-print"><em><span>Zoe Fisher receives funding from Health Care Research Wales </span></em></p><p class="fine-print"><em><span>Katie Gibbs does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Brain injury survivors report the sport can give constant opportunities for learning and a way to reevaulate emotions.Katie Gibbs, Research and Innovation Assistant and PhD Student of Psychology at Swansea University, Swansea UniversityAndrew H Kemp, Professor and Personal Chair, Swansea UniversityZoe Fisher, Consultant Clinical Psychologist, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2047022023-05-02T14:59:59Z2023-05-02T14:59:59ZConcussion: almost half of people still show signs of brain injury after six months<figure><img src="https://images.theconversation.com/files/523828/original/file-20230502-1704-vb0nir.jpg?ixlib=rb-1.1.0&rect=7%2C7%2C4985%2C3735&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Our study found changes in the way the thalamus functioned in people who'd had concussion.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-rendered-medically-accurate-illustration-thalamus-1292650525">SciePro/ Shutterstock</a></span></figcaption></figure><p>Around <a href="https://brain-amn.org/global-incidence-of-tbi/#:%7E:text=In%20conclusion%2C%2069%20million%20people,suffer%20a%20severe%20TBI%20annually.">56 million people globally</a> suffer a concussion each year. It’s common for concussion to cause <a href="https://www.mayoclinic.org/diseases-conditions/concussion/symptoms-causes/syc-20355594">short-term symptoms</a> such as a headache, nausea, sensitivity to light and problems concentrating. </p>
<p>But many people also struggle with long-term symptoms – including fatigue, trouble sleeping and concentrating, and emotional distress. <a href="https://onlinelibrary.wiley.com/doi/10.1111/acem.13844">Previous research</a> found that clinicians estimated one in ten people might experience long-term symptoms after a concussion. </p>
<p>But our recent study estimates that post-concussive symptoms are far more common. Our study, published in <a href="https://academic.oup.com/brain/advance-article/doi/10.1093/brain/awad056/7051141">Brain</a>, found that almost half of people who suffered a concussion had not fully recovered six months after their injury. </p>
<p>To conduct our study, we analysed brain scans from over 100 patients who had recently experienced concussion from all across Europe. These brain scans were conducted using a technique called resting-state functional MRI (fMRI). </p>
<p>A resting-state fMRI measures brain activity when a person is at rest, which can be used to understand how different regions of the brain communicate. This allows us to understand if the brain is functioning as it should or if there are problems with a person’s brain connectivity.</p>
<p>A resting-state fMRI can also tell us more than a CT scan or MRI might. While these types of scans are often given to concussion patients, both only look for structural changes in the brain – such as inflammation or bruising. </p>
<p>Such changes often don’t occur in mild concussion cases soon after injury, which may lead clinicians to believe no brain damage has occurred. But a resting-state fMRI can show us more subtle changes in brain function – and may help us better predict who is more likely to develop long-term symptoms. </p>
<p>In our analyses, we specifically looked for changes in a region in the centre of the brain called the thalamus. This region is important in integrating sensory information and relaying it throughout the entire brain. </p>
<p>The thalamus is also thought to be <a href="https://link.springer.com/article/10.1007/s11065-020-09474-0/figures/2">very vulnerable</a> to the kind of external force that leads to concussion (such as a fall or blow to the head). </p>
<p>Our research found that concussion was associated with increased functional connectivity between the thalamus and the rest of the brain very shortly after injury, when compared to 76 healthy control subjects. </p>
<p>In other words, the thalamus was trying to communicate more as a result of the injury. This was despite routine MRI and CT imaging showing no structural changes in the brain.</p>
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<img alt="Two football players lie on the ground holding their heads." src="https://images.theconversation.com/files/523829/original/file-20230502-28-u2s167.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523829/original/file-20230502-28-u2s167.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523829/original/file-20230502-28-u2s167.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523829/original/file-20230502-28-u2s167.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523829/original/file-20230502-28-u2s167.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523829/original/file-20230502-28-u2s167.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523829/original/file-20230502-28-u2s167.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The thalamus may be particularly sensitive to the kind of forces that cause concussions.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/lubin-poland-june-05-2014-michal-197028332">Dziurek/ Shutterstock</a></span>
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<p>While many of us would assume that more connectivity in the brain is a good thing, research looking at <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6664441/">more severe head injuries</a> indicates that greater connectivity between brain regions might actually be a sign of the brain trying to compensate and offset damage across the brain.</p>
<p>We also found that almost half of people with concussion had not fully recovered six months after the injury. Our analysis showed that participants who had signs of greater thalamus connectivity in their brain very soon after injury were more likely to later develop post-concussive symptoms, such as fatigue and poor concentration.</p>
<h2>Concussion treatment</h2>
<p>Our research makes an important step in understanding concussion, showing that even a single brain injury can have clear consequences in some people. This damage may also not show up in the types of scans concussion patients are routinely given, suggesting it may be time to expand the types of imaging used. </p>
<p>We found that in people who experienced long-term symptoms, functional changes were still present in the brain 12 months after the injury. These effects were found in a sub-group who returned for scanning a year after their injury, and were not seen in patients without long-term symptoms. </p>
<p>Concussion is often viewed as a short-term event, but these findings suggest it can be a long-term disease, and some people may take longer to recover than others. </p>
<p>Our study also found that the long-term symptoms a person experiences may relate to different areas of the brain. We found that people who experienced long-term cognitive symptoms (such as concentration and memory problems) had increased connectivity from the thalamus to areas of the brain linked with noradrenaline – a chemical messenger in the brain. </p>
<p>Whereas people who experienced long-term emotional problems (such as depression or irritability) had greater connectivity to areas that produced a different chemical messenger, serotonin. </p>
<p>This not only shows us how concussion affects people differently, it may also give us targets we can use to develop drugs that alleviate concussion symptoms. </p>
<p>While concussion is considered a “mild” traumatic brain injury, our findings show it’s anything but – and can have long-term consequences for a large proportion of people. Although there’s still a lot we don’t know about concussion – including the effects that repetitive concussion may have on the brain – it’s promising to see this condition is being taken more seriously, especially in sports where it can be common. </p>
<p><a href="https://www.sportandrecreation.org.uk/policy/research-publications/concussion-guidelines">New UK guidelines</a> for grassroots sports like football and rugby now require players to sit out of play for at least 24 hours after a suspected concussion, which may help to prevent concussion and improve recovery after one.</p><img src="https://counter.theconversation.com/content/204702/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca Woodrow receives funding from the Medical Research Council and the Pinsent Darwin Trust. </span></em></p><p class="fine-print"><em><span>David Menon receives research funding from the National Institute for Health Research, UK; UK Research and Innovation (UKRI); the Medical Research Council (UK); the Canadian Institute for Advanced Research (CIFAR); Addenbrooke's Charitable Trust; the Brain Research Trust (UK). He has consultancy or research collaboration agreements with NeuroTrauma Sciences LLC, Gryphon Inc, GlaxoSmithKline Ltd; Lantmannen AB; Pressure Neuro Ltd; Integra NeuroSciences Ltd; Cortirio Ltd; and Calico LLC.</span></em></p><p class="fine-print"><em><span>Emmanuel A Stamatakis receives funding from the Canadian Institute for Advanced Research and the Stephen Erskine Fellowship, Queens’ College, University of Cambridge.</span></em></p>Long-term symptoms of concussion can include trouble concentrating and emotional distress.Rebecca Woodrow, PhD Student in Clinical Neurosciences, University of CambridgeDavid Menon, Professor, Head of Division of Anaesthesia, University of CambridgeEmmanuel A Stamatakis, Lead, Cognition and Consciousness Imaging Group, Division of Anaesthesia, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1996582023-02-10T18:07:25Z2023-02-10T18:07:25ZThe Super Bowl — what we love but mostly hate about it<figure><img src="https://images.theconversation.com/files/509786/original/file-20230213-21-vm1b6d.jpg?ixlib=rb-1.1.0&rect=0%2C6%2C4493%2C2984&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kansas City Chiefs quarterback Patrick Mahomes holds the trophy after defeating the Philadelphia Eagles in the NFL Super Bowl on Sunday. </span> <span class="attribution"><span class="source">(AP Photo/Matt Slocum)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/the-super-bowl-—-what-we-love-but-mostly-hate-about-it" width="100%" height="400"></iframe>
<p>This past weekend, <a href="https://www.nbcsports.com/chicago/world-cup-2022/how-does-world-cups-viewership-tickets-and-attendance-compare-nfls-super#:%7E:text=World%20Cup%20vs.-,Super%20Bowl%3F,of%20227.27%20million%20per%20day.">millions of North American (and worldwide) eyeballs were glued to their TVs</a>, beer and chicken wings in hand, to celebrate perhaps the last truly bipartisan “national holiday” that America has left: the Super Bowl.</p>
<p>While the Super Bowl is ostensibly a football game for the NFL championship, it is really a combination of sporting event, concert and advertising convention. </p>
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Read more:
<a href="https://theconversation.com/protests-not-welcome-in-the-spectacle-of-sports-84817">Protests not welcome in the spectacle of sports</a>
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<p>This year, <a href="https://www.bbc.com/news/entertainment-arts-64602594">Rihanna performed at halftime</a> in a much-anticipated return to the stage. And 30-second <a href="https://www.espn.co.uk/nfl/story/_/id/35587895/super-bowl-2023-commercials">advertising spots</a> sold for as much as $7 million apiece. </p>
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<img alt="Signer Rihanna in a black outfit sitting on a couch speaking into a microphone." src="https://images.theconversation.com/files/509267/original/file-20230209-24-g29sqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/509267/original/file-20230209-24-g29sqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/509267/original/file-20230209-24-g29sqj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/509267/original/file-20230209-24-g29sqj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/509267/original/file-20230209-24-g29sqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/509267/original/file-20230209-24-g29sqj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/509267/original/file-20230209-24-g29sqj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Rihanna will perform at halftime during the Super Bowl LVII NFL football game.</span>
<span class="attribution"><span class="source">(AP Photo/Mike Stewart)</span></span>
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<p>One <a href="https://www.summitwealthgroup.com/blog/2023-super-bowl-by-the-numbers">investment management group estimated</a> the event will bring $700 million to the city of Phoenix, and an estimated $16 billion <a href="https://www.cbssports.com/nfl/news/super-bowl-2023-20-percent-of-american-adults-expected-to-bet-on-chiefs-vs-eagles-according-to-survey/">will be wagered on the game</a>.</p>
<p>And, oh yeah, the Kansas City Chiefs beat the Philadelphia Eagles 38-35 in what turned out to be an entertaining game.</p>
<h2>Professional sport is primarily a business</h2>
<p>While the league may like to promote itself as simply men playing sport for the love of the game, their teammates, and the city they have been drafted or signed to play for, elite and professional sport is first and foremost a business. </p>
<p>More specifically, it is a commodity spectacle where athletes put their bodies and brains on the line for our entertainment. They are both workers and product. Dollars and cents come to the league through ticket sales, TV licensing deals, merchandise, advertisement and anything else the league and its organizations can possibly sell. </p>
<p>While we may know elite sport is business, rarely do we ask what the business and profit-making mean for everyone involved in the NFL business ecosystem, from the workers (players) to the capitalists (managers and owners) to the consumers (fans). </p>
<p>This is by design. The NFL, like most businesses, does not want its consumers to see how their sausage is made, especially when it involves the amount of violence, exploitation and harm that exists in football.</p>
<h2>Threat of brain injury</h2>
<p>The most obvious of these harms is the long-term injury — specifically brain injury — to players. There is continued evidence of football’s relationship with traumatic brain injury, dementia, memory loss, depression and premature death.</p>
<p><a href="https://doi.org/10.1001/jama.2017.8334">A 2017 study</a> published by the <em>Journal of the American Medical Association</em>, said 177 of 202 former football players studied of all levels had <a href="https://www.nhs.uk/conditions/chronic-traumatic-encephalopathy">Chronic traumatic encephalopathy (CTE)</a>, including 110 of the 111 NFL players studied.</p>
<p>In the latest <a href="https://www.bu.edu/articles/2023/bu-finds-cte-in-nearly-92-percent-of-former-nfl-players-studied/?utm_source=twitter&utm_medium=link&utm_content=research_brain&utm_campaign=social_main">research out of Boston University,</a> 345 of the 376 former NFL players studied had (CTE). </p>
<p>Because CTE can only be diagnosed post-mortem, these studies contain samples of brains that were donated by concerned families, and therefore are more likely to have CTE. Still, they show rates of 92 per cent for the NFL players studied. </p>
<p>In contrast, a <a href="https://www.bu.edu/articles/2023/bu-finds-cte-in-nearly-92-percent-of-former-nfl-players-studied/?utm_source=twitter&utm_medium=link&utm_content=research_brain&utm_campaign=social_main">2018 Boston University study</a> looked at 164 donated brains of men and women: only one had CTE, and he was a former college football player. </p>
<p>It is harrowing to imagine how many players — not just in the NFL, but in college and at the high school level — are developing CTE, and suffering irreparable and lifetime damage to their brains and lives.</p>
<p>Football is not the only sport where athletes are at risk of lifelong injury (rugby, ice hockey and combat sports are other big culprits), but many football players aren’t even able to earn any money for their bodily sacrifice. </p>
<h2>Labour exploitation</h2>
<p>While the NFL and the college football industry sell the dream of scholarships and superstardom, only 6.5 per cent of high school students will even play college football. And they do not get paid for their labour. And a miniscule 0.00075 per cent (800-900 out of 1.1 million) will <a href="https://www.sportskeeda.com/college-football/how-many-ncaa-football-players-make-nfl">play the game professionally</a>.</p>
<p>If players do beat these lottery-level odds and make it to the NFL, <a href="https://www.nytimes.com/2023/01/29/sports/football/nfl-contracts-injuries-young-players.html">football player careers average about three to four years</a>. Many contracts are not guaranteed, with teams able to cut players and not pay them the full amount of their salaries. </p>
<p>Add to this the exploitation of a predominantly Black workforce of unpaid players who sacrifice their bodies and brains to <a href="https://link.springer.com/book/10.1057/9780230105539">fill the coffers of largely white coaches and team owners.</a></p>
<p>As scholars <a href="https://www.theguardian.com/sport/2021/sep/07/race-money-and-exploitation-why-college-sport-is-still-the-new-plantation">Nathan Kalman-Lamb, Derek Silva and Johanna Mellis put it in <em>the Guardian</em>,</a> “big-time college sport is often about rich white people using Black people for profit.”</p>
<p>The treatment of athletes as mere commodities or investments, to be drafted and traded, used for value and profit extraction and then thrown away, permeates every layer of the NFL. </p>
<h2>Super Bowl traditions have a strong hold</h2>
<p>There are other issues too: this is not an exhaustive list of the harms associated with football and the NFL. These are just some of the behind-the-scenes facts and relationships that the NFL does not want fans thinking about, least of all during the Super Bowl.</p>
<p>The Super Bowl — as the culmination of the NFL’s season long coverage — is meant to make sure we continue to ignore these issues <a href="https://theconversation.com/protests-not-welcome-in-the-spectacle-of-sports-84817">by providing us with a spectacle to take our minds off the hard questions</a>. </p>
<p>Karl Marx originally coined religion as the “opiate of the masses,” and sport scholars have long adapted this passage to sport, and <a href="https://doi.org/10.1080/14775085.2017.1401383">specifically to mega-events</a> like the Super Bowl or the Olympic Games.</p>
<p>Beyond distracting fans from their own personal problems and the unequal world they inhabit, the goal of football’s spectacle (from the league’s perspective) is also to distract fans from the very harms that the sport itself produces.</p>
<p>Super Bowl traditions have a strong hold, and the game is often something that brings family and friends together. But at the very least, keep in mind the violence and harm that it takes to get to this game, and remember that there are human beings under those helmets.</p><img src="https://counter.theconversation.com/content/199658/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Daniel Sailofsky does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Super Bowl is more than a game — it’s an ecosystem of parties, the halftime show, the ads and 100 million people watching despite the sport’s ugly and dangerous side.Daniel Sailofsky, Lecturer, Department of Criminology, Middlesex UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1951502022-11-25T07:42:36Z2022-11-25T07:42:36ZWorld Cup concussion rules may be putting players’ lives at risk<p>In the eighth minute of their Fifa men’s World Cup match against England, Iranian goalkeeper Alireza Beiranvand <a href="https://www.thetimes.co.uk/article/iran-goalkeeper-alireza-beiranvand-in-hospital-after-fifa-s-concussion-disgrace-b860mblvr">collided face-first with a teammate</a>. The clash left the keeper bloodied, unsteady on his feet, and apparently disoriented - in no state to play. </p>
<p>But after lengthy treatment he played on. Within minutes he had fallen to the floor and was carried off on a stretcher. He was later taken to hospital. </p>
<p>Former England player, Jermaine Jenas, who was commentating on the match, said the situation was “<a href="https://www.independent.co.uk/sport/football/world-cup/iran-goalkeeper-head-injury-concussion-england-b2229703.html">ridiculous</a>” and “out of order”. Given the serious nature of Beiranvand’s injury, medical knowledge suggests he should have been taken off the pitch immediately. </p>
<p>But he allegedly refused to do so, <a href="https://www.goal.com/en-gb/news/why-iran-goalkeeper-alireza-beiranvand-not-substituted-head-injury-england/bltfb7ad2dc2c2bd772">according to some reports</a>, most likely because he knew that if he did go off, he wouldn’t be able to take part in the rest of the game. This highlights a problem with Fifa’s concussion protocols that is arguably putting players’ lives at risk.</p>
<p>A blow to the head, as Beiranvand took, or a blow to the body that causes the head and brain to move back and forth rapidly can cause <a href="https://www.cdc.gov/headsup/basics/concussion_whatis.html">concussion</a>, which is a type of brain injury. It’s not something that can be run off or played through, and attempting to do so is <a href="https://journals.sagepub.com/doi/10.1177/21674795211027292">not a sign of toughness</a>. </p>
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<p>Playing with a concussion is extremely dangerous – especially so if a player hits their head again. Sustaining a second brain injury before recovering from an earlier one can result in what’s known as <a href="https://www.ncbi.nlm.nih.gov/books/NBK448119/">second impact syndrome</a>. </p>
<p>This happens when the brain swells rapidly after a person suffers a second head injury while symptoms from an earlier head injury or concussion are still present. And it <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672291/">can often be fatal</a>. </p>
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Read more:
<a href="https://theconversation.com/football-and-dementia-heading-must-be-banned-until-the-age-of-18-150575">Football and dementia: heading must be banned until the age of 18</a>
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<p>Repeated head impacts – for instance heading a football many times – can also <a href="https://www.headway.org.uk/news-and-campaigns/news/2021/study-reinforces-link-between-dementia-in-professional-footballers-and-heading-the-ball/">lead to neurodegenerative diseases</a> such as dementia or <a href="https://pubmed.ncbi.nlm.nih.gov/35937061/">chronic traumatic encephalopathy</a>.</p>
<h2>Fifa’s flawed protocols</h2>
<p>This is the first Fifa men’s World Cup to allow <a href="https://www.independent.co.uk/sport/football/world-cup/concussion-subs-rules-world-cup-england-b2229692.html">concussion substitutions</a>. Teams can make an extra substitution if a player suffers or is suspected to have suffered a concussion. </p>
<p>Every game also has a “<a href="https://www.theguardian.com/football/2021/may/06/fifa-to-bring-in-concussion-spotters-for-qatar-world-cup">concussion spotter</a>”. This is a member of the medical team who sits in the stands with access to video replays and whose job it is to identify possible brain injuries. Concussion spotters have been used at rugby union fixtures and in the <a href="https://operations.nfl.com/gameday/behind-the-scenes/atc-spotters/">NFL for some time</a>.</p>
<p>Fifa’s <a href="https://digitalhub.fifa.com/m/11dc529ca641c307/original/FIFA-Medical-Concussion-Protocol.pdf">medical concussion protocol</a> indicates that after an initial (on-pitch) examination an off-pitch or quiet-area examination should follow. This step is vital and the need for it to be conducted in quiet is important. It also takes considerable time, particularly as signs and symptoms of concussion can be delayed - sometimes not appearing <a href="https://www.nhs.uk/conditions/head-injury-and-concussion/">for up to three weeks</a>. </p>
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<p>Yet while <a href="https://www.youtube.com/watch?v=a54j94TfDho&t=1s">Fifa emphasises</a> the need for off-field assessment, it does not allow players to be temporarily removed to allow a full assessment in a quiet environment. And because coaches want their best players on the pitch, athletes are often pressured to play through injuries and are <a href="https://www.westernsydney.edu.au/ics/news/blog/what_sam_burgess_face_tells_us_about_australian_sport">heroised for doing so</a>. </p>
<p>Team doctors have even been <a href="https://www.theguardian.com/uk-news/2016/jun/06/chelsea-doctor-eva-carneiro-jose-mourinho-insult-filha-filho-da-puta-tribunal-told">abused by managers for treating injured</a> players and there are also stories of <a href="https://www.washingtonpost.com/news/early-lead/wp/2018/07/31/athletes-can-easily-trick-popular-concussion-test-study-finds/">players being coached</a> on how to “cheat” <a href="http://en.espn.co.uk/scrum/rugby/story/208943.html">concussion tests</a> so they can remain on the pitch. </p>
<p>Earlier this year, an <a href="https://concussionfoundation.org/node/3591">open letter</a> called on the International Football Association Board (IFAB), which determines the game’s rules, to allow temporary concussion substitutions. It was signed by former players, leading scientists, advocates and the family of former players. IFAB <a href="https://apnews.com/article/soccer-sports-world-cup-qatar-doha-17634c37923d6b999c9e548390fec68c">rejected this call</a>. </p>
<p>As a co-founder of the <a href="https://abiresearchnetwork.wordpress.com/">Acquired Brain Injury Research Network</a>, I believe this decision is wrong, and the rules need to be changed to allow players to be temporarily substituted from play for assessment. Knowing that the substitution is not permanent removes some of the pressure on players to stay on regardless of their condition. And away from the field of play, a more suitable and thorough assessment can then take place, meaning the player can return if they are fit to do so. </p>
<p>Fifa responded to these allegations saying:</p>
<blockquote>
<p>If there is a suspicion of a concussive injury at any stage, Fifa encourages all team doctors to remove the player from the match or training session and assess and treat them appropriately. </p>
<p>While the ultimate responsibility in terms of concussion diagnosis and management lies with the relevant team doctor, Fifa expects all teams to act in the best interests of their players and their health.</p>
</blockquote>
<h2>How to spot concussion</h2>
<p>While football’s attitude towards <a href="https://www.researchgate.net/publication/350840290_The_shifting_media_discourse_surrounding_head_injuries_in_association_football">concussion has improved</a>, results are still put above the health of players. Ultimately, the decision to play on should not be in the hands of players or anyone associated with the team. </p>
<p>There has been <a href="https://www.theguardian.com/football/2022/nov/21/iran-goalkeeper-head-clash-headway-world-cup">widespread media criticism</a> of the handling of Beiranvand’s injury. This is a positive change as previously <a href="https://journals.sagepub.com/doi/full/10.1177/2167479520948048">reporting was full of misconceptions</a>, incorrect information and worrying attitudes - particularly from former players. But there is still much confusion over concussion.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/sport-induced-traumatic-brain-injury-families-reveal-the-hell-of-living-with-the-condition-172828">Sport-induced traumatic brain injury: families reveal the 'hell' of living with the condition</a>
</strong>
</em>
</p>
<hr>
<p>Each concussion is <a href="https://www.qualitative-research.net/index.php/fqs/article/view/3615/4718">experienced differently</a> so they can be hard to identify, but there are things that everyone can look out for. The <a href="https://concussionfoundation.org/concussion-resources/what-is-concussion">symptoms of having a concussion</a> include a headache or dizziness, memory loss, sleep symptoms and emotional symptoms such as anxiety. </p>
<p>There are also visible signs that anyone watching may be able to spot. Following the phrase “<a href="https://www.theguardian.com/sport/2021/feb/01/peter-robinson-schools-rugby-brain-injury-concussion-campaign">If in doubt, sit them out</a>” may save a person’s life. A player should be taken out of the game and medical attention sought if any of these are seen:</p>
<ul>
<li>problems with balance </li>
<li>glazed look in the eyes</li>
<li>delayed response to questions</li>
<li>amnesia</li>
<li>vomiting</li>
<li>inappropriate crying or laughter</li>
<li>forgetting instructions</li>
<li>confusion over position or the current game or score</li>
<li>loss of consciousness.</li>
</ul>
<p>Alireza Beiranvand’s injury adds to a growing list of players that have remained in <a href="https://www.headway.org.uk/news-and-campaigns/news/2022/premier-league-needs-to-define-what-doubt-means/">matches after a brain injury</a>. Here’s hoping this is a wake-up call for Fifa and the International Football Association Board, because the current rules do not appear to be protecting players.</p><img src="https://counter.theconversation.com/content/195150/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Keith Parry is affiliated with the Concussion Legacy Foundation (UK)</span></em></p>World Cup 2022: the risk of playing on with concussion and why the rules in football need to change.Keith Parry, Deputy Head Of Department in Department of Sport & Event Management, Bournemouth UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1923902022-11-10T13:43:24Z2022-11-10T13:43:24ZConcussions can cause disruptions to everyday life in both the short and long term – a neurophysiologist explains what to watch for<figure><img src="https://images.theconversation.com/files/494518/original/file-20221109-16873-evqs5d.jpg?ixlib=rb-1.1.0&rect=400%2C16%2C5166%2C3638&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sleep plays a critically important role in the recovery process in the days following a concussion.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/skiing-accident-royalty-free-image/164528977?phrase=concussion&adppopup=true">nicolamargaret/E+ via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://www.cnn.com/2022/10/19/sport/nfl-tua-tagovailoa-concussion-spt-intl">repeat concussions</a> suffered by Miami Dolphins quarterback Tua Tagovailoa less than a week apart in September 2022 have brought the seriousness of traumatic brain injury back into the public eye and <a href="https://www.washingtonpost.com/health/2022/09/30/tua-concussion-protocol-nfl/">triggered scrutiny</a> of the NFL’s concussion protocols. And the upcoming World Cup soccer competition, which begins Nov. 20, 2022, will likely include highly visible head injuries.</em></p>
<p><em>The Conversation asked David Howell, <a href="https://profiles.ucdenver.edu/display/15074432">director</a> of the <a href="https://medschool.cuanschutz.edu/orthopedics/research/labs/howell-concussion-lab/our-research">Colorado Concussion Research Laboratory</a> at the University of Colorado School of Medicine, to explain the latest science behind concussions and why a recently injured brain is more vulnerable to repeat injury. Howell’s work focuses on the many different areas of concussion-related dysfunction and recovery, including <a href="https://doi.org/10.3390/s20216297">movement deficits</a>, <a href="https://doi.org/10.1097/jsm.0000000000000803">sleep problems</a> and <a href="https://doi.org/10.1177/03635465211069372">rehabilitation</a>.</em></p>
<h2>How widespread are concussions?</h2>
<p>The word concussion can evoke a variety of different images for different people. While concussions are most visible during high-profile sporting events, they can also occur on the playground, during the junior varsity football team practice or on the ski slope. The effects can be just as severe for children and teens as for high-profile athletes.</p>
<p>Concussion effects range from mild to severe, from short term to long term, and can affect many different facets of life. A concussion is defined as a traumatic brain injury caused by an impact to the head, resulting in an alteration of brain function. </p>
<p>A concussion often leads to disruptions to everyday life – whether it be a job, academics, sports, physical activity or sleep. Given how unique people’s brains are and how differently they may respond to the injury, concussion recognition, diagnosis and treatment remain challenging for patients and clinicians alike. </p>
<h2>What happens to the brain during a concussion?</h2>
<p>There is a complex set of events that occur within the brain during and after a concussion occurs. </p>
<p>As a result of the trauma to the brain, brain cells – or neurons – stop functioning as they typically do when healthy. Generally there is not one specific area of the brain that is affected by a concussion. Instead, the injury can affect a widespread set of brain regions, not necessarily at the impact point. Thus, each person may experience a unique set of symptoms or functional problems following the injury. </p>
<p>One main problem that arises following a concussion is an <a href="https://doi.org/10.1016/j.csm.2020.08.001">energy crisis</a> of sorts. This occurs when the brain requires a large volume of energy, in the form of glucose delivered by blood flow to the brain, to restore the injured processes. The body also may have trouble delivering blood to the brain because of a brain blood flow disruption <a href="https://doi.org/10.3389/fneur.2018.00196">caused by the injury</a>, at the very time the brain needs extra energy to restore the injured areas. This mismatch can produce a variety of different symptoms people experience following a concussion.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/7Lfc7aZfd0Y?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Research suggests that a concussion can alter the brain’s wiring.</span></figcaption>
</figure>
<h2>What signs should you look for if you suspect a concussion?</h2>
<p>Concussions produce a wide range of signs and symptoms, such as problems with walking and balance, dizziness, mood changes, disruptions to sleep and more. </p>
<p>Some of the main signs that health care providers look for following an impact to the head or body include unsteadiness of gait, loss of consciousness, seizures or other concussion symptoms like headache, cognitive impairment or problems with vision or balance.</p>
<p>It is critical that if a concussion is suspected, individuals cease playing their sport or activity. A simple mantra of “<a href="https://sportscotland.org.uk/media/3382/concussionreport2018.pdf">If in doubt, sit them out</a>” should always be applied, regardless of the setting. </p>
<h2>Why is the injured brain more vulnerable to repeat injury?</h2>
<p>Miami Dolphins quarterback Tua Tagovailoa, who was <a href="https://www.cnn.com/2022/10/19/sport/nfl-tua-tagovailoa-concussion-spt-intl">carted off the field</a> in late September 2022 after his second head injury in less than a week, serves as an example of how vulnerable the brain can be to additional trauma following an initial concussion.</p>
<p>Research shows that the rate of second concussions is highest in the immediate <a href="https://doi.org/10.1136/bjsports-2019-100579">days following an initial concussion</a>. In addition, recent studies have found that athletes who continue to play following a concussion <a href="https://doi.org/10.1177/0363546518757984">experience longer recovery times</a> and <a href="https://doi.org/10.1007/s40279-022-01668-1">more severe symptoms</a>. </p>
<p>While athletes of all ages may want to continue competing after a concussion, relying on a person with an injured brain to determine whether their brain is healthy enough to continue playing is flawed logic. Qualified health care professionals should always make these sorts of decisions for an athlete, rather than someone with a vested interest such as the athletes themselves or their coaches.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Football players stand in a circle looking at a teammate stretched on the ground." src="https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Teammates gather around Miami Dolphins quarterback Tua Tagovailoa after an injury during the first half of an NFL game on Sept. 29, 2022.</span>
<span class="attribution"><a class="source" href="https://www.apimages.com/metadata/Index/Dolphins-Bengals-Football/2fc554f4223f4e0c9234f61e9f7e62da/1/0">AP Photo/Emilee Chinn/</a></span>
</figcaption>
</figure>
<p>Given the energy crisis described above that occurs following a head injury, the brain simply cannot handle the added and cumulative stress of two injuries occurring in short succession. A second insult to the brain is often simply too much for the brain to handle, and the brain will preserve its most basic functions, such as breathing, above all else. </p>
<p>This is why it is imperative that athletes who experience a concussion be removed from the field of play and allowed to recover fully before returning to unrestricted sport participation. This often involves <a href="https://doi.org/10.1136/bjsports-2017-097699">a stepwise reintegration approach</a>, which allows for a gradual and safe reintroduction into physical activity at first, and an appropriately safe return to play under medical care.</p>
<h2>You’ve had a concussion – now what?</h2>
<p>The first step following a concussion is to stop playing sports and to rest for a day or two. Sleep is <a href="https://doi.org/10.1089/neu.2021.0295">critically important</a> in the days following a concussion. </p>
<p>A myth that continues to persist is that a person should be woken up every hour following a concussion. This is simply not supported by science. In fact, poor sleep after a concussion has been widely documented as being a <a href="https://doi.org/10.1097/jsm.0000000000000803">predictor of poor outcomes</a>, including <a href="https://doi.org/10.1177/0009922816681603">longer recovery times</a> and more severe anxiety, depression or <a href="https://doi.org/10.1089/neu.2018.6257">cognitive symptoms</a>. Waking someone up every hour applies to <a href="https://doi.org/10.1093/bja/aem128">more severe brain injuries</a> that would be ruled out by a health care provider during diagnosis.</p>
<p>In addition, <a href="https://doi.org/10.1136/bjsports-2018-100338">recent guidelines</a> and <a href="https://doi.org/10.1542/peds.2014-0966">past research</a> suggest that complete physical and cognitive rest, which is <a href="https://doi.org/10.1097/wco.0000000000000611">sometimes called cocoon therapy</a>, can actually be <a href="https://doi.org/10.3389/fneur.2019.00362">harmful to recovery</a>. </p>
<p>Therefore, it is important to keep a balanced approach in mind. Following a day or two of physical rest, people with a concussion should begin resuming <a href="https://doi.org/10.1016/j.jpeds.2020.07.049">light physical and cognitive activity</a> that does not provoke or exacerbate ongoing symptoms. </p>
<p>When a person begins to feel better following a concussion, they should gradually add in higher intensity and greater amounts and duration of exercise, dictated by whether their symptoms are not significantly provoked. Recent studies have focused on the value of an individualized aerobic exercise program in the week following a concussion. Past work suggests that performing aerobic exercise at a heart rate just below the level at which symptoms are exacerbated is <a href="https://doi.org/10.1016/s2352-4642(21)00267-4">safe and effective for recovery</a>.</p>
<p>It is important to note that the effects of a concussion may also result in secondary conditions, such as anxiety or depression due to the biological, social or psychological effects of the injury. A recent study showed that adolescents who sustained a concussion have a <a href="https://doi.org/10.1001/jamanetworkopen.2022.1235">higher risk of mental health issues</a> compared to those with an orthopedic injury.</p><img src="https://counter.theconversation.com/content/192390/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr. Howell has received research support from the Eunice Kennedy Shriver National Institute of Child Health & Human Development, the National Institute of Neurological Disorders And Stroke, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, 59th Medical Wing Department of the Air Force, MINDSOURCE Brain Injury Network, the Tai Foundation, and the Colorado Clinical and Translational Sciences Institute and he serves on the Scientific/Medical Advisory Board/owns shares for Synaptek, LLC.</span></em></p>While high-profile concussions in the NFL have brought renewed attention to the gravity of head injuries, they can also occur on the playground or during junior varsity practices – with lasting effects.David Howell, Assistant Professor of Orthopedics,, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1942492022-11-10T04:09:03Z2022-11-10T04:09:03ZFirst Nations women are 69 times more likely to have a head injury after being assaulted. We show how hard it is to get help<figure><img src="https://images.theconversation.com/files/494551/original/file-20221110-17-4yfpkn.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-sitting-on-ground-arm-holding-461451844">Shutterstock</a></span></figcaption></figure><p><em>First Nations people, please be advised that the following article mentions family violence and assault.</em></p>
<hr>
<p>Aboriginal and Torres Strait Islander women are <a href="https://www.mja.com.au/journal/2008/188/10/hospitalisation-head-injury-due-assault-among-indigenous-and-non-indigenous">69 times more likely</a> than non-First Nations women to go to hospital with a head injury because of an assault.</p>
<p>But not all First Nations women get the support they need.</p>
<p><a href="https://www.mdpi.com/1660-4601/19/22/14744">Our new study</a> shows how health and support services working in remote areas are not equipped with the tools to identify the potential of a head injury for women who experience violence.</p>
<p>Not only are service workers not asking women about a potential traumatic brain injury, there’s a lack of referral options, and often no diagnosis, limiting women’s access to services and supports for recovery.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/four-corners-how-many-more-reveals-the-nations-crisis-of-indigenous-women-missing-and-murdered-193216">Four Corners' 'How many more?' reveals the nation's crisis of Indigenous women missing and murdered</a>
</strong>
</em>
</p>
<hr>
<h2>What is traumatic brain injury?</h2>
<p>Head injuries after an assault range from cuts and bruises to the type that can cause longer-term damage, known as traumatic brain injury. </p>
<p>Traumatic brain injury <a href="https://www.sciencedirect.com/science/article/pii/S0003999310006507">is defined as</a> damage to, or alteration of, brain function due to a blow or force to the head. Non-fatal strangulation can also lead to <a href="https://www.biausa.org/public-affairs/media/strangulation-domestic-violence-and-brain-injury-an-introduction-to-a-complex-topic">brain injury</a> as the brain is deprived of oxygen.</p>
<p>Such injury can have short-term (acute) effects or cumulative effects (over months or years). Changes vary from person to person but can include memory loss, difficulty with motivation, impaired awareness, sensory problems, mood changes and anxiety. </p>
<p>Some types of traumatic brain injury are also a <a href="https://theconversation.com/having-a-brain-injury-does-not-mean-youll-get-dementia-97254">risk factor</a> for early onset dementia.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-traumatic-brain-injury-75546">Explainer: what is traumatic brain injury?</a>
</strong>
</em>
</p>
<hr>
<h2>We’re talking about family violence</h2>
<p>Our work tries to understand the needs and priorities of First Nations women who have experienced a traumatic brain injury due to family violence.</p>
<p>Timely and culturally safe care, and support, following such brain injury is vital. But not all First Nations women <a href="https://theconversation.com/aboriginal-australians-want-care-after-brain-injury-but-it-must-consider-their-cultural-needs-115128">get access</a> to it.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1542331369497366533"}"></div></p>
<p>So, in early 2022, we spoke to 38 professionals from various sectors – including health, crisis accommodation and support, disability, family violence, and legal services – working across remote areas of the Northern Territory.</p>
<p>The data offers insights into the barriers that can prevent people asking First Nations women about possible brain injury, and women’s access to health care afterwards.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/aboriginal-australians-want-care-after-brain-injury-but-it-must-consider-their-cultural-needs-115128">Aboriginal Australians want care after brain injury. But it must consider their cultural needs</a>
</strong>
</em>
</p>
<hr>
<h2>Often, there’s no follow-up</h2>
<p>Participants told us that while the more severe cases were evacuated from a remote community to a hospital, less-severe cases were not always followed up.</p>
<p>One participant told us: </p>
<blockquote>
<p>Women are often not evac-ed out following a head injury, if it’s assessed to not be an urgent thing, so might not necessarily be getting CT scans.</p>
</blockquote>
<p>CT scans can help inform diagnosis, treatment and support. </p>
<p>Service providers were also often unaware of follow-up pathways to identify and connect women with the right supports, should they have ongoing symptoms.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1541936693799833600"}"></div></p>
<h2>A fly-in, fly out workforce</h2>
<p>Participants told us that high workforce turnover and <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-017-0229-9">fly-in, fly-out health services</a> in remote regions could also affect identification of traumatic brain injury.</p>
<p>They told us short-term staff can lack knowledge and familiarity of working in remote communities, and in building community relationships.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/fly-in-fly-out-heath-care-fails-remote-aboriginal-communities-7948">Fly-in, fly-out heath care fails remote Aboriginal communities</a>
</strong>
</em>
</p>
<hr>
<h2>Lack of referral, diagnosis, training</h2>
<p>Not all women were referred to neuropsychologists (health professionals who might assess symptoms), which led to gaps in medical reports and formalised assessments. One participant told us: </p>
<blockquote>
<p>I don’t know any who actually have a confirmed diagnosis.</p>
</blockquote>
<p>This has implications for how women are managed and the supports they receive.</p>
<p>None of the staff we interviewed had completed training about traumatic brain injury. One told us:</p>
<blockquote>
<p>We get ADD [attention-deficit disorder] workshops, we get domestic and family violence workshops, disability support workshops, but nothing around brain injury.</p>
</blockquote>
<p>Other than some legal services, service providers did not ask specific questions of women who had experience violence and assaults about possible traumatic brain injury. </p>
<p>One participant said: </p>
<blockquote>
<p>We’ll screen for domestic violence, but we don’t screen for specific injuries.</p>
</blockquote>
<h2>What can we do about it?</h2>
<p>As our research shows, First Nations women with traumatic brain injury need better access to support and services, which is critical for their long-term recovery. </p>
<p>Here’s how we support frontline staff:</p>
<ul>
<li><p>design and roll out education about traumatic brain injury to develop staff knowledge and confidence. This education needs to be tailored to the type of frontline staff (remote area nurses will clearly need different education to housing staff), be designed with First Nations input and be culturally appropriate</p></li>
<li><p>ask women about the possibility of traumatic brain injury as part of existing family violence and health assessments</p></li>
<li><p>ask culturally appropriate questions that are not meant to diagnose traumatic brain injury, but help to identify cognitive impairment and complex disability </p></li>
<li><p>explore different ways of delivering rehabilitation for mild traumatic brain injury, and whether telehealth might be appropriate under some circumstances.</p></li>
</ul>
<p>Giving a voice to First Nations women living with traumatic brain injury is also crucial to providing the necessary supports during their rehabilitation and recovery.</p>
<hr>
<p><em>If this article raises issues for you or someone you know, contact <a href="https://1800respect.org.au">1800 RESPECT</a> (1800 737 732) or <a href="https://www.13yarn.org.au/">13YARN</a> (13 92 76). In an emergency, call 000.</em></p>
<hr>
<p><em>Dr Gail Kingston (Townsville Hospital and Health Service) and Elaine Wills (Western Sydney University and Menzies School of Health Research) are co-authors of the journal paper on which this article is based. The authors would like to thank members of the project advisory group and all participants who shared their time and knowledge.</em></p><img src="https://counter.theconversation.com/content/194249/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michelle Fitts receives funding from the Australian Research Council and the National Health and Medical Research Council. </span></em></p><p class="fine-print"><em><span>Jennifer Cullen receives funding from the Department of Social Services and the NDIS. She is the CEO of Synapse Australia.</span></em></p><p class="fine-print"><em><span>Karen Soldatic receives funding from the Australian Research Council and the National Health and Medical Research Council. </span></em></p>Health and service workers are not asking women about a potential traumatic brain injury, there’s a lack of referral options, and often no diagnosis.Michelle Fitts, ARC DECRA Fellow, Institute for Culture and Society, Western Sydney UniversityJennifer Cullen, Adjunct Associate Professor, College of Healthcare Sciences, James Cook UniversityKaren Soldatic, Professor, School of Social Sciences & Institute Principle Fellow, Institute for Culture and Society, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1843112022-08-18T20:05:46Z2022-08-18T20:05:46ZFriday essay: how a bike accident changed me, by a philosopher of hope<figure><img src="https://images.theconversation.com/files/478620/original/file-20220811-9577-tzdr0u.jpg?ixlib=rb-1.1.0&rect=29%2C29%2C3946%2C2628&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Photo by David Newheiser</span></span></figcaption></figure><p>Cycling once made me feel free unlike anything else. I loved the sensation of slicing through the air, flying past pedestrians and cars stalled in traffic. Where I live (in Melbourne’s inner north), the best way to get around is by bike.</p>
<p>One sunny Sunday in March last year, my partner and I set off to explore the city. As I approached an intersection near our home, I felt some fear, as I always did with cars nearby. Out of the corner of my eye I watched an SUV driving alongside me, worried it would turn suddenly and hit me across the side.</p>
<p>As I accelerated to avoid that danger, another car made an illegal turn ahead of me, blocking the bike path. I remember yelling, hearing the crunch of my body hitting the car – but after that there’s a gap.</p>
<p>“Blacking out” is a good name for it. We spend roughly eight hours each day in a state of semi-consciousness. However, as our half-remembered dreams remind us, the mind remains active while we’re asleep. This felt different, a forcible blank.</p>
<p>The next thing I knew, I was picking myself off the asphalt, rushing to drag myself out of an eight-lane thoroughfare before another wave of traffic arrived.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/478613/original/file-20220811-9577-dbb2tp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/478613/original/file-20220811-9577-dbb2tp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478613/original/file-20220811-9577-dbb2tp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478613/original/file-20220811-9577-dbb2tp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478613/original/file-20220811-9577-dbb2tp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478613/original/file-20220811-9577-dbb2tp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478613/original/file-20220811-9577-dbb2tp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478613/original/file-20220811-9577-dbb2tp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The author’s bike.</span>
<span class="attribution"><span class="source">Author provided</span></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/3-in-4-people-want-to-ride-a-bike-but-are-put-off-by-lack-of-safe-lanes-172868">3 in 4 people want to ride a bike but are put off by lack of safe lanes</a>
</strong>
</em>
</p>
<hr>
<h2>An unreliable mind</h2>
<p>At first I thought my injuries were only musculoskeletal, but within a week my head started hurting – and it hasn’t stopped since. Although I was wearing a helmet, I’d suffered a mild traumatic brain injury. Whereas most people recover completely within weeks, some cases take longer to resolve. I am in that minority.</p>
<p>For a year my headache was piercing, a constant intrusion. Now it simply pervades, colouring everything. What’s worse, sustained concentration intensifies my headache and makes me feel woozy. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/479496/original/file-20220816-18271-u60oql.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/479496/original/file-20220816-18271-u60oql.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/479496/original/file-20220816-18271-u60oql.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/479496/original/file-20220816-18271-u60oql.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/479496/original/file-20220816-18271-u60oql.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/479496/original/file-20220816-18271-u60oql.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/479496/original/file-20220816-18271-u60oql.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/479496/original/file-20220816-18271-u60oql.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">David Newheiser photographed last month.</span>
<span class="attribution"><span class="source">Author provided</span></span>
</figcaption>
</figure>
<p>In the first few months, chatting with a friend would leave me exhausted after just a few minutes. Even now, as my brain tires, it becomes harder to find the right words.</p>
<p>I have learned how claustrophobic chronic pain can become, but for me this wasn’t the worst of it. Because writing and thinking are at the centre of my life, it broke my heart to find that my mind was unreliable. It’s not just that it was harder to connect with others – I felt alienated even from myself.</p>
<p>I have sometimes found it difficult to keep hope, cut off from the future I had imagined. However, in my loneliest moments I was sustained by the care of doctors, nurses, friends and neighbours.</p>
<p>This experience of unexpected connection has transformed me in ways I couldn’t predict. Before my accident I enjoyed the unconscious confidence of the chronically well. I knew that everyone’s health runs out eventually, but somehow that seemed like a problem for other people.</p>
<p>Now, I carry a constant reminder that disaster can come for any of us. As a result, I have a renewed conviction that everyone should have the support required for a flourishing life. This is important because we are all vulnerable, and we all rely on others. However, it is particularly urgent in the context of the ongoing pandemic.</p>
<p>According to the best estimates, the pandemic has killed <a href="https://www.economist.com/graphic-detail/coronavirus-excess-deaths-estimates">20 million people</a> and left <a href="http://doi.org/10.1093/infdis/jiac136">millions more</a> with long-term respiratory, cardiac and neurological symptoms. Faced with figures like these, fatalism is an understandable response. After all, COVID is a global force that even the most conscientious individual can’t do much to change.</p>
<p>At the same time, COVID reminds us we aren’t just individuals – the ebb and flow of case numbers makes clear that our wellbeing is interconnected. Much as my recovery has shown we are all knit within networks of support, the pandemic is an opportunity to imagine a world in which no one is left behind. </p>
<p>As I have found, each individual is limited, but there is power in solidarity.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/472424/original/file-20220705-22-biy0cd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/472424/original/file-20220705-22-biy0cd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/472424/original/file-20220705-22-biy0cd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/472424/original/file-20220705-22-biy0cd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/472424/original/file-20220705-22-biy0cd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/472424/original/file-20220705-22-biy0cd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=539&fit=crop&dpr=1 754w, https://images.theconversation.com/files/472424/original/file-20220705-22-biy0cd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=539&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/472424/original/file-20220705-22-biy0cd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=539&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Each individual is limited but there is power in solidarity.</span>
<span class="attribution"><span class="source">Photo by the author.</span></span>
</figcaption>
</figure>
<h2>Love and marmalade</h2>
<p>For most of my life, I was confident I would be able to address whatever challenges I’d face. After my accident, however, my capacities were suddenly altered, and so I found myself reliant on others.</p>
<p>The help I needed was, first of all, practical. Within moments of my collision, I had to get out of the road despite being in a state of extreme disorientation. For that I have to thank a stranger whose name I no longer remember.</p>
<p>In the following months, I received care from a number of specialists: physicians, physiotherapists, a speech pathologist, a neuropsychologist, an occupational therapist, and others. I’m much better off than I would have been without them, but at the same time I have seen the limits of medicine. There is no pill to magically make my symptoms disappear. Instead, my carers have taught me to manage while waiting for slow, unsteady improvements.</p>
<p>I am lucky to live in a society that promises broad access to medical care. Even so, due to my injury I found the logistics of my treatment overwhelming, and so my partner managed the details. Two weeks after my accident, however, she had an accident of her own. Just when my resources were lowest, I spent a week by her bed in hospital, waiting for surgery to reconstruct her shattered jaw.</p>
<p>With both of us stricken, the care we received from friends and neighbours was astonishing. Many people left soup on our doorstep, and those who lived too far away sent some instead. For months we rested in the knowledge that we didn’t need to worry about what was for dinner. During a time when we were overwhelmed by the weight of each day, this made life a little easier, but it also meant something more.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/478663/original/file-20220811-24-oeo40l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/478663/original/file-20220811-24-oeo40l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/478663/original/file-20220811-24-oeo40l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478663/original/file-20220811-24-oeo40l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478663/original/file-20220811-24-oeo40l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478663/original/file-20220811-24-oeo40l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478663/original/file-20220811-24-oeo40l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478663/original/file-20220811-24-oeo40l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>At my lowest moment, several months in, two parcels arrived on the same day. Both contained care package standards: herbal tea, biscuits, a mug, and so forth. (For variety, there was also one jar of a “gentleman’s relish” made from pulverised anchovies.)</p>
<p>As I opened the second box, I broke down and sobbed for several minutes.</p>
<p>In itself, the marmalade I held in my hand didn’t change my situation. However, the fact that someone had thought to send it to me cut through the fog and funk I was feeling. This was love, and it gave me a line to life.</p>
<h2>Worlds bigger than my imagination</h2>
<p>A year before my accident, I’d published my first book, <a href="https://doi.org/10.1017/9781108595100">Hope in a Secular Age</a>. It was the culmination of two decades in higher education – first as a student, then as a scholar. I loved feeling the pulse of a quicksilver conversation, mustering the imagination to help it forward, but after my accident this was beyond me.</p>
<p>For most of a year I found myself unable to sustain the concentration required to contribute to my discipline. In fact, reading so much as a page would wreck me. Having lost the person I had worked to become, the life I hoped for seemed out of reach.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/478665/original/file-20220811-18-wdm2i8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/478665/original/file-20220811-18-wdm2i8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/478665/original/file-20220811-18-wdm2i8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=909&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478665/original/file-20220811-18-wdm2i8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=909&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478665/original/file-20220811-18-wdm2i8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=909&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478665/original/file-20220811-18-wdm2i8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1142&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478665/original/file-20220811-18-wdm2i8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1142&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478665/original/file-20220811-18-wdm2i8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1142&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
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<p>I write about hope because I believe it is <a href="http://doi.org/10.1111/jore.12328">difficult but indispensable</a>. In my book, I reflect on the affinity between atheism and faith, reconsider the place of religion in politics, and trace the thread that connects medieval mysticism and postmodern theory. Most of all, however, I meditate on our capacity to persist even though the future is fragile.</p>
<p>We all have desires that are vulnerable to disappointment. It’s the reason the people we love and the causes we care about can break our hearts – whether because we don’t get what we want or (even worse) because we do, but it wasn’t what we expected.</p>
<p>In the book I argue that hope is what enables us to hold these desires even though we don’t know how things will turn out. To say “I hope” acknowledges that we aren’t sure whether what we want will come to pass, but hope doesn’t take this as a cause to quit. Instead, it endures without guarantees.</p>
<p>The challenges I’ve faced are small compared to what some people experience, but they have tested my capacity for endurance. I spent so much of my life trying to contribute to the world through my work, but suddenly I couldn’t work any more. </p>
<p>Because my aspirations seemed out of reach – for how long, I did not know – there were days when I found it difficult to imagine what my life was for.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/473276/original/file-20220711-18-wl4t3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/473276/original/file-20220711-18-wl4t3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/473276/original/file-20220711-18-wl4t3j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/473276/original/file-20220711-18-wl4t3j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/473276/original/file-20220711-18-wl4t3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/473276/original/file-20220711-18-wl4t3j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/473276/original/file-20220711-18-wl4t3j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Melbourne street art. Photo by the author.</span>
</figcaption>
</figure>
<p>I can now see that my symptoms were improving even then, but at the time any change was imperceptible. Without hope I was becalmed, untethered from the tug of the future.</p>
<p>But in retrospect, the hopes I had for my work were always too narrow, too tightly tied to systems of labour and reward. In contrast, that jar of marmalade carried the promise of breakfast but also a love that was offered freely, regardless of what I could offer in return.</p>
<p>An everyday gift reminded me that I am held within worlds that are <a href="http://doi.org/10.1111/moth.12506">bigger than my imagination</a>.</p>
<h2>Our interdependence</h2>
<p>Although hope is a capacity that each of us has, <a href="http://doi.org/10.1177/20503032211044432">no one hopes alone</a>. The care I received gave me the energy to reconsider what my life is for, and this expanded vision put solidarity at the centre. As I have found, even our very resilience is sustained by the support of others.</p>
<p>In Western societies, we often picture politics as a conglomeration of atoms, each independent in itself. On this view, we are autonomous from the outset; the question is when and how we come together for the purpose of cooperation. This focus on the individual has won important protections for sexual and racial minorities. However, my experience suggests that imagining each person as isolated distorts what human life is like.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/472681/original/file-20220706-14-hzrycn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/472681/original/file-20220706-14-hzrycn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=735&fit=crop&dpr=1 600w, https://images.theconversation.com/files/472681/original/file-20220706-14-hzrycn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=735&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/472681/original/file-20220706-14-hzrycn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=735&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/472681/original/file-20220706-14-hzrycn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=924&fit=crop&dpr=1 754w, https://images.theconversation.com/files/472681/original/file-20220706-14-hzrycn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=924&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/472681/original/file-20220706-14-hzrycn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=924&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">You are worth so much more than your productivity. Photo by the author.</span>
</figcaption>
</figure>
<p>Each of us was born unable to provide for ourselves, but someone fed us. As adults, we all rely on complex networks that enable us to access shelter, food, and everything else we require but can’t create on our own. For this reason, feminist theorists like <a href="https://www.versobooks.com/books/3758-the-force-of-nonviolence">Judith Butler</a> conclude that we are linked in relations of interdependence.</p>
<p>Before my accident I imagined myself as fairly self-sufficient, but now I have seen how deeply I rely on the support of others. As I have described, in those moments when my hope ran dry, others renewed me. It is not simply that relationships enrich my life: interdependence is essential to who I am.</p>
<p>If this is true, we owe each other more than we often acknowledge. In a medical crisis, many people are disoriented by pain and fear, just as I was, but they don’t have the support I enjoyed. Not everyone lives in a community where people bring soup to their neighbours in need. Not everyone has a partner who can spend hours navigating the healthcare system. In many places, medical care is a privilege only the wealthy can afford.</p>
<p>My life would have been limited without the care I received, but this shouldn’t be a question of luck. This is the central lesson of my recovery: if everyone exists by virtue of their connection to others, we must work to ensure everyone has the support they need to flourish.</p>
<h2>Imagining a more equal world</h2>
<p>As it stands, in both the <a href="https://doi.org/10.1016/S0140-6736(17)30398-7">United States</a> (my birthplace) and <a href="https://www.aihw.gov.au/reports/australias-health/health-across-socioeconomic-groups">Australia</a> (my home), the wealthy live longer, healthier lives than those who are poorer. This was true before the pandemic, but COVID has made these <a href="http://doi.org/10.1073/pnas.2020685118">inequalities</a> worse.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/473278/original/file-20220711-45271-rb7ugm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/473278/original/file-20220711-45271-rb7ugm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/473278/original/file-20220711-45271-rb7ugm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/473278/original/file-20220711-45271-rb7ugm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/473278/original/file-20220711-45271-rb7ugm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/473278/original/file-20220711-45271-rb7ugm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/473278/original/file-20220711-45271-rb7ugm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Melbourne street art. Photo by the author.</span>
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</figure>
<p>Australians living in poverty have been <a href="https://theconversation.com/australia-is-failing-marginalised-people-and-it-shows-in-covid-death-rates-177224">three times</a> more likely to die from the coronavirus than the wealthy. In the US, <a href="https://www.apmresearchlab.org/covid/deaths-by-race">Indigenous, Black, and Latino Americans</a> are between one and a half times and twice as likely to die of COVID as white Americans. Recent research shows that disadvantaged groups are also more likely to be impacted by the ongoing burden of <a href="https://theconversation.com/first-covid-hit-disadvantaged-communities-harder-now-long-covid-delivers-them-a-further-blow-183908">long COVID</a>.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australia-is-failing-marginalised-people-and-it-shows-in-covid-death-rates-177224">Australia is failing marginalised people, and it shows in COVID death rates</a>
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<hr>
<p>Although the available vaccines greatly reduce one’s chance of dying from COVID, it remains a significant danger. Over the past year, the high number of infections have made COVID a <a href="https://www.actuaries.digital/2022/08/04/covid-19-excess-mortality-continues-for-april-2022/">leading cause of death</a> among <a href="https://insidemedicine.bulletin.com/the-million-us-covid-dead-are-younger-than-you-think">the young</a> as well as the old.</p>
<p>At the same time, even a mild or asymptomatic infection can have lasting consequences. The US Centers for Disease Control <a href="http://dx.doi.org/10.15585/mmwr.mm7121e1">estimates</a> that one in five adults develop a new health problem following a COVID infection (such as heart disease, fatigue, or kidney failure), while a recent study sets the figure at <a href="https://doi.org/10.1016/S0140-6736(22)01214-4">12.7%</a>. Studies indicate that vaccination provides <a href="https://doi.org/10.1038/s41591-022-01840-0">limited protection</a> against long COVID, and it <a href="https://doi.org/10.21203/rs.3.rs-1749502/v1">appears</a> that the risks increase with each reinfection.</p>
<p>These risks continue to fall heaviest on those who were already disadvantaged. Those with less wealth have greater difficulty accessing <a href="https://doi.org/10.1016/S0140-6736(71)92410-X">health care</a>, and they face greater <a href="https://rooseveltinstitute.org/2022/06/28/economic-cost-of-covid-19/">exposure</a> to the virus. In addition, these people are at particular risk because the rest of us depend on them.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/472645/original/file-20220705-5022-os4vnk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/472645/original/file-20220705-5022-os4vnk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/472645/original/file-20220705-5022-os4vnk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/472645/original/file-20220705-5022-os4vnk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/472645/original/file-20220705-5022-os4vnk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/472645/original/file-20220705-5022-os4vnk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/472645/original/file-20220705-5022-os4vnk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/472645/original/file-20220705-5022-os4vnk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The risks are greatest for those disadvantaged.</span>
<span class="attribution"><span class="source">Photo by the author</span></span>
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</figure>
<p>While some of us are able to work from home during periods of high transmission, we require “<a href="http://doi.org/10.1177/07311214211005491">essential workers</a>” to staff our warehouses, factories and grocery stores. In many cases, they are compelled to risk infection by <a href="http://doi.org/10.1177/0263276415619997">economic necessity</a>: because many low-income workers don’t have access to <a href="https://www.bls.gov/opub/ted/2021/paid-sick-leave-was-available-to-79-percent-of-civilian-workers-in-march-2021.htm">paid sick leave</a>, they are more likely to be exposed to a coworker who is contagious.</p>
<p>COVID has made existing inequalities worse, but it is also a reminder that we rely on the labour of communities we sometimes forget. For this reason, the pandemic is an invitation take seriously our interdependence by <a href="http://doi.org/10.1093/jaarel/lfx026">imagining</a> a more equal world.</p>
<h2>The global web of wellbeing</h2>
<p>Here in Melbourne, the first year of the pandemic was hard. We spent months in lockdown, which is an experience I do not wish to relive. However, the very pressure of that period reminded us we were working together to flatten the curve, support the hospital system, and protect the vulnerable.</p>
<p>I believe we have the capacity to rediscover this sense of common purpose. As I have described, <a href="https://jacobin.com/2021/01/covid-19-business-work-public-health">the workplace</a> has been a key site of COVID transmission, and this has left vulnerable communities at particular risk. In response, many <a href="https://www.australianunions.org.au/campaign/covid-aware/">unions</a> have argued that employers have a duty to keep their employees safe from COVID, and there is evidence that their work has <a href="http://doi.org/10.1377/hlthaff.2021.01687">reduced</a> infection and morality rates.</p>
<p>In keeping with this vision of coordinated action, <a href="https://ozsage.org/media_releases/covid-19-has-become-a-leading-cause-of-death-in-australia-urgent-call-for-action/">health experts</a> have <a href="https://www.independentsage.org/what-should-learning-to-live-with-covid-really-mean-in-2022/">argued</a> that, although vaccination is enormously important, more must be done. Crucially, rather than returning to the heavy-handed approach we saw early in the pandemic, these recommendations emphasise the need for effective supports.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/472672/original/file-20220706-26-cz4z53.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/472672/original/file-20220706-26-cz4z53.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=749&fit=crop&dpr=1 600w, https://images.theconversation.com/files/472672/original/file-20220706-26-cz4z53.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=749&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/472672/original/file-20220706-26-cz4z53.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=749&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/472672/original/file-20220706-26-cz4z53.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=941&fit=crop&dpr=1 754w, https://images.theconversation.com/files/472672/original/file-20220706-26-cz4z53.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=941&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/472672/original/file-20220706-26-cz4z53.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=941&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Melbourne street art. Photo by the author.</span>
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</figure>
<p>Because <a href="https://www.pnas.org/doi/10.1073/pnas.2119266119">studies have shown</a> mask wearing in public reduces COVID transmission, experts argue governments should provide high-quality masks (as the state of Victoria has <a href="https://www.premier.vic.gov.au/free-masks-keep-victorians-safe-winter">recently done</a>). Since N95 masks (or equivalent) are <a href="https://nymag.com/intelligencer/article/why-you-should-upgrade-your-face-mask-to-an-n95.html">far more protective</a> than cloth or surgical masks, experts encourage governments to educate the public about their importance. We also need free home tests, income support for those who are unwell, and improved indoor air in public spaces through ventilation and filtration.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/473272/original/file-20220711-45421-8i64tl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/473272/original/file-20220711-45421-8i64tl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/473272/original/file-20220711-45421-8i64tl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/473272/original/file-20220711-45421-8i64tl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/473272/original/file-20220711-45421-8i64tl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/473272/original/file-20220711-45421-8i64tl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/473272/original/file-20220711-45421-8i64tl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Melbourne street art. Photo by the author.</span>
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<p>Implementing these measures at the state or national level would do a great deal to reduce the harms caused by COVID, but the web of wellbeing is global as well. Although <a href="https://blogs.worldbank.org/voices/covid-vaccines-why-we-must-succeed-every-country">only 12%</a> of people in low-income countries are fully vaccinated, wealthy countries have thrown out <a href="https://www.nbcnews.com/news/us-news/covid-vaccine-doses-wasted-rcna31399">many millions</a> of <a href="https://www1.racgp.org.au/newsgp/clinical/a-perfect-storm-vaccine-wastage-doubles-as-demand">doses</a> in recent months. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/two-years-into-the-pandemic-unequal-access-to-covid-19-treatments-threatens-the-global-recovery-178990">Two years into the pandemic, unequal access to COVID-19 treatments threatens the global recovery</a>
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</em>
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<p>This harms people living in lower-income countries (who are <a href="https://www.nature.com/articles/d41586-022-01767-z">twice as likely</a> to die from the virus), but it also makes all of us unsafe. Since unchecked transmission enables new variants of the virus to emerge, it is in everyone’s interest to vaccinate the world.</p>
<p>Because COVID is so <a href="https://www.scientificamerican.com/article/omicrons-surprising-anatomy-explains-why-it-is-wildly-contagious/">contagious</a>, it requires a collective response. As we have seen, insisting upon <a href="https://www.theguardian.com/australia-news/2021/dec/20/scott-morrison-to-hold-unscheduled-national-cabinet-meeting-as-omicron-cases-rise">personal responsibility</a> in place of public health leads to high levels of transmission, death, and disability.</p>
<p>In this way, COVID underlines what I have learned from my slow recovery: because we are all connected, each of us will do best if we all have the support required to flourish.</p>
<h2>Rupture and recovery</h2>
<p>In my own life, I experience hope as a restlessness that won’t let me go.</p>
<p>For a year following my accident, it wasn’t clear whether and when I would be able to write again. There were times when I wished I could give up the hope to find the fluency that used to be mine, but the desire was lodged too deeply within me.</p>
<p>I don’t know how my recovery will progress from here, and I’m keenly aware of what I’ve already lost. Still, I am trying to embrace the idea that – along with this insistent headache – the experience has left me with something worth preserving.</p>
<p>I think the pandemic presents us all with a similar possibility. Like my injury, it is in no way a good thing. Compared with the challenges I have faced, the suffering caused by COVID is staggering. Still, as a <a href="http://doi.org/10.1111/moth.12579">rupture</a> with the normal run of things, it invites us to radical imagination.</p>
<p>Before the pandemic, our world was unequal in many ways. COVID has made these inequalities worse, but it has also made things fragile. Since we have seen that things can change in a flash, we have the chance to work for a world animated by the power of solidarity.</p><img src="https://counter.theconversation.com/content/184311/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Newheiser does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Reliance on the support of others after an accident showed philosopher David Newheiser the power of solidarity. We need a similar sense of communal connection in our approach to COVID, he writes.David Newheiser, Senior Research Fellow in the Institute for Religion and Critical Inquiry, Australian Catholic UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1847402022-07-21T12:25:29Z2022-07-21T12:25:29ZSilent, subtle and unseen: How seizures happen and why they’re hard to diagnose<figure><img src="https://images.theconversation.com/files/470665/original/file-20220623-64215-3tfegq.jpg?ixlib=rb-1.1.0&rect=7%2C22%2C5104%2C3380&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Approximately 10% of people will experience at least one seizure during their lifetime.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/brain-and-brain-waves-in-epilepsy-royalty-free-illustration/973895626?adppopup=true">Kateryna Kon/Science Photo Library via Getty Images</a></span></figcaption></figure><p>The dramatic and incapacitating nature of seizures is reflected in the word itself, which derives from the Greek “to take hold” – like an invisible force suddenly grasping someone and controlling their body. This sense of an unknown force has driven many superstitions and misrepresentations of seizures throughout history.</p>
<p>Over the past century, the public’s understanding of seizures has been gleaned mostly from depictions in movies and television, which are often as disturbing as they are inaccurate. While these dramatic representations intensify visual storytelling, they frequently perpetuate stigma and <a href="https://doi.org/10.1111/j.1528-1157.1999.tb00836.x">understate the complexity of seizures</a>. </p>
<p>The truth is, seizures are far more varied than what you see in popular culture. Instead, they are often subtle, silent and unseen.</p>
<p><a href="https://som.ucdenver.edu/Profiles/Faculty/iframeProfile/30305">As a neurologist</a> who focuses on the comprehensive care of people who experience seizures, I subspecialize in the treatment of those with epilepsy. That includes identifying and improving gaps in epilepsy care. Research shows there are many.</p>
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<figcaption><span class="caption">Epilepsy is a complex condition, but it is also treatable.</span></figcaption>
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<h2>Why seizures occur</h2>
<p>A seizure is caused by sudden uncontrolled <a href="https://www.cureepilepsy.org/for-patients/understanding/basics/what-is-seizure/?">electrical activity from a group of neurons</a>. This hyperactivity overwhelms the brain’s normal tendency to suppress such abnormal activity on both a cellular and network level. </p>
<p>Not all seizures are indicative of epilepsy. An otherwise normal brain may experience seizures during alcohol withdrawal. Seizure-like events may also occur with an acute decrease in blood flow, which can cause fainting. </p>
<p>Seizures associated with epilepsy, on the other hand, are <a href="https://www.epilepsydiagnosis.org/">unprovoked and often very difficult to predict</a>. A broad spectrum of underlying abnormalities can all lead to the development of epileptic seizures, including brain tumors, infections, strokes, traumatic brain injury, autoimmune conditions, developmental abnormalities and genetic predispositions.</p>
<h2>Seizures are not uncommon</h2>
<p>Approximately 1 in 10 people <a href="https://doi.org/10.1212/WNL.40.8.1163">will experience a seizure</a> during their lifetime. But only those with a risk of recurrent unprovoked seizures are <a href="https://doi.org/10.1111/epi.13670">considered to have epilepsy</a>, which represents about <a href="https://doi.org/10.1111/J.1528-1157.1993.TB02586.X">1 in 26 people</a></p>
<p>Because of the wide variety of symptoms, substantial <a href="https://doi.org/10.1007/s11910-021-01161-8">delays to diagnosis and treatment</a> can happen. When unrecognized and untreated, seizures worsen over time and lead to <a href="https://doi.org/10.1016/j.yebeh.2015.10.020">decreased quality of life</a>, <a href="https://doi.org/10.1111/epi.16707">cognitive impairments</a>, <a href="https://doi.org/10.1111/j.1528-1157.1995.tb01660.x">injuries, including motor vehicle accidents</a>, and <a href="https://doi.org/10.1093/brain/awt117">sometimes death</a>. </p>
<p>The irony is, much of the suffering is unnecessary. Most people with epilepsy <a href="https://doi.org/10.1111/j.1528-1167.2009.02481.x">can be seizure-free</a> through the use of an inexpensive medication.</p>
<h2>Focal seizures</h2>
<p>Regardless of the cause, <a href="https://doi.org/10.1111/j.1528-1167.2009.02481.x">focal seizures</a> are the most common type found in adults. This seizure type arises from hyperactivation of a confined brain region. For instance, a seizure arising from the left motor cortex of the brain may result in shaking of the right arm. A seizure arising from the visual cortex may cause a person to see flashes of light or other strange visual phenomena. </p>
<p>The most common brain region for focal seizures to arise is one of the temporal lobes, of which there are two – one on either side of the brain. These lobes serve many functions and are involved in vocal, auditory and visual processing, as well as emotions and memory. This is why seizures arising from these areas can lead to a variety of unusual symptoms.</p>
<p>Frequently, focal temporal lobe seizures are relatively subtle, particularly to witnesses. Sometimes they are comprised of purely unusual internal sensations such as sudden intense fear, a sudden sense of déjà vu or possibly a strong odor. Until a seizure spreads to involve more areas of the brain, it may not cause loss of consciousness or convulsions.</p>
<p>Because untreated seizures become more frequent and severe over time, it is not uncommon for epilepsy to begin with these relatively subtle focal seizures, then worsen as the seizures begin to involve more brain tissue, and eventually progress to convulsions.</p>
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<figcaption><span class="caption">People affected by epilepsy discuss the myths surrounding the condition.</span></figcaption>
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<h2>Delays in diagnosis</h2>
<p>A patient of mine described having strange symptoms for over a decade – symptoms he had not discussed before with me or anyone else. He described recurrent, sudden-onset euphoric sensations, which progressed to an inability to speak for one to two minutes. A bystander would think he was just staring into space. Over the years, these sensations increased in frequency. They eventually became more severe and led to loss of consciousness. </p>
<p>After the patient began an anti-seizure medication regimen, the sensations went away, and he reported improvements in both memory and cognition. Fortunately, he did not experience physical injury, or worse, before his evaluation. But many people are not so lucky.</p>
<p>Recent studies have confirmed that <a href="https://doi.org/10.1002/epi4.12443">delays in diagnosis are common</a> among people who have epilepsy. Undoubtedly, this is because the early subtle and unusual symptoms are not well recognized by patients, families or medical professionals. </p>
<h2>A revealing study</h2>
<p><a href="http://www.humanepilepsyproject.org/">The Human Epilepsy Project</a> is a large, multinational prospective study that followed nearly 500 people with newly treated focal epilepsy for five years. I was among the researchers who analyzed the study’s data, and we found a striking diagnostic delay among many participants. Many of them experienced seizures for <a href="https://doi.org/10.1111/epi.16707">several months or even several years before diagnosis</a>. </p>
<p>From those first seizures to the diagnosis, half the participants experienced injuries; 5% had car accidents attributable to seizures. Extrapolating this data to the general population suggests that every year in the U.S., over 1,800 motor vehicle accidents are due to <a href="https://doi.org/10.1111/epi.16707">undiagnosed subtle focal seizures</a>. With a timely diagnosis, these accidents are potentially preventable.</p>
<p>However, even those evaluated for seizures don’t always receive the correct diagnosis or treatment. Nearly two-thirds of those participating in the Human Epilepsy Project sought an initial seizure evaluation in an emergency department. About 90% were there only after their first convulsive seizure – that is, after the seizure spread and now involved the full brain. </p>
<p>But leading up to that first convulsive seizure, nearly half of participants had been experiencing nonmotor focal seizures, which went largely unrecognized. For that reason, many people who <a href="https://doi.org/10.1111/acem.14114">could have been diagnosed with epilepsy</a> and started on treatment were not. </p>
<p>As it stands now, about 200,000 U.S. adults <a href="https://doi.org/10.1111/j.1528-1167.2008.01443.x">seek evaluation at a hospital’s emergency department</a> for a first lifetime seizure every year. Often, they are diagnosed with epilepsy at that time or shortly thereafter. Poor recognition of subtle seizures bears significant consequences for individuals, communities and the health care system. Improving our understanding of the diverse ways seizures arise and affect lives will help us close the gap and lessen the consequences.</p><img src="https://counter.theconversation.com/content/184740/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jacob Pellinen receives funding in the form of grants from the University of Colorado Department of Neurology, NIH/NCATS Colorado CTSA Grant Number UL1 TR002535, and from the American Epilepsy Society.</span></em></p>Because some seizures are relatively subtle, they can go unrecognized, leading to a delay in diagnosis.Jacob Pellinen, Assistant Professor of Neurology, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1789702022-04-26T19:53:34Z2022-04-26T19:53:34ZNaked mole rats, frogs and other animals may hold the secrets to preventing brain injury<figure><img src="https://images.theconversation.com/files/459413/original/file-20220425-11-htoyzz.jpg?ixlib=rb-1.1.0&rect=0%2C23%2C5327%2C3556&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Naked molerats have evolved mechanisms to protect the brain from the effects of low oxygen.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/naked-mole-rats--frogs-and-other-animals-may-hold-the-secrets-to-preventing-brain-injury" width="100%" height="400"></iframe>
<p>The brain is the organ that orchestrates all the diverse functions and complex decisions that take place in biological systems. Despite its critical nature, it is equally as fragile: the neurons that make up the brain <a href="https://doi.org/10.1007/s11064-019-02844-y">do not regenerate like many other cell types</a>. </p>
<p>While cells found in many other organs constantly divide to replenish themselves or heal in case of injury, neurons do not divide and therefore cannot regenerate upon death. Injuries involving cell death in the brain are severe and often long-lasting — think <a href="https://doi.org/10.3389/fneur.2019.00713">concussions</a>, <a href="https://doi.org/10.2174/1570159X16666180302115544">strokes</a> and <a href="https://doi.org/10.1111/j.1750-3639.2004.tb00056.x">head trauma</a>. </p>
<p>It is of vital importance to protect the brain from damage and stresses than can lead to cell death. To uncover mechanisms by which we can protect these crucial cells, we look to nature. Amazingly, many organisms have evolved to live through periods of harsh conditions such as <a href="https://doi.org/10.1016/j.bbagen.2015.02.001">low oxygen</a>, <a href="https://doi.org/10.1007/s11010-021-04072-x">dehydration</a> and <a href="https://doi.org/10.1152/physrev.00016.2016">freezing temperatures</a>: these conditions would be lethal to a human brain, and yet these animals show no damage to their own.</p>
<h2>Switching off</h2>
<p>Generally, for animals to survive these periods of stress, they must induce a state of <a href="https://doi.org/10.1017/s1464793103006195">hypometabolism</a>. Hypometabolism, or hypometabolic states, occurs when organisms shut down certain biological processes which are not immediately necessary for survival. </p>
<p>Some examples of animals which use hypometabolism include <a href="https://doi.org/10.1242/jeb.066225">ground squirrels</a> and <a href="https://doi.org/10.2307/3872551">bears</a>, which hibernate, <a href="https://doi.org/10.3354/cr005053">frogs, which freeze solid</a> over the winter, and snails and certain frogs, which <a href="https://doi.org/10.1086/416717">estivate</a> (enter a state of dormancy) to survive periods of drought.</p>
<p>So, what exactly are the details of hypometabolism, and how does the brain use it to survive? Hypometabolism is a network of various molecular parts and processes that need to work together to achieve a global result: think of an orchestra symphony where the different instruments, notes and sections contribute to a whole. </p>
<p>MicroRNAs are short, single-stranded RNA molecules that target and attach to messenger RNA (the instructions for making a functional protein) to destroy them and prevent the protein from being made. This allows the protein to be switched off without actually changing the gene that codes for the protein to begin with. This allows microRNAs to change the expression of many different genes which could help brains survive.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/459874/original/file-20220426-24-ae77t1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="an image of microDNA on a blue background" src="https://images.theconversation.com/files/459874/original/file-20220426-24-ae77t1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/459874/original/file-20220426-24-ae77t1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=500&fit=crop&dpr=1 600w, https://images.theconversation.com/files/459874/original/file-20220426-24-ae77t1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=500&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/459874/original/file-20220426-24-ae77t1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=500&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/459874/original/file-20220426-24-ae77t1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=628&fit=crop&dpr=1 754w, https://images.theconversation.com/files/459874/original/file-20220426-24-ae77t1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=628&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/459874/original/file-20220426-24-ae77t1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=628&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">MicroRNAs are short, single-stranded RNA molecules that affect messenger RNA to change the expression of genes.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>By looking at the levels and types of microRNA found in the brain tissue of a variety of animals, <a href="https://doi.org/10.1093/jmcb/mjq045">our research</a> has been trying to shed light on how these molecules make changes to gene expression and promote the survival of neurons through extreme conditions.</p>
<h2>Preventing damage</h2>
<p>One of the animals we study is the wood frog, <a href="https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/rana-sylvatica"><em>Rana sylvatica</em></a>, which can survive being completely frozen for extended periods without incurring any brain damage. </p>
<p>When tissues go through freeze-thaw cycles, they have to deal with ischemia: reduced or halted blood flow to a tissue. In humans, this commonly occurs alongside strokes and causes severe damage, often resulting in the death of large groups of cells. To prevent damage during ischemia, cells have to undergo vast metabolic changes.</p>
<p>Our research suggests that <a href="https://doi.org/10.1007/s00018-018-2821-0">microRNAs could be involved in providing neuroprotection from ischemic brain injury</a>.</p>
<p>Another study we conducted found <a href="https://doi.org/10.1016/j.gene.2015.07.027">12 microRNAs</a> that were downregulated (fewer microRNAs in dehydrated brains than in “normal” brains) in response to extreme dehydration in the African clawed frog, <a href="https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/xenopus-laevis"><em>Xenopus laevis</em></a>. The data suggested that microRNA had a specific role in the frog brain’s response to dehydration - a response that could involve cell death and/or an important protein called brain-derived neurotrophic factor. This protein is involved with learning, memory and aging: all of which are affected in human brain injury.</p>
<p>Indeed, further analysis of the downregulated microRNAs showed that they were likely involved in regulating a pathway which may be responsible for memory and learning. These findings show us that microRNA is a key element in the regulation of metabolism in response to environmental stress. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/459815/original/file-20220426-20-2hvvto.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two frogs: on the left African clawed frog and on the right frozen wood frog" src="https://images.theconversation.com/files/459815/original/file-20220426-20-2hvvto.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/459815/original/file-20220426-20-2hvvto.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=263&fit=crop&dpr=1 600w, https://images.theconversation.com/files/459815/original/file-20220426-20-2hvvto.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=263&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/459815/original/file-20220426-20-2hvvto.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=263&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/459815/original/file-20220426-20-2hvvto.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=330&fit=crop&dpr=1 754w, https://images.theconversation.com/files/459815/original/file-20220426-20-2hvvto.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=330&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/459815/original/file-20220426-20-2hvvto.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=330&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The African clawed frog Xenopus laevis (left) and a frozen wood frog Rana sylvatica (right).</span>
<span class="attribution"><span class="source">(Kenneth and Janet Storey)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Additionally, we found that in naked mole rats, <a href="https://doi.org/10.1002/JCP.30216">microRNAs play important roles in coordinating neuroprotective defences which contribute to the tolerance of hypoxia (reduced oxygen)</a>. Eighteen different microRNAs were found to have levels that differed significantly in brain tissues subjected to hypoxia, compared with brain tissues held at normal levels of oxygen. Further analyses revealed that these microRNAs had an active role in suppression of energy-expensive processes such as protein production and cellular proliferation.</p>
<h2>Potential implications</h2>
<p>Our research found that the changes in specific microRNA can be linked to increased activity in neuroprotective pathways. Clearly, these microRNAs are important for maintaining the brain and future research could seek application in human medicine.</p>
<p>If we can understand how animals use microRNA to implement large-scale changes to neural tissues and prevent brain damage, perhaps we could someday learn to apply them in other situations. Understanding how to implement these microRNAs in humans could lead to new therapies. It has the potential to be revolutionary in terms of prevention of brain damage and many other types of tissue damage. </p>
<p>An interesting way that microRNAs are currently being applied in the medical industry is in treatment of genetic diseases and pathogenic conditions (diseases caused by microorganisms). Several microRNA targeted therapeutics have reached preclinical and clinical trials. <a href="https://doi.org/10.1038/NRD.2016.246">These therapeutics are being developed for a wide variety of conditions</a> such as cancers, diabetes, hepatitis and more.</p>
<p>Another interesting avenue that this research could explore would be to unlock hypometabolic states in humans. If we could enter a state of pseudo-hibernation without any damage to the brain — suspended animation, if you will — then we could potentially extend lifespans.</p><img src="https://counter.theconversation.com/content/178970/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kenneth B. Storey receives funding from the Natural Science and Engineering Research Council of Canada (NSERC), grant
number RGPIN-2020-04733.</span></em></p><p class="fine-print"><em><span>Aline Ingelson-Filpula and Mackenzie Parent do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Some animals use microRNA to protect the brain from various stressors. Understanding how they do this and applying it to humans has potential for revolutionary treatments.Aline Ingelson-Filpula, Ph.D. Student in Biochemistry and Molecular Biology, Carleton UniversityKenneth B. Storey, Professor of Biochemistry, Carleton UniversityMackenzie Parent, Master's Student, Molecular Biology, Carleton UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1804992022-04-04T20:43:37Z2022-04-04T20:43:37ZBruce Willis’s aphasia diagnosis draws attention to a common language disorder<figure><img src="https://images.theconversation.com/files/456211/original/file-20220404-13-kc2qvo.jpg?ixlib=rb-1.1.0&rect=230%2C15%2C3052%2C2302&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Aphasia is a language disorder that affects about 30 per cent of stroke patients.</span> <span class="attribution"><span class="source">(Denis Makarenko/Shutterstock.com)</span></span></figcaption></figure><p>Until the recent news that <a href="https://variety.com/2022/film/news/bruce-willis-retiring-acting-apashia-1235219017/">Bruce Willis</a> had been diagnosed with aphasia and was retiring from acting, many people were <a href="https://www.aphasia.org/2020-aphasia-awareness-survey/">unfamiliar with the condition</a>. Despite its low profile, aphasia is not uncommon. </p>
<p>Across <a href="https://www.sac-oac.ca/news-events/news/speech-hearing-month-2021-what-aphasia">Canada</a> and the <a href="https://www.aphasia.org/">United States</a>, it’s estimated that more than two million people are living with aphasia and its associated challenges in communication and in using and understanding language.</p>
<p><a href="https://www.aphasia.ca/">Aphasia</a> affects language abilities, including listening, speaking, reading and writing. Some common language symptoms that occur in individuals living with aphasia are:</p>
<ul>
<li><p>Difficulty coming up with the right word. An individual might use a related word (for example, they may say or write “daughter” when trying to find the word “niece”) or even use a made up word (for example, say or write “pitsy” when trying to find the word “niece”).</p></li>
<li><p>Making mistakes in grammar or syntax such as omitting word endings. Examples include leaving off the plural “s” or “ed” to indicate past tense, or putting words in the wrong order, such as: “The cat was his ran house out.”</p></li>
<li><p>Needing more time to process what is said to them and needing more time to formulate a response.</p></li>
<li><p>Difficulty understanding individual letters, speech sounds or words when listening or reading, even though prior to the onset of aphasia, these letters, sounds and words were automatically understood.</p></li>
</ul>
<p>For individuals with aphasia who use sign language, their ability to use and understand signs is also negatively affected. Some people with aphasia may also experience problems using and understanding nonverbal means of communication, such as gestures and facial expressions.</p>
<h2>Causes of aphasia</h2>
<figure class="align-center ">
<img alt="A silhouette of a head with a maze, and a red line going from through the maze from the braid to the mouth" src="https://images.theconversation.com/files/456217/original/file-20220404-15-yuez6j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/456217/original/file-20220404-15-yuez6j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=376&fit=crop&dpr=1 600w, https://images.theconversation.com/files/456217/original/file-20220404-15-yuez6j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=376&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/456217/original/file-20220404-15-yuez6j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=376&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/456217/original/file-20220404-15-yuez6j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=472&fit=crop&dpr=1 754w, https://images.theconversation.com/files/456217/original/file-20220404-15-yuez6j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=472&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/456217/original/file-20220404-15-yuez6j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=472&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Aphasia affects language abilities including listening, speaking, reading and writing.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Aphasia is not a disease, but rather a consequence of damage to the language-dominant regions of the brain. This brain damage is typically caused by a stroke (<a href="https://www.heartandstroke.ca/stroke/what-is-stroke">interruption of blood flow to or within the brain</a>), or sometimes by a traumatic brain injury, a brain tumour or an infection, such as meningitis. Stroke is the <a href="https://doi.org/10.3109/17549507.2010.520090">most common cause</a>, with aphasia affecting approximately <a href="https://doi.org/10.1016/j.apmr.2016.03.006">30 per cent of stroke patients</a>. </p>
<p>Aphasia is also <a href="https://doi.org/10.1002/ana.410110607">a key component</a> of a progressive neurodegenerative disease called <a href="https://www.aphasia.org/aphasia-resources/primary-progressive-aphasia/">primary progressive aphasia</a>, a type of <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/dementia/frontotemporal-dementia">frontotemporal dementia</a>.</p>
<p>Because the parts of the brain that support language also support other cognitive abilities, individuals living with aphasia may experience some difficulties in <a href="https://doi.org/10.1044/1058-0360(2012/11-0067)">attention, memory and thinking skills</a> like problem solving or planning. People living with aphasia may be challenged in these other cognitive functions because we often use and understand language in concert with these other functions. For example, rehearsing out loud or using your inner mind’s voice to repeat silently the items you have been asked to pick up at the store.</p>
<p>There is great <a href="https://doi.org/10.1093/brain/awab377">variability in the language symptoms</a> experienced by individuals living with aphasia. For example, one individual may experience significant difficulties equally across all language modalities. Another person may experience difficulties primarily in their verbal output and few difficulties with understanding what is said, written or gestured. </p>
<p>Likewise, there is a spectrum of aphasia severity. Some people with aphasia may only be able to understand short, common words. Others may only experience comprehension difficulties when reading books or following complex podcasts that include, for example, technical jargon or complex stories. </p>
<p>Variability also is common among those living with aphasia who are bilingual or multilingual. One individual with aphasia might experience similar difficulties in all of their languages while another might struggle more in one versus another of their languages.</p>
<h2>Living with aphasia</h2>
<figure class="align-right ">
<img alt="A bald man in a black suit with other people behind him" src="https://images.theconversation.com/files/456213/original/file-20220404-21-pldbem.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/456213/original/file-20220404-21-pldbem.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=852&fit=crop&dpr=1 600w, https://images.theconversation.com/files/456213/original/file-20220404-21-pldbem.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=852&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/456213/original/file-20220404-21-pldbem.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=852&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/456213/original/file-20220404-21-pldbem.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1071&fit=crop&dpr=1 754w, https://images.theconversation.com/files/456213/original/file-20220404-21-pldbem.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1071&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/456213/original/file-20220404-21-pldbem.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1071&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Like Bruce Willis, who has retired from acting, many people with aphasia are unable to remain in their vocation of choice.</span>
<span class="attribution"><span class="source">(THE CANADIAN PRESS/Frank Gunn)</span></span>
</figcaption>
</figure>
<p>Regardless of the breadth and severity of the language symptoms, aphasia is challenging for those living with the language disorder, as well as for their family and friends. Having aphasia can make it difficult to complete daily activities like reading prescription medication labels, booking an appointment or using a phone. </p>
<p>Like Willis, many individuals with aphasia will not be able to remain in their vocation of choice. Aphasia also can lead to negative consequences for social roles, relationships and activities. Consider how many components of parenting involve language (listening to your child’s day at school, reading with your child, reprimanding) and how essential communication is to maintaining close relationships with family and friends. </p>
<p>Most leisure activities similarly involve language, whether it is reading for pleasure, watching movies or travelling. Because of these daily struggles, many individuals with aphasia also experience <a href="https://doi.org/10.1186/s13063-016-1257-9">mental health issues such as depression</a>.</p>
<h2>Assessment and services for people with aphasia</h2>
<p>However, there is help and hope for those with aphasia. Decades of aphasia research indicate <a href="https://doi.org/10.1002/14651858.CD000425.pub4">there are many interventions</a> to improve individuals’ language abilities and help them compensate for their language impairments. An important first step for getting help is <a href="https://doi.org/10.1161/STR.0b013e3181e7512b">seeking an assessment from a speech-language pathologist</a>. </p>
<p>Given the various manifestations of aphasia, a comprehensive assessment is needed to determine its presence and an individual’s language and communication strengths and weaknesses. The assessment also will help the <a href="https://www.sac-oac.ca/">speech-language pathologist</a> identify <a href="https://www.heartandstroke.ca/services-and-resources/aphasia-services">interventions that can help individuals living with aphasia</a> and their family and friends achieve their language and communication goals.</p>
<p>In addition to assessment and intervention services, family and friends can <a href="https://www.sac-oac.ca/sac-resource-page-stroke-awareness">find other ways</a> to <a href="https://www.aphasia.ca/">support someone living with aphasia</a>. </p>
<p>By sharing his diagnosis of aphasia, Willis and his family are helping <a href="https://doi.org/10.1080/02687038.2019.1702847">increase awareness</a> of this complex and often debilitating language disorder. Increasing awareness among the public and health-care professionals is an important step in ensuring that individuals living with aphasia <a href="https://doi.org/10.1080/09638288.2020.1722264">can participate in their community and receive appropriate health-care services</a>.</p><img src="https://counter.theconversation.com/content/180499/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Across Canada and the United States, more than two million people are living with aphasia and its language and communication challenges.Laura Murray, Associate Dean of Graduate and Postdoctoral Studies, Faculty of Health Sciences, Western UniversityJ.B. Orange, Professor and Acting Director, School of Communication Sciences and Disorders; Scientific Director, Canadian Centre for Activity and Aging, Western UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1681682021-12-14T13:26:48Z2021-12-14T13:26:48ZBlocking an immune system molecule in mice may help prevent long-term disabilities after traumatic brain injury<figure><img src="https://images.theconversation.com/files/436207/original/file-20211207-141213-17pbntd.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2090%2C1432&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An estimated 69 million people worldwide experience a traumatic brain injury every year.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/mri-brain-with-headache-royalty-free-image/938046810">Iaremenko/iStock via Getty Images Plus</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>Blocking an immune system molecule that accumulates after traumatic brain injury could significantly reduce the injury’s detrimental effects, according to a recent mouse study <a href="https://gladstone.org/people/jeanne-paz">my neuroscience lab and I</a> published <a href="https://doi.org/10.1126/science.abj2685">in the journal Science</a>.</p>
<p>The <a href="https://courses.lumenlearning.com/teachereducationx92x1/chapter/cerebral-cortex/">cerebral cortex</a>, the part of the brain involved in thinking, memory and language, is often the primary site of head injury because it sits directly beneath the skull. However, we found that another region near the center of the brain that regulates sleep and attention, the <a href="https://doi.org/10.1016/j.neuron.2019.06.005">thalamus</a>, was even more damaged than the cortex months after the injury.</p>
<p>This may be due to increased levels of a molecule called C1q, which triggers a part of the immune system called the <a href="https://doi.org/10.1186/s12974-020-02024-8">classical complement pathway</a>. This pathway plays a key role in rapidly clearing pathogens and dead cells from the body and helps control the inflammatory immune response.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/BSypUV6QUNw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A branch of the immune system called the complement system is composed of trillions of proteins that enhance immune response.</span></figcaption>
</figure>
<p>C1q plays both <a href="https://doi.org/10.1186/s12974-020-02024-8">helpful and harmful roles in the brain</a>. On the one hand, accumulation of C1q in the brain can trigger abnormal elimination of synapses – the structures that allow neurons to communicate with one another – and <a href="https://doi.org/10.1126/science.aad8373">contribute to neurodegenerative disease</a>. On the other hand, C1q is also involved in <a href="https://doi.org/10.1016/j.cell.2007.10.036">normal brain development</a> and <a href="https://doi.org/10.1186/s12974-018-1066-z">protects the central nervous system from infection</a>. </p>
<p>In the case of traumatic brain injury, we found that C1q lingered in the thalamus at abnormally high levels for months after the initial injury and was associated with inflammation, dysfunctional brain circuits and neuronal death. This suggests that higher levels of C1q in the thalamus could contribute to several long-term effects of traumatic brain injury, such as sleep disruption and epilepsy.</p>
<p>C1q does provide some protection for the brain during traumatic injury, however. When we used genetically engineered mice that lack C1q at the time of trauma, the brain injury appeared much worse. This suggests that C1q is likely very important right when the injury happens in preventing cell death.</p>
<p>We collaborated with scientists at the biopharmaceutical company Annexon Biosciences to see if we could avoid C1q’s detrimental effects without losing its protective ones. We found that treating mice with an antibody that blocks C1q 24 hours after brain injury prevented detrimental effects like chronic inflammation and neuronal loss in the thalamus. Additionally, antibody treatment helped restore disrupted <a href="https://doi.org/10.1016/j.cub.2018.03.046">sleep spindles</a> – these are normal brain rhythms during the early stages of sleep that are important for memory consolidation. It also prevented the development of <a href="https://www.ncbi.nlm.nih.gov/books/NBK98139/">epileptic spikes</a>, or abnormal fluctuations in brain activity, which can disrupt <a href="https://doi.org/10.1016/0013-4694(88)90004-1">cognition and behavior</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/436214/original/file-20211207-19-julmtx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustration of IgM bound to antigens on the surface of a membrane and activating the C1 complex of the complement system." src="https://images.theconversation.com/files/436214/original/file-20211207-19-julmtx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/436214/original/file-20211207-19-julmtx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/436214/original/file-20211207-19-julmtx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/436214/original/file-20211207-19-julmtx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/436214/original/file-20211207-19-julmtx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/436214/original/file-20211207-19-julmtx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/436214/original/file-20211207-19-julmtx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">C1q is part of a larger structure called C1, colored here in violet. When activated, this C1 structure plays a role in attracting and activating immune cells to attack invaders and clear foreign and damaged debris.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/igm-mediated-complex-activation-molecular-model-royalty-free-image/1316978215">Juan Gaertner/Science Photo Library via Getty Images</a></span>
</figcaption>
</figure>
<h2>Why it matters</h2>
<p>Traumatic brain injury can happen to anyone. It affects <a href="https://doi.org/10.3171/2017.10.jns17352">69 million people worldwide per year</a> and is a <a href="https://www.who.int/mental_health/neurology/neurological_disorders_report_web.pdf">leading cause of disability</a> in children and adults. Yet there are currently no therapies available to prevent the long-term disabilities that can result from brain trauma, such as epilepsy, sleep disruption and sensory processing difficulty.</p>
<p>We believe that targeting C1q after a brain injury could have protective benefits and help prevent some of the devastating consequences. Our study also answered some big questions in the field about where and how changes happen in the brain after trauma, and which ones actually cause deficits.</p>
<h2>What still isn’t known</h2>
<p>It remains unknown whether blocking C1q could also prevent epileptic seizures that develop after severe traumatic brain injury. Researchers <a href="https://doi.org/10.1038/s41582-021-00461-4">are looking for biomarkers</a> that would help identify people at high risk of developing epilepsy and working to understand the basic mechanisms leading from <a href="https://doi.org/10.1007/s13311-021-01119-1">traumatic brain injury to epilepsy</a>. There is no cure yet for post-traumatic epilepsy.</p>
<h2>What’s next</h2>
<p>My lab will continue working to expand our understanding of what happens in the brain after injury. Next, we want to focus on whether we can target C1q to prevent the convulsive seizures often reported among people with severe traumatic brain injuries.</p>
<p>C1q inhibitors are currently being tested in clinical trials for an autoimmune disorder known as <a href="https://n.neurology.org/content/94/15_Supplement/763">Guillain-Barré syndrome</a>. This could help accelerate treatment development for patients with traumatic brain injury.</p><img src="https://counter.theconversation.com/content/168168/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeanne Paz receives funding from the Department of Defense and the NIH. This research was conducted collaboratively with Annexon Biosciences.</span></em></p>The molecule C1q has both protective and detrimental effects after traumatic brain injury. Blocking it after injury in mice restored normal brain rhythms during sleep and prevented epileptic spikes.Jeanne Paz, Associate Investigator at Gladstone Institutes and Associate Professor of Neurology, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1694182021-10-07T10:37:35Z2021-10-07T10:37:35ZClues to consciousness: how dopamine fits into the mystery of what makes us conscious – podcast<figure><img src="https://images.theconversation.com/files/425210/original/file-20211007-27-1ems2y0.jpg?ixlib=rb-1.1.0&rect=33%2C49%2C3609%2C2009&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Scientists are still puzzling over the mystery of what makes us conscious.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/human-face-on-dark-background-gold-1690467910">Lidiia/Shutterstock</a></span></figcaption></figure><p>What’s happening in our brains to create consciousness? In this episode of <a href="https://theconversation.com/uk/topics/the-conversation-weekly-98901">The Conversation Weekly</a> podcast, we hear from two scientists uncovering clues to this mystery that could help people with severe brain injuries to recover. And the story of how artificial intelligence – and its human helpers – completed Beethoven’s unfinished 10th symphony. </p>
<iframe src="https://embed.acast.com/60087127b9687759d637bade/615eb6f8cdd5280012b115c3" frameborder="0" width="100%" height="190px"></iframe>
<p><iframe id="tc-infographic-561" class="tc-infographic" height="100" src="https://cdn.theconversation.com/infographics/561/4fbbd099d631750693d02bac632430b71b37cd5f/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Philosophers have pondered the meaning of consciousness for generations. But for a long time, scientists didn’t pay the question much attention. And as recently as the 1980s, the science of consciousness <a href="https://www.nature.com/articles/d41586-019-02207-1#ref-CR9">remained a controversial topic</a>. </p>
<p>That all <a href="https://www.theguardian.com/science/2015/jan/21/-sp-why-cant-worlds-greatest-minds-solve-mystery-consciousness">began to change in the 1990s</a>, and since then neuroscientists and doctors around the world have discovered tantalising clues about what’s going on in our brains to make us conscious – or unconscious. </p>
<p>Emmanual Stamatakis, who leads the cognition and consciousness imaging group at the Division of Anaesthesia, University of Cambridge in the UK, explains how consciousness seems to work along a continuum. At one end are people in a coma, followed by those under anaesthesia and then an alert person with regular levels of consciousness. “In the last ten years or so, we started extending in a different direction,” he says, by exploring how stimulants such as LSD will “I hesitate saying this: increase your consciousness”. </p>
<p>Stamatakis and his colleagues are currently looking at how brain networks are connected to consciousness. He explains the results of their <a href="https://www.pnas.org/content/pnas/118/30/e2026289118.full.pdf">recent study</a> which found the chemical dopamine may play a crucial role. </p>
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<strong>
Read more:
<a href="https://theconversation.com/consciousness-how-the-brain-chemical-dopamine-plays-a-key-role-new-research-165498">Consciousness: how the brain chemical 'dopamine' plays a key role – new research</a>
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</em>
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<p>Other researchers are already testing drugs that boost dopamine levels in patients with severe brain injuries. Leandro Sanz, a medical doctor and PhD candidate in medical sciences at the University of Liège in Belgium, talks to us about a randomised controlled trial he’s working on that is testing if molecules that mimic dopamine – called dopamine agonists – could help these patients recover better. “It’s a very active field because if we find the treatment that even has slight improvements in all the patients, that would be a huge step forward,” says Sanz.</p>
<p>In our second story (30m30), we shift from the power and mystery of the human brain to the power of artificial intelligence to mimic it. On October 10 in Bonn, the Beethoven Orchestra will <a href="https://www.telekom.com/en/media/media-information/archive/world-premiere-the-completion-of-beethovens-tenth-symphony-637336">give the world premiere</a> of Ludwig van Beethoven’s Unfinished 10th symphony. The project came out of a collaboration between computer scientists and musicologists. Ahmed Elgammal, a professor of computer science and director of the Art and AI lab at Rutgers University in New Jersey, who led the artificial intelligence side of the project, tells us how they did it. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-a-team-of-musicologists-and-computer-scientists-completed-beethovens-unfinished-10th-symphony-168160">How a team of musicologists and computer scientists completed Beethoven's unfinished 10th Symphony</a>
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</em>
</p>
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<p>Plus, Holly Squire, arts and culture editor at The Conversation in the UK, gives us some of her recommended reads from the past week (44m45). </p>
<p>This episode of The Conversation Weekly was produced by Mend Mariwany and Gemma Ware, with sound design by Eloise Stevens. Our theme music is by Neeta Sarl. You can find us on Twitter <a href="https://twitter.com/TC_Audio">@TC_Audio</a>, on Instagram at <a href="https://www.instagram.com/theconversationdotcom/?hl=en">theconversationdotcom</a> or via email on podcast@theconversation.com. You can also sign up to <a href="https://theconversation.com/newsletter?utm_campaign=PodcastTCWeekly&utm_content=newsletter&utm_source=podcast">The Conversation’s free daily email here</a>.</p>
<p>Musical extracts from the Beethoven 10th symphony project in this episode from <a href="https://www.youtube.com/watch?v=kS6h1TKuOrw">Deutsche Telekom</a> and Beethoven’s 9th symphony via <a href="https://www.youtube.com/watch?v=EnUQJZ5ZpNw">YouTube’s Audio Library</a>. </p>
<p><em>You can listen to The Conversation Weekly via any of the apps listed above, download it directly via our <a href="https://feeds.acast.com/public/shows/60087127b9687759d637bade">RSS feed</a>, or find out how else to <a href="https://theconversation.com/how-to-listen-to-the-conversations-podcasts-154131">listen here</a>.</em></p><img src="https://counter.theconversation.com/content/169418/count.gif" alt="The Conversation" width="1" height="1" />
Plus, how a team of musicologists and computer scientists completed Beethoven’s unfinished 10th Symphony using AI. Listen to The Conversation Weekly podcast.Gemma Ware, Head of AudioDaniel Merino, Associate Breaking News Editor and Co-Host of The Conversation Weekly PodcastLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1617732021-06-03T18:31:15Z2021-06-03T18:31:15ZRugby, concussions and duty of care: why the game is facing scrutiny<figure><img src="https://images.theconversation.com/files/403396/original/file-20210528-14-1lfgwh3.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C500&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The long-term health effects in professional contact sports have come under global scrutiny since the 2015 $1 billion lawsuit filed by former professional American football players against the NFL</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/two-male-rugby-players-fight-ball-1151091581">Shutterstock</a></span></figcaption></figure><p>There’s growing concern about concussion-related injuries in contact sports like rugby and American football. </p>
<p>Several high-profile collisions between participants and a <a href="https://theconversation.com/concussion-can-accelerate-ageing-of-the-brain-research-from-the-rugby-pitch-146495">growing body of research</a> about their impact have drawn attention to the adequacy of the safety protocols in place to protect players.</p>
<p>Since 2020, the <a href="https://www.bbc.co.uk/sport/rugby-union/55345195">debate has taken a legal direction</a>, with an increasing number of former rugby union players joining a potential negligence action against the Rugby Football Union (RFU), the Wales Rugby Union (WRU) and World Rugby. The ex-players claim they’ve been left with permanent brain damage because of repeated head collisions and concussion.</p>
<p>The impact of this litigation could be significant for sport. It raises some important questions about why there are concerns about concussion, how a sports body can be found responsible for negligence and the overall impact on the sport itself. </p>
<h2>Why is concussion such an issue?</h2>
<p>Brain injuries and the long-term health effects in professional sport came under intense scrutiny in 2013 during the <a href="https://www.nytimes.com/2013/08/30/sports/football/judge-announces-settlement-in-nfl-concussion-suit.html">$1 billion (£705.7m) lawsuit</a> filed by former professional American football players against the National Football League (NFL) in the United States. </p>
<figure class="align-center ">
<img alt="Rugby players in a scrum with stadium in the background" src="https://images.theconversation.com/files/404227/original/file-20210603-13-9rhi5w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/404227/original/file-20210603-13-9rhi5w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=314&fit=crop&dpr=1 600w, https://images.theconversation.com/files/404227/original/file-20210603-13-9rhi5w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=314&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/404227/original/file-20210603-13-9rhi5w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=314&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/404227/original/file-20210603-13-9rhi5w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=395&fit=crop&dpr=1 754w, https://images.theconversation.com/files/404227/original/file-20210603-13-9rhi5w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=395&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/404227/original/file-20210603-13-9rhi5w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=395&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">21% of elite male rugby players in England suffered at least one concussion during the 2018-19 season.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/composition-rugby-players-scrum-purple-background-1978925963">Shutterstock</a></span>
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<p>Allegations included concealing data that showed an increased risk of brain diseases among professional American football players. One of those risks include chronic traumatic encephalopathy (CTE), a degenerative brain disease which is diagnosed upon death and can be caused by repeated blows to the brain. Symptoms associated with CTE can include depression, short-term memory loss, confusion and dementia.</p>
<p>Focus on concussion in other contact sports like rugby became amplified following the NFL litigation, particularly due to the similarities between the styles of the two sports. The case had a substantial impact on rugby at all levels, including the introduction of restrictions on scrums and tackles in school rugby. </p>
<p>Concussion might be an inevitable part of the game of rugby but can lead to serious irreversible health conditions like CTE which for many years haven’t been the focus of attention. Second impact syndrome (where the brain suffers two successive blows in quick succession) is another related condition that <a href="https://pubmed.ncbi.nlm.nih.gov/33303526/">can be fatal</a>. </p>
<p>In order to mitigate the risk of injury, the RFU’s current rules state that players must not do anything <a href="https://www.englandrugby.com//dxdam/13/1346edc1-1bbd-410e-8b36-4f3dacc74850/Regulation%209.pdf">reckless or dangerous to others on the pitch</a>. Still, there are concerns around whether these rules provide sufficient protection.</p>
<h2>Proving negligence</h2>
<p>The <a href="https://www.theguardian.com/sport/2020/dec/13/rugby-union-players-claim-for-brain-injury-dementia-world-rugby">rugby players</a> involved in the lawsuit claim that the governing bodies breached their duty of care by failing to ensure their individual safety and protect them from permanent brain injury. </p>
<p>Negligence is a civil law mechanism that protects claimants and places liability on those who commit a civil wrong through the identification of a duty of care between two parties, a breach of that duty, a causal link to the harm, and foreseeability of damage. The application of the traditional rules of negligence to sport has been continuously debated in the courts but they have confirmed in various cases that a duty of care is owed by participants, referees, occupiers of sports premises, governing bodies, coaches, and medical professionals.</p>
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<img alt="Back of man facing stadium lights and holding rugby ball over his head" src="https://images.theconversation.com/files/404230/original/file-20210603-21-hukyni.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/404230/original/file-20210603-21-hukyni.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/404230/original/file-20210603-21-hukyni.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/404230/original/file-20210603-21-hukyni.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/404230/original/file-20210603-21-hukyni.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/404230/original/file-20210603-21-hukyni.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/404230/original/file-20210603-21-hukyni.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Government intervention in sport is limited and the law tends to be mindful of the special qualities of sporting activity.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/3d-athlete-throwing-rugby-ball-against-532295398">Shutterstock</a></span>
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<p>However, the courts have also recognised the intricacy of applying negligence to sport, emphasising that in identifying the standard of care owed, there must be consideration of the specific and unique nature of sporting activity. There are inherent risks associated with sport that result in injury and these are generally accepted as being a key part of the essence of contact sport. That’s why there’s such a struggle of balance between attempting to differentiate between inevitable injury resulting from the sport and unlawful harm resulting from a failure to protect players.</p>
<p>Rugby players are likely to face several legal challenges, notably around the successful application of the negligence criteria. The courts have varied views on extending the scope of negligence to the liability of a governing body to its participant.</p>
<p>One of the main challenges for this group of former rugby players will be proving the protocols on head injuries during their career under the auspices that governing bodies were inadequate, based on knowledge at the time, in safely managing brain injuries. If proven, the next challenge would be to show this inadequate management is what has caused their permanent brain damage. </p>
<h2>The wider impact on rugby</h2>
<p>The relationship between sport and the law and the legal accountability of sports bodies is complicated. In the UK, government intervention in sport is limited and the law tends to be mindful of the special qualities of sporting activity, instead deferring to the autonomous and self-regulatory authority of the governing body. This regulatory struggle often leaves athletes in a <a href="https://link.springer.com/article/10.1007/s40318-021-00182-2">vulnerable position when seeking protection of their rights</a>.</p>
<p>Nevertheless, the Rugby Players’ Association (RPA) insists that player welfare is a <a href="https://www.skysports.com/rugby-union/news/12321/12221048/progressive-rugby-outlines-player-head-injury-concerns-to-world-rugby-in-bid-to-reform-the-game">key priority</a> and is <a href="https://www.birmingham.ac.uk/news/latest/2021/03/rugby-concussion-saliva-test-research.aspx">supporting scientific research</a> into diagnosing concussion. Players need a representative body with complete independence whereby they can assert their rights freely and get support with understanding law, sport and wider issues.</p>
<p>Overall, while there’s an established duty of care between rugby’s governing authorities and its participants, <a href="https://www.theguardian.com/sport/2020/dec/13/rugby-union-players-claim-for-brain-injury-dementia-world-rugby">it won’t be easy</a> for the players to prove that sports bodies’ negligence caused their unfortunate injuries. </p>
<p>The players have indicated this isn’t about changing the game or preventing people from playing but rather ensuring the game is as safe as possible while maintaining its unique characteristics. Beyond that, this is also about athletes’ rights. It’s been suggested that a settlement may even be the best option to place athlete welfare at the top of the agenda, assisting with medical bills <a href="https://www.theguardian.com/sport/2020/dec/13/rugby-union-players-claim-for-brain-injury-dementia-world-rugby">rather than suffering costs in court</a>. Whatever the outcome, the impact on sport and the future welfare of players, will be significant.</p>
<hr>
<p><em>Elliott Hagan, LPC student at BPP University in Manchester and former paralegal at British Cycling, contributed to this article. Elliott graduated from Nottingham Trent University with a degree in law with criminology and a masters degree in sports law</em></p><img src="https://counter.theconversation.com/content/161773/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Seema Patel does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Brain injuries and the long-term health effects in professional sport have become significant issues in the past decade.Seema Patel, Senior lecturer, Nottingham Trent UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1300612020-05-26T19:43:26Z2020-05-26T19:43:26ZConcussion affects 1 in 10 youth athletes every year. Here’s what needs to change.<figure><img src="https://images.theconversation.com/files/336927/original/file-20200522-57725-azc8dm.jpg?ixlib=rb-1.1.0&rect=10%2C339%2C3641%2C2124&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rule changes, training strategies and equipment recommendations can help protect youth athletes from concussion.</span> <span class="attribution"><span class="source">(Unsplash)</span></span></figcaption></figure><p>While sports facilities and leagues are still gauging how and when to reopen in the wake of the coronavirus, now is the best time to think about concussion prevention: before young people get back on the playing field. </p>
<p>The benefits of <a href="https://www150.statcan.gc.ca/n1/pub/82-625-x/2019001/article/00003-eng.htm">sport and physical activity are significant</a>, and yet, every day young people put themselves at risk of concussion through participation in sports. The highest concussion incidence rates among youth in Canada are seen in <a href="http://dx.doi.org/10.1136/bjsports-2015-094978">rugby, ice hockey and football</a>.</p>
<p>We expect <a href="https://doi.org/10.1097/01.jsm.0000184638.72075.b7">one in 10 Canadians ages 13 to 18 to seek medical attention</a> every year for a sport-related concussion. Forty per cent of these <a href="https://doi.org/10.1097/jsm.0000000000000673">youth have experienced a previous concussion, and 20 per cent will have a variety of persistent symptoms for longer than one month</a>. </p>
<p>These symptoms may include <a href="http://dx.doi.org/10.1136/bjsports-2017-097699">headache, dizziness, sleep disturbance, cognitive difficulties or depression</a>. Long-term consequences of concussion in youth may also include reduced levels of physical activity, overweight or obesity, psychosocial consequences and significant health-care costs. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/333921/original/file-20200511-49556-1jhho18.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/333921/original/file-20200511-49556-1jhho18.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/333921/original/file-20200511-49556-1jhho18.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/333921/original/file-20200511-49556-1jhho18.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/333921/original/file-20200511-49556-1jhho18.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/333921/original/file-20200511-49556-1jhho18.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/333921/original/file-20200511-49556-1jhho18.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Rugby, hockey and football have the highest concussion incidence in Canadian youth.</span>
<span class="attribution"><span class="source">(Unsplash/BJ Pearce)</span></span>
</figcaption>
</figure>
<p>As chair of the <a href="https://ucalgary.ca/siprc/">Sport Injury Prevention Research Centre (faculty of kinesiology, University of Calgary)</a>, I lead a research program that aims to reduce the burden of youth concussion in Canada. The best way to do that, and to keep kids active in the sports they love, is by moving towards prevention. Providing a safe environment for youth to participate in sport is critical to ensure lifelong participation in sport and recreation. As such, a key public health priority should be concussion prevention in youth sport to promote an active lifestyle in all Canadian youth.</p>
<h2>How can we prevent concussion in youth sport?</h2>
<p><a href="http://dx.doi.org/10.1136/bjsports-2016-097452">Research has shown</a> that rule changes, training strategies, equipment recommendations and legislation of evidence-informed management protocols can all help to prevent concussion and the recurrence of concussion in youth sport.</p>
<p><a href="https://doi.org/10.1001/jamapediatrics.2018.5498">Rule changes may be the low-hanging fruit</a> in reducing the risk of concussion in youth sport. In 2010, we demonstrated a <a href="http://doi.org/10.1001/jama.2010.755">four-fold greater risk of concussion</a> in 11- and 12-year-old ice hockey players when body checking was allowed in games at all levels of play, compared to Québec where body checking was not allowed. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/336923/original/file-20200522-57670-1l0ru0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/336923/original/file-20200522-57670-1l0ru0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/336923/original/file-20200522-57670-1l0ru0o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/336923/original/file-20200522-57670-1l0ru0o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/336923/original/file-20200522-57670-1l0ru0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=491&fit=crop&dpr=1 754w, https://images.theconversation.com/files/336923/original/file-20200522-57670-1l0ru0o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=491&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/336923/original/file-20200522-57670-1l0ru0o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=491&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Every year, one in 10 youth athletes seeks medical attention for concussion.</span>
<span class="attribution"><span class="source">(Unsplash)</span></span>
</figcaption>
</figure>
<p>This study, among others, informed a 2013 Hockey Canada national policy change delaying body checking until age 13. This led to a <a href="http://dx.doi.org/10.1136/bjsports-2016-097392">64 per cent reduction in concussion rates, preventing over 4,800 concussions nationally each year</a> in young players, and keeping more players in the game.</p>
<p>This research further informed local and provincial policy change in non-elite levels of play (70 per cent of players by division of play) in older age groups (ages 13-17). <a href="http://dx.doi.org/10.1136/bjsports-2019-101092">Evidence in 13- and 14-year-old non-elite ice hockey leagues supports a policy disallowing body checking in games</a>, with a 54 per cent reduction in all injuries and estimated prevention of 4,000 injuries in 13- and 14-year-old players annually in Canada.</p>
<p>If body checking continues to be disallowed in games in 11- and 12-year-old leagues and non-elite levels in 13- to 17-year-old leagues, the public health impact would be the prevention of 10,000 concussions annually. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/333692/original/file-20200508-49565-ltbc6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/333692/original/file-20200508-49565-ltbc6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=744&fit=crop&dpr=1 600w, https://images.theconversation.com/files/333692/original/file-20200508-49565-ltbc6a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=744&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/333692/original/file-20200508-49565-ltbc6a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=744&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/333692/original/file-20200508-49565-ltbc6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=934&fit=crop&dpr=1 754w, https://images.theconversation.com/files/333692/original/file-20200508-49565-ltbc6a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=934&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/333692/original/file-20200508-49565-ltbc6a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=934&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">One of Canada’s largest hockey associations will ban bodychecking for peewee players.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Andrew Vaughan</span></span>
</figcaption>
</figure>
<p>Prevention should be our priority, but not everyone involved in the game sees it this way. Some parents believe that delaying body checking to age 13 may reduce concussion risk but that this policy will also reduce their child’s opportunities to play at elite and professional levels. </p>
<p><a href="https://cdn.agilitycms.com/hockey-canada/Corporate/About/Downloads/2018-19-hockey-canada-annual-report-e.pdf">In Canada, 70,000 11- and 12-year-old ice hockey players are registered annually</a>. Possibly 70 of these kids may have an opportunity to compete in the National Hockey League (<a href="https://bleacherreport.com/articles/1533035-nhl-hockey-how-much-are-a-childs-hockey-dreams-worth">one in 1,000</a>) and perhaps 7,000 may continue to play in an adult recreational league. </p>
<p>One might argue that the other 62,930 young players should be our public health priority. Our goal should be to keep these kids in the game for lifelong participation in sport and recreation. </p>
<p>Another rule change targeting concussion prevention in youth sport includes <a href="https://doi.org/10.1177%2F0363546519860120">limiting full-contact play during football practice</a>. </p>
<p>Other evidence-informed prevention strategies include sport-specific <a href="http://dx.doi.org/10.1136/bjsports-2015-094639">neuromuscular training (NMT) warm-up programs</a> (including aerobic, balance, strength, agility) that have been shown to reduce the risk of all injury, including concussion, by more than 35 per cent across multiple team sports including <a href="https://www.ncbi.nlm.nih.gov/pubmed/20547668">soccer</a>, <a href="http://dx.doi.org/10.1136/bjsports-2016-097434">rugby</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/29864071">basketball</a> and in <a href="http://dx.doi.org/10.1136/bjsports-2019-101117">physical education</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/333700/original/file-20200508-49573-ez8s8o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/333700/original/file-20200508-49573-ez8s8o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/333700/original/file-20200508-49573-ez8s8o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/333700/original/file-20200508-49573-ez8s8o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/333700/original/file-20200508-49573-ez8s8o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/333700/original/file-20200508-49573-ez8s8o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/333700/original/file-20200508-49573-ez8s8o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Limiting full-contact play during practices may help prevent concussion in youth football.</span>
<span class="attribution"><span class="source">(Unsplash/Ben Hershey)</span></span>
</figcaption>
</figure>
<p>We should not underestimate the potential of preventive equipment including <a href="https://bjsm.bmj.com/content/early/2020/01/14/bjsports-2019-101011">mouth guards</a> with recent evidence demonstrating that wearing a mouth guard (off the shelf or custom fit) reduced odds of concussion in youth ice hockey players by more than 60 per cent. <a href="https://doi.org/10.1177/1941738116639027">Helmet fit</a> criteria have also been developed and evaluated in youth ice hockey and tackle football, suggesting the potential for a protective effect and reduced concussion severity with optimal helmet fit.</p>
<h2>Can concussions lead to catastrophic outcomes?</h2>
<p>Catastrophic outcomes following concussion in youth sport are rare, however we should work to ensure that not one more child dies following concussion. Rowan Stringer was a 17-year-old high school rugby player who suffered multiple concussions in one week in 2013 and died as a result of her injuries. Stringer’s lasting legacy is <a href="https://www.ola.org/en/legislative-business/bills/parliament-41/session-2/bill-193">Rowan’s Law</a> that was subsequently introduced into Ontario legislation following her death.</p>
<p>Rowan’s Law is a wake-up call to sport associations, sport facilities and schools to implement concussion protocols mandating the removal from play of any youth athlete with a suspected concussion. Rowan’s Law also makes concussion education mandatory for certain individuals involved with youth sport. Additionally, it informs appropriate protocols for concussion follow-up including assessment by a physician and adherence to evidence-informed return-to-sport and return-to-school guidelines. </p>
<p>The <a href="https://parachute.ca/wp-content/uploads/2019/06/Canadian-Guideline-on-Concussion-in-Sport.pdf">Canadian Guidelines on Concussion in Sport</a> were informed by the <a href="http://dx.doi.org/10.1136/bjsports-2017-097699">International Consensus on Concussion in Sport</a>, available online at <a href="https://parachute.ca/en/injury-topic/concussion/">Parachute</a> along with other evidence-informed concussion resources.</p>
<h2>Canadian researchers raising the bar</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/333919/original/file-20200511-49542-7pd2ho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/333919/original/file-20200511-49542-7pd2ho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/333919/original/file-20200511-49542-7pd2ho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/333919/original/file-20200511-49542-7pd2ho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/333919/original/file-20200511-49542-7pd2ho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/333919/original/file-20200511-49542-7pd2ho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/333919/original/file-20200511-49542-7pd2ho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sports with high concussion risk include hockey, football, rugby, lacrosse, wrestling, ringette, soccer, basketball, volleyball and cheerleading.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>Through a research program funded by the NFL’s Scientific Advisory Board, our team at the Sport Injury Prevention Research Centre is leading a pan-Canadian multidisciplinary research group focused on the prevention, detection, diagnosis, prognosis and management of sport-related concussion in youth. <a href="https://www.ucalgary.ca/news/nfl-gives-significant-funding-help-youth-shred-burden-concussion">SHRed Concussions</a> (Surveillance in High School to Reduce Concussions and their Consequences in Youth Sport) is the first study of its kind in Canada. It aims to recruit 6,000 high school athletes (ages 13-18) in 60 schools (in British Columbia, Alberta, Manitoba, Ontario and Québec), with followup over three years. </p>
<p>The goal of SHRed Concussions is to raise the bar in youth sport-related concussion research and to inform a significant public health impact in the reduction of sport-related concussions and their consequences in youth across multiple sports including tackle football, rugby, ice hockey, lacrosse, wrestling, ringette, soccer, basketball, volleyball and cheerleading.</p>
<h2>Why are we so afraid of change?</h2>
<p>Canada’s youth are our biggest and most important natural resource. <a href="https://www.cbc.ca/news/canada/ottawa/rowan-stringer-hit-stop-sit-ontario-concussion-ad-1.5169263">Rowan Stringer</a> reminds us every day that there is a lot to do to keep sports safe and prevent sport-related concussions in youth. We must ensure legislation is in place for concussion prevention and management protocols to minimize the risk of catastrophic outcomes and reduce the burden of concussions in youth sport. </p>
<p>The benefits of changing the rules of the game, safety equipment legislation and evidence-informed training strategies have been significant in reducing the burden of concussion in youth sport. <a href="https://www.ucalgary.ca/news/nfl-gives-significant-funding-help-youth-shred-burden-concussion">Evaluation of concussion prevention strategies is ongoing across multiple youth sports</a>. Our priority must be to keep all youth participating in sports and also physically active for life.</p><img src="https://counter.theconversation.com/content/130061/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carolyn Emery receives funding from Canadian Institutes of Health Research, Canadian Foundation for Innovation, Canada Research Chairs Government of Canada, National Basketball Association/General Electric, National Football League Scientific Advisory Board, Alberta Innovates, Alberta Children's Hospital Foundation, Hotchkiss Brain Institute, O'Brien Institute of Public Health and the University of Calgary.</span></em></p>Every year, about 10 per cent of youth athletes experience a concussion. Research shows there are steps we can take to help prevent these injuries, but we can’t be afraid to make changes.Carolyn Emery, Professor, Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1332092020-03-16T14:38:57Z2020-03-16T14:38:57ZSevere brain injuries: technology can tell what patients are thinking – here’s what to consider before using it<figure><img src="https://images.theconversation.com/files/320789/original/file-20200316-27648-1ge9oro.jpg?ixlib=rb-1.1.0&rect=15%2C0%2C5097%2C2874&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">fNIRS can be done at a patient's bedside. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/computer-screen-showing-mri-ct-image-1197120001">Gorodenkoff/ Shutterstock</a></span></figcaption></figure><p>When a person sustains a severe brain injury that leaves them unable to communicate, decisions about their treatment must be made for them. In some cases, these decisions can mean the difference between life and death. But <a href="https://www.frontiersin.org/articles/10.3389/fnins.2020.00105/full">new research</a> may have found a new way of communicating with patients who might otherwise have been unable to. </p>
<p>Researchers asked volunteers with normal brain function to imagine playing a game of tennis, which activates a specific area of the brain used for <a href="https://www.sciencedirect.com/topics/neuroscience/supplementary-motor-area">planning complex movements</a>. Researchers were able to see the brain activity using <a href="https://www.ncbi.nlm.nih.gov/pubmed/17366276">functional near-infrared spectroscopy</a> (fNIRS), which is a headset that, when placed on a patient’s head, uses beams of light to detect which <a href="https://www.ncbi.nlm.nih.gov/pubmed/17366276">areas of the brain are active</a>. </p>
<p>Volunteers were then told to imagine playing tennis to answer “yes” or to stay relaxed to answer “no”. If researchers saw activity in the brain’s <a href="https://www.sciencedirect.com/topics/neuroscience/supplementary-motor-area">supplementary motor area</a>, they knew the person was responding “yes”. This breakthrough could potentially give patients with severe brain damage the ability to communicate with doctors and family members – and could potentially transform how treatment decisions are made. </p>
<p>For example, if families can’t communicate with their loved one, they may feel pressure to make treatment decisions quickly to avoid leaving them “trapped” in a severely disabled state. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3185074/">Research has shown</a> that 50% of families who withdraw treatment do so within the first 72 hours of patient admission to hospital. This means that some patients who could have made a good recovery die. Communication could allow patients to convey what treatment they want early on.</p>
<p>This new research is a significant step forward from <a href="https://www.nature.com/articles/nrn3608">foundational neuroimaging studies</a> developed over the last decade. In these early studies, severely brain-injured patients thought to be unconscious were placed in a functional magnetic resonance imaging scanner (fMRI), and asked to imagine playing tennis, or navigating their homes. By imagining these specific scenarios, patients could show they were conscious. <a href="https://jnnp.bmj.com/content/87/5/485.long">Several studies</a> have shown almost 15% of patients thought to be in a persistent vegetative state – defined by a complete lack of awareness of the self or environment – are actually conscious, based on <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073717/">brain activity shown during scans</a>.</p>
<p>However, many severely brain injured patients <a href="https://academic.oup.com/brain/article/139/1/292/2468793">cannot be scanned using fMRI</a>, leaving them no way to communicate. By adapting the tennis task to fNIRS, researchers can safely and easily scan patients at the bedside, potentially meaning a greater number of patients could communicate with researchers at a time when important treatment decisions are being made.</p>
<h2>Important questions</h2>
<p>Though this method could ultimately allow patients to choose their own treatment, there are at least two conditions that must be met before fNIRS can be ethically applied in this way.</p>
<p>First, researchers need to ensure they’re interpreting a patient’s brain responses correctly. In the study, the researchers were correctly able to identify in volunteers without brain injury 79% of “yes” responses and 71% of “no” responses. But if we plan to administer treatment (or not) based on a patient’s response, how sure do we need to be that a patient has responded “yes” rather than “no”?</p>
<p>One approach is to think about the consequences of getting things wrong. If we ask a patient whether they prefer to watch hockey over football, 79% accuracy is probably enough, because the consequences of a mistake are minor. If we ask a patient if they’re depressed, 79% accuracy might also be acceptable, because the consequences of ignoring a depressed patient are potentially worse than offering treatment to someone who isn’t depressed. But if we’re asking a patient if they want to continue with life-sustaining treatment, we need to be very sure about their response.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/320792/original/file-20200316-27643-o4of13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/320792/original/file-20200316-27643-o4of13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/320792/original/file-20200316-27643-o4of13.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/320792/original/file-20200316-27643-o4of13.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/320792/original/file-20200316-27643-o4of13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/320792/original/file-20200316-27643-o4of13.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/320792/original/file-20200316-27643-o4of13.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A brain injury might change our ability to make decisions.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/puzzle-head-brain-concept-human-face-269726339">ESB Professional/ Shutterstock</a></span>
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<p>Second, we need to be sure that the patient has the capacity to make the decision we’re asking them to make. We usually assume that otherwise healthy adults can make their own medical decisions. But a patient with dementia might have to demonstrate their ability to a doctor by showing they understand the decision and its consequences, and can communicate this understanding. But severe brain injuries can cause cognitive deficits – giving us reason to be sceptical of a patient’s decision-making ability, especially complex decisions about <a href="https://www.tandfonline.com/doi/abs/10.1080/21507740.2013.821189">life-sustaining treatment</a>.</p>
<p>Of course, a patient could have the capacity to decide to end their life. Patients have the <a href="https://www.nhs.uk/common-health-questions/nhs-services-and-treatments/do-i-have-the-right-to-refuse-treatment/">right to refuse treatment</a>, even if this is likely to result in their death. For example, a patient with terminal cancer may refuse chemotherapy. <a href="http://www.bbc.co.uk/ethics/euthanasia/overview/introduction.shtml">In some countries</a>, patients can be actively assisted by physicians in ending their own lives.</p>
<p>But asking a severely brain-injured patient to decide about life-sustaining treatment is different. In the cancer case, the patient’s diagnosis may be sudden, but death from cancer may not be imminent – giving them time to think about what treatment is best for them. In the assisted dying case, the patient’s death is imminent, but not sudden. They will have had time to reflect on their decision. But a severe brain injury is sudden, and death will be imminent without treatment.</p>
<p>It’s difficult to imagine a patient being able to understand and appreciate the consequences of a life-or-death decision given these circumstances. They may be in severe pain or distress, which may impair their ability to weigh their present suffering against the potential for recovery in the future. Research also suggests that people <a href="https://www.ncbi.nlm.nih.gov/pubmed/10390038">tend to overestimate</a> how much worse off their lives would be with a severe disability. A patient that initially views a life of severe disability as worse than death may <a href="https://bmjopen.bmj.com/content/1/1/e000039">see things differently</a> once they adjust to their circumstances.</p>
<p>However, using fNIRS to communicate with patients could still be incredibly useful for assessing a patient’s experiences, allowing them to report on symptoms, and <a href="https://link.springer.com/article/10.1007%2Fs10677-017-9836-8">express wishes or preferences</a>. Even without the ability to make decisions, people can still have values, desires and preferences which affect their quality of life, and we don’t need to presume decision-making capacity to take these preferences and wishes seriously.</p><img src="https://counter.theconversation.com/content/133209/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mackenzie Graham receives funding from the Wellcome Trust. </span></em></p>By imagining a unique scenario to answer “yes” or “no” questions, this research could potentially be used to communicate with locked-in patients.Mackenzie Graham, Research Fellow of Philosophy, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1238202019-10-04T13:28:39Z2019-10-04T13:28:39ZHow routine sparring can cause short-term impairment to boxers’ brains<figure><img src="https://images.theconversation.com/files/295591/original/file-20191004-118209-1g0l0ef.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/two-boxers-fighting-ring-34651705">Shutterstock</a></span></figcaption></figure><p>Thrilling the masses for millennia, boxing has evolved down the centuries – rules have changed, equipment improved, training enhanced. However, one key aspect has essentially stayed the same: incapacitating the opponent before they incapacitate you. </p>
<p>Boxers are mostly exposed to <a href="https://concussionfoundation.org/CTE-resources/subconcussive-impacts">subconcussive head impacts</a>, that is, impacts that do not result in visible symptoms of concussion, much like heading the ball in football. But for many years, debate has raged around the safety of boxing, often focusing on the heavy blows inflicted during competitive fights. But we decided to look at these subconcussive impacts inflicted during training – or <a href="https://www.expertboxing.com/boxing-sparring-for-beginners">sparring</a> – sessions.</p>
<p>Boxing, football and rugby are of particular interest to our work because athletes are routinely exposed to repetitive subconcussive head impacts, both in training and competition. We have <a href="https://www.ebiomedicine.com/article/S2352-3964(16)30490-X/fulltext">previously shown</a> that a single soccer heading drill affects how the brain “talks” to the muscles. </p>
<p>Sparring sessions – where boxers trade light blows in protective headgear – are well suited for research because they often form part of an athlete’s training regime, and are fairly easy to replicate in a controlled laboratory environment, which is really important if you want to understand cause and effect.</p>
<p>Our latest <a href="https://www.frontiersin.org/articles/10.3389/fnhum.2019.00294/full">research</a> is one of the first studies to show that routine impact in sport – often thought to be fairly harmless – results in measurable changes in the brain.</p>
<h2>Boxing and brain function</h2>
<p>By the late 1920s scientists suspected that repetitive head impacts were associated with damage to the brain. Research from 1928 describes “punch drunk” syndrome, where boxers appeared to stagger around as if under the influence of alcohol. Scientists noted that the first symptoms of this “dementia pugilistica” – or what we now refer to as <a href="https://www.nhs.uk/conditions/chronic-traumatic-encephalopathy/">Chronic Traumatic Encephalopathy</a> (CTE), was an impairment in brain-to-muscle communication.</p>
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<p>CTE is a neurodegenerative disease with <a href="https://www.nhs.uk/conditions/alzheimers-disease/">Alzheimer’s</a>-like symptoms, characterised by structural, behavioural and cognitive changes in the brain. Since the 1920s, knowledge of this disease has expanded, but this does not necessarily mean it is fully understood. </p>
<p>For example, it is now believed that CTE can be caused by a combination of <a href="https://www.nhs.uk/conditions/minor-head-injury/">concussive</a> and subconcussive injuries (rather than only concussive ones). Yet, not all athletes exposed to concussion/subconcussion develop CTE, meaning that other factors – such as genetics or the environment – have to play a role.</p>
<h2>Short term changes in the brain</h2>
<p>We recruited 20 boxers and <a href="https://punchermedia.com/what-is-muay-thai/">Muay Thai</a> athletes, plus 20 healthy individuals who would not receive any blows to the head. All participants completed tests before and after a 3x3 minute sparring session for boxers and Muay Thai athletes, or a 3x3 minute mock-sparring session where participants only hit pads with boxing gloves.</p>
<p>The tests completed ranged from measures of how well the brain communicates commands to the muscles (done by zapping the brain with a magnetic stimulator and seeing what happens in the muscle), to tasks designed to test participants’ memory. </p>
<p>We found that, much like heading a ball in football, the results of those engaged in the sparring session demonstrated increased inhibitory mechanisms within the central nervous system. The human body needs a balance of excitatory and inhibitory mechanisms to function properly. If we pretend the brain is a busy junction with a traffic light, green (excitation) allows information to flow from one part of the body to the other; red (inhibition) ensures that this information moves in a safe and controlled manner. </p>
<p>One hour after sparring, participants showed impaired brain-to-muscle communications and decreased memory performance. Because normal brain chemistry was (temporarily) disrupted by these subconcussive impacts during the session, the information going from the brain to the muscles slowed down, affecting how they worked, and it was more difficult for participants to remember things. After 24 hours, these effects returned to normal.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/295595/original/file-20191004-118234-14f3lha.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/295595/original/file-20191004-118234-14f3lha.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=395&fit=crop&dpr=1 600w, https://images.theconversation.com/files/295595/original/file-20191004-118234-14f3lha.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=395&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/295595/original/file-20191004-118234-14f3lha.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=395&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/295595/original/file-20191004-118234-14f3lha.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=496&fit=crop&dpr=1 754w, https://images.theconversation.com/files/295595/original/file-20191004-118234-14f3lha.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=496&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/295595/original/file-20191004-118234-14f3lha.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=496&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">There has always been debate surrounding the safety of boxing, often focusing on the heavy blows inflicted during big competitive fights with the likes of famous boxers like Muhammad Ali.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/manila-philippines-september-1975-muhammad-ali-724182109">Shutterstock</a></span>
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</figure>
<h2>What do these results mean?</h2>
<p>Increased inhibition in the brain is also seen following a concussion and in this case is thought to be a protective mechanism, slowing down the brain’s processes to prevent further injury and help recovery. Problems may arise if this safeguarding response is activated without any actual injury (such as following subconcussive head impacts), as it could create a toxic environment and ultimately damage brain cells.</p>
<p>Also, if communication between brain and muscles is not occurring as it should, individuals may be at greater risk of muscular injury because muscles are not being properly controlled by the brain. We already know that athletes returning to play after a concussion are <a href="https://bjsm.bmj.com/content/50/15/926">more likely</a> to sustain an injury. </p>
<p>Ultimately, our studies are the first steps in lifting the veil on what goes on the brain after routine impact in sport. We show that sparring (as we did with heading a ball) results in acute and temporary changes to brain performance. This may be an indication of circuit dysfunction, an important mechanism in understanding the link between brain impact, brain health and disease. We need to better understand how circuit dysfunction affects the brain when there is repeated exposure to subconcussive impacts over the course of a sporting career.</p><img src="https://counter.theconversation.com/content/123820/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Angus Hunter received funding from the National Institute for Health Research. </span></em></p><p class="fine-print"><em><span>Magdalena Ietswaart received funding from the National Institute for Health Research and the Chief Scientist Office of the Scottish Government Health Directorates. Magdalena is a member of the SINAPSE collaboration (<a href="http://www.sinapse.ac.uk">www.sinapse.ac.uk</a>), a pooling initiative funded by the Scottish Funding Council and the Chief Scientific Office of the Scottish Executive.</span></em></p><p class="fine-print"><em><span>Thomas Di Virgilio does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New research reveals that routine sparring can have immediate effects on the brain, putting athletes at greater risk of injury when brain-muscle communication is impaired.Thomas Di Virgilio, Lecturer, University of StirlingAngus Hunter, Reader in Exercise Physiology, University of StirlingMagdalena Ietswaart, Cognitive Neuroscientist and Associate Professor, University of StirlingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1218872019-09-04T12:48:19Z2019-09-04T12:48:19ZEye-tracking can help diagnose concussion, but it’s under-utilised<figure><img src="https://images.theconversation.com/files/289424/original/file-20190826-8885-2jdvsz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Concussion can cause serious damage if it's not properly diagnosed and treated.</span> <span class="attribution"><span class="source">Dziurek/Shutterstock/Editorial use only</span></span></figcaption></figure><p>Sports-related concussion has been described by some experts as a “<a href="https://www.brainline.org/article/brain-injuries-silent-epidemic">silent epidemic</a>” because it often goes unrecognised.</p>
<p>It’s defined in the 2017 <a href="https://bjsm.bmj.com/content/51/11/838">Berlin Consensus Statement on Concussion in Sport</a> as a “traumatic brain injury induced by biomechanical forces”. It typically manifests in the rapid onset of short-term impairment of neurological function. Common symptoms include headaches, nausea, dizziness, confusion or feeling as if you’re in a fog.</p>
<p>A concussion may lead to neuropathological changes – at the level of the nervous system tissue. But it’s not a structural injury. It doesn’t change the brain in a way that can be seen with the naked eye or on traditional neuro-imaging screens. This is part of the reason that it’s not always diagnosed, and why there is still no universal tool to detect concussion. Clinicians have to rely largely on their experience and on the symptoms that injured athletes report. </p>
<p>The problem with self-reporting, though, is that athletes are often not too keen to be removed from the field, so they sometimes understate their symptoms. Younger athletes also struggle to properly verbalise what they feel and don’t necessarily understand the implications of the injury.</p>
<p>Researchers worldwide are working on solutions and methods that will help clinicians to diagnose concussion. One such method could be using eye-tracking. This is a technology for recording eye movements with a small externally mounted camera and then analysing, for example, how fast the eyes move or how accurately they can follow a certain target. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3212396/">Research has already established</a> that eye-tracking can be used successfully in diagnosing and classifying brain disorders such as schizophrenia or autism. </p>
<p>We believe that eye-tracking also shows promise in concussion assessment. <a href="https://iopscience.iop.org/article/10.1088/1361-6579/aaef44">According to research</a>, up to 80% of concussed athletes show some eye movement dysfunction. </p>
<p>But do clinicians know this? We conducted a <a href="https://www.tandfonline.com/doi/abs/10.1080/00913847.2019.1645577?journalCode=ipsm20">survey</a> among sports medicine clinicians who deal with concussions to find out. A total of 171 clinicians from 32 countries shared whether they were aware that concussed athletes may have impaired eye movements, and whether they believed that eye-tracking technology has a potential to assist them in assessing concussion.</p>
<h2>Clinicians’ feedback</h2>
<p>Our survey revealed a few interesting facts. </p>
<p>On whether they knew that concussed athletes may have impaired eye movements, we found that the respondents on average saw eye movement impairments in only 30% of their concussion patients. That’s lower than what we expected.</p>
<p>The reason for this may be that, even though measuring the eye movements without the equipment is possible – for example, asking a patient to look side to side – it is not as accurate. On top of that, 20% of our respondents admitted that they were not checking for any eye movement deficits at all, which indicates they probably were not aware that concussion may lead to abnormal eye-tracking.</p>
<p>And then on the potential of eye-tracking technology to help them assess concussions, most clinicians did see benefits in using eye-tracking. These benefits include objectivity, ease of use (both for the clinician and the patient), replicability of the tests, and the fact that the results can be quantified. </p>
<p>But despite this, many seemed reluctant to implement this technology in their practice. Only 49% of the survey respondents explicitly said that utilising eye-tracking technology for concussion diagnostics was advisable.</p>
<p>There are several understandable reasons for this reluctance: they may not be familiar with this still rather novel technology at all; may lack access to the equipment; or may lack training. </p>
<h2>Using technology</h2>
<p>The survey happened against the backdrop of several recent developments in eye-tracking for concussion assessment. </p>
<p>First, there have been significant technological advancements in recent years. In 2018 two eye-tracking devices designed specifically for concussion assessment were approved by the US Food and Drug Administration. A third device is currently undergoing <a href="https://clinicaltrials.gov/ct2/show/NCT02877732">a clinical trial</a> in the US.</p>
<p>The prices of the eye-tracking equipment have also dropped tremendously. </p>
<p>It’s important to point out that eye-tracking technology isn’t perfect and certainly shouldn’t be the only approach to diagnosing concussion. These developments nevertheless suggest that eye-tracking technology has a valuable role to play in clinical settings. </p>
<h2>The way forward</h2>
<p>We believe that with ongoing education of clinicians on current developments in the field, and particularly with reference to continuing technological advances, eye-tracking technology could become more common in clinical settings.</p>
<p>Our results suggest that the level of exposure to novel diagnostic tools and clinicians’ acceptance possibly go hand in hand. That’s why we strongly recommend creating training opportunities for concussion evaluation, including the use of potential innovative technology. We also suggest facilitating close interaction between researchers and clinicians regarding the use of latest tools for concussion assessment such as eye-tracking. </p>
<p>All of this could lead to the technology being adopted at a higher rate. This in turn might enable the evaluation of currently somewhat neglected eye movement deficits caused by concussion – and ultimately more accurate evaluation of concussion resolution over days to weeks.</p>
<p><em>Dr Karen Welman, Stellenbosch University; Professor Wayne Derman, Stellenbosch University & International Olympic Committee (IOC) Research Centre and Professor Jon Patricios, University of the Witwatersrand, co-authored this article.</em></p><img src="https://counter.theconversation.com/content/121887/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nadja Snegireva received FIFA research scholarship.</span></em></p>Sports medicine clinicians see benefit in using eye-tracking for concussion diagnostics, but only few of them actually work with it.Nadja Snegireva, PhD Researcher in Sport Sciences, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1195852019-07-02T11:14:07Z2019-07-02T11:14:07ZWill they ever wake up? New study on consciousness after brain injury shows ‘maybe’<figure><img src="https://images.theconversation.com/files/281820/original/file-20190628-94688-tuw6q8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new study on consciousness could help answer the question"will they ever wake up?"</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/magnetic-resonance-image-mri-scan-brain-560923147?src=HyyclycWLE_EDjrx5tWc-Q-2-31&studio=1"> create jobs 51/shutterstock.com</a></span></figcaption></figure><p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5234377/">Acute brain injury</a> can result in significant damage and loss of consciousness, warranting life support and admission to an intensive care unit. A complex journey toward recovery begins, sometimes involving daily life-and-death battles. </p>
<p>As the acuity of the life-threatening injury declines and the patient’s condition stabilizes a bit, the dust starts to settle. But then so many questions begin. </p>
<p>“Will they ever wake up?” is one of the most common and challenging questions that families navigating this emotional rollercoaster journey ask us. </p>
<p>It is also one of the most daunting questions for care teams. As in many situations, the honest and so unfulfilling answer has to be, “We don’t know.”</p>
<p>We are both neurologists specializing in neurocritical care, with clinical and research interests in acute brain damage and outcomes. We think a <a href="http://dx.doi.org/10.1056/NEJMoa1812757">recent study</a> provides new insights into the wide spectrum of states between consciousness and unconsciousness, and opens intriguing possibilities for further research, and perhaps predicting outcomes. </p>
<h2>How do care teams try to determine if someone is conscious?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/281822/original/file-20190628-94712-1iky3ve.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/281822/original/file-20190628-94712-1iky3ve.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/281822/original/file-20190628-94712-1iky3ve.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/281822/original/file-20190628-94712-1iky3ve.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/281822/original/file-20190628-94712-1iky3ve.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/281822/original/file-20190628-94712-1iky3ve.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/281822/original/file-20190628-94712-1iky3ve.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Neurological machines are used to help read brain activity.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/laboratory-man-wearing-brainwave-scanning-headset-1036798345?src=kRAd7KRiWvq4dEuDp-2BNw-1-21&studio=1">Gorodenkoff/shutterstock.com</a></span>
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<p>Let’s start by defining <a href="https://www.merriam-webster.com/dictionary/consciousness">consciousness</a>, or the ability to maintain alertness and to be aware and interact with the surroundings. Physicians prompt patients to follow instructions such as “Wiggle your toes” and “Stick out your tongue,” in order to assess their level of awareness and delineate signs of consciousness. </p>
<p>What is traditionally termed a “simple command” actually requires a complex array of brain functions in order to be carried out correctly. Hearing needs to be intact, the meaning of the commands to be understood and processed, planning of the expected task to be on point, and last, the nerves telling the respective muscles to contract need to be functioning. <a href="http://dx.doi.org/10.1056/NEJMoa0905370">Different areas of the brain are activated</a> depending on the task being planned or performed.</p>
<p>A tool that can help is an <a href="https://www.healthline.com/health/eeg">electroencephalogram</a>, or EEG, which tests brain waves. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3379170/">Functional brain imaging</a>, such as functional MRI, is another tool used to gain more insight into what is going on inside a brain by monitoring the change in activity of certain areas, especially, if no such “simple commands” can be executed. </p>
<p>However, none of these means so far has offered a granular insight into what exactly is going on “in there,” or even if there is someone trapped “in there,” so early in the course of severe acute brain injury.</p>
<h2>New insights may bring new promise</h2>
<p>In the <a href="http://dx.doi.org/10.1056/NEJMoa1812757">recent study</a> published in the New England Journal of Medicine, neurointensive care physicians – doctors who take care of patients with brain injury in intensive care – and researchers took brain wave analysis to the next level. They connected unresponsive patients with acute brain injury to continuous EEG, and asked them to perform simple commands while their brain waves were being recorded. The EEG data then were fed into a machine-learning algorithm derived from healthy volunteers, which compared the change in brain activity from the state while at rest to the activity recorded following the commands.</p>
<p>Of 104 patients studied, 15% showed activation of brain activity corresponding to the command, even though bedside examiners did not see any visible response – a phenomenon termed cognitive-motor dissociation.</p>
<p>In a particularly striking finding, the researchers found that patients who showed brain activation were more than three times as likely, compared to those who showed no brain activation, to make strides in recovery and gain at least partial independence over the year following the brain injury. They were also nearly twice as likely to be able to demonstrate visible response and actually follow commands by the end of their hospital stay.</p>
<p>This finding is important because, for the first time, scientists could see such a pattern of hidden brain activity in unresponsive patients early after severe brain injury and connect these findings to long-term outcomes, suggesting that such activity might be an early sign for recovery. </p>
<h2>Where does this lead?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/281823/original/file-20190628-94720-75ogdt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/281823/original/file-20190628-94720-75ogdt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/281823/original/file-20190628-94720-75ogdt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/281823/original/file-20190628-94720-75ogdt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/281823/original/file-20190628-94720-75ogdt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/281823/original/file-20190628-94720-75ogdt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/281823/original/file-20190628-94720-75ogdt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Even after the study, there are still questions about consciousness we need to answer.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/laboratory-man-wearing-brainwave-scanning-headset-1036798345?src=kRAd7KRiWvq4dEuDp-2BNw-1-21&studio=1">Gorodenkoff/shutterstock.com</a></span>
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<p>Does this answer all our questions about consciousness?</p>
<p>Certainly not. Many questions remain. Several assessments of brain activity in the same patient showed that detection of <a href="https://news.weill.cornell.edu/news/2015/10/editorial-new-terminology-needed-for-brain-injured-patients">cognitive-motor dissociation </a> was not a static phenomenon, but rather inconsistent. This makes sense, as even healthy brains go through phases such as deep sleep where one would likely not activate their brain when called to “wiggle your toes.”</p>
<p>However, in the setting of an intensive care unit normal sleep-wake cycles are disturbed. Also, patients often are sedated, and the presence of sedative drugs might interfere with these assessments. Further, even without clear outer stimuli, fluctuations in the level of neurologic function are common in patients with brain injury throughout their ICU stay. Thus, the findings of this study still need to be replicated in different patients and places.</p>
<p>Consciousness is much more than what we humans are able to detect with our bare eyes, even for seasoned experts. Combined with a technology that is five years short of celebrating its 100th birthday since the first EEG recording in 1924, artificial intelligence has demonstrated its potential to enhance the yield of EEG in illuminating the black box of the brain. </p>
<p>This study allows a peek under an iceberg and may transform how we practice neurologic outcome prediction. The use of machine learning to process data that the human eye would not be able to appreciate has already started to revolutionize the field of medicine. But, we also have to accept that this is just the beginning. What that means is that in many instances, when relatives ask “Will they ever wake up?” in the first few days after a severe brain injury, the honest answer still is “We don’t know.” But the patient might hear us already. </p>
<p>[ <em><a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=thanksforreading">Thanks for reading! We can send you The Conversation’s stories every day in an informative email. Sign up today.</a></em> ]</p><img src="https://counter.theconversation.com/content/119585/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katharina Busl serves on the Board of Directors of "The Art of Medicine", a non-for-profit organization that supports brain injury research </span></em></p><p class="fine-print"><em><span>Carolina B. Maciel receives funding from Claude D. Pepper Older Americans Independence Center Junior Scholar award that supports pre-clinical studies of mechanisms of secondary brain injury in a rodent cardiac arrest model. </span></em></p>Consciousness has long been debated, particularly in the decades since devices have been used to keep people alive after brain injury. A new study suggests that some people can “wake up” after injury.Katharina M. Busl, Associate Professor of Neurology; Chief of the Division of Neurocritical Care, Department of Neurology, University of FloridaCarolina B. Maciel, Assistant Professor of Neurology; Director of Research for the Division of Neurocritical Care, Department of Neurology, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1182012019-06-05T14:59:58Z2019-06-05T14:59:58ZHidden epidemic? Childhood concussion may lead to long term cognitive and behavioural problems<figure><img src="https://images.theconversation.com/files/277651/original/file-20190603-69063-bz896o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Brain injury can happen even if you don't pass out.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/300079928?src=g69pDTHTJGY5y2WFwW-rTw-1-35&size=huge_jpg">TinnaPong/Shutterstock</a></span></figcaption></figure><p>At age 15, Jamie is a keen soccer player who loves nothing more than getting stuck into every tackle, practice and game. As a result, Jamie experiences injury like any young person might do. During a routine sports physical, Jamie complains to the doctor about headaches, sleeping difficulties and feeling kind of foggy at school. The doctor thinks the young patient is stressed, and recommends ibuprofen and a good night’s sleep. The topic of concussion, or brain injury, does not come up.</p>
<p>Although this story is fictional, there are many <a href="https://www.ktvz.com/health/sisters-woman-inspires-legislation-on-concussions/68300552">examples like it</a> in the real world. Mild traumatic brain injury, or concussion, is a more common condition than many people realise – causing dizziness, confusion, headache, nausea and sometimes loss of consciousness. There is strong evidence that in an average class of 30 children, <a href="https://www.ncbi.nlm.nih.gov/pubmed/18240046">at least five will experience a brain injury</a> before the age of 15. The symptoms of mild injury typically resolve in a few days or weeks. But in about <a href="https://www.pedneur.com/article/S0887-8994(15)00221-0/abstract">10% of these cases</a>, mild injuries are estimated to lead to long-term deficits – causing problems with memory, concentration, behaviour, mood and personality. </p>
<p>Researchers base their estimates of the prevalence of brain injury on a strong association between concussion and persistent negative outcomes. For example, one study showed that children injured during their pre-school years were <a href="https://jnnp.bmj.com/content/73/3/281">significantly more likely</a> to have evidence of antisocial behaviour and/or psychiatric disorders during their teen years. These problems persisted into adulthood, with evidence of increased drug and alcohol abuse at the age of 25. </p>
<p>As brain injury is a hidden disability – you often can’t tell that there has been an injury – we don’t know a huge amount about. In fact, the symptoms many children experience after brain injury may be attributed to something else. For example, a child who has trouble concentrating and turning in schoolwork on time may seem to have attention problems and be mislabelled as having Attention Deficit Hyperactivity Disorder (ADHD). </p>
<p>Research has shown that misdiagnosis of brain injury <a href="https://www.researchgate.net/publication/299437422_Traumatic_Brain_Injury_Persistent_Misconceptions_and_Knowledge_Gaps_Among_Educators">is a real problem</a>. Without accurate diagnosis, brain injury can be mistaken for another disability, leading to inappropriate provision of support and services. A child with brain injury will likely have complex deficits which require frequent monitoring and adaptive service provision as the child’s brain matures. </p>
<p>Also, many children do relatively well following injury, until school demands and expectations for independence increase, at which point they may suddenly struggle. At this point, parents and teachers may have forgotten about the childhood injury or simply fail to make the connection between the injury and the learning and behaviour challenges of their older child. In other words, effect does not always immediately follow cause when it comes to brain injury.</p>
<p>The lack of recognition of brain injury means that the public, families, healthcare providers, educators and members of the criminal justice system <a href="https://www.ncbi.nlm.nih.gov/pubmed/29660961">hold many misconceptions</a> about what brain injury is and is not. Although the majority of children with injuries go on to live happy and fulfilling lives, brain injury can make some lives harder. </p>
<h2>Ways forward</h2>
<p>We need to be aware that support and greater consideration are necessary to help these children reach their full potential. However, those in the best position to help – educators – receive no training in how to support a child with brain injury. This lack of training means that teachers may be ill prepared to understand and meet the learning needs of these children. Currently, many children with brain injury are not well served in school and become dissatisfied with schooling, have poor educational attainment, and <a href="https://www.ncbi.nlm.nih.gov/pubmed/18650769">may leave school unprepared</a> for adult life. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/277652/original/file-20190603-69075-90ureu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/277652/original/file-20190603-69075-90ureu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=316&fit=crop&dpr=1 600w, https://images.theconversation.com/files/277652/original/file-20190603-69075-90ureu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=316&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/277652/original/file-20190603-69075-90ureu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=316&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/277652/original/file-20190603-69075-90ureu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=398&fit=crop&dpr=1 754w, https://images.theconversation.com/files/277652/original/file-20190603-69075-90ureu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=398&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/277652/original/file-20190603-69075-90ureu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=398&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Doctors often fail to ask about head injuries.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/child-pediatricians-office-holding-ice-pack-1374685001?src=g69pDTHTJGY5y2WFwW-rTw-2-33">Rocketclips, Inc./Shutterstock</a></span>
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<p>We know that children who stay in school have better occupations and earn more than those who leave school early. Children who leave school early may also get into trouble with the law. Interestingly, research shows <a href="https://www.ncbi.nlm.nih.gov/pubmed/21069616%20https://pure.qub.ac.uk/portal/en/publications/traumatic-brain-injury-and-social-competence-among-young-male-offenders(17fe9c0b-01df-45bf-9a52-ba37bf0b9db1).html">high rates of self-reported brain injury</a> among young offenders (87%) and the general prison population (65%). </p>
<p>But it is definitely possible to access appropriate supports and services. Let’s go back to Jamie. If the symptoms don’t improve, Jamie could go to the football coach who could ask for more information, including whether Jamie had received a knock to the head. Jamie could then reveal that while there had been no blow to the head, the symptoms had started after a collision with a goal post a few months earlier and hadn’t realised that a concussion could happen without being knocked out. After a follow-up visit with the doctor, it could then be determined that Jamie had indeed sustained a concussion. </p>
<p>In this case, the doctor should recommend sitting out the spring football season and getting accommodations at school so Jamie doesn’t fall behind. This information should be passed on to Jamie’s school counsellor, who should share <a href="https://cbirt.org/">information about concussion</a> with school staff, including some web-based resources on how to support students with concussion at school. Jamie should also be allowed to take rest breaks at school in the nurse’s office as needed, turn in assignments late, and take tests in a quiet room. After taking a six-month break, Jamie could then start making a gradual return to soccer.</p><img src="https://counter.theconversation.com/content/118201/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ann Glang receives funding from National Institute on Disability, Independent Living and Rehabilitation Research.</span></em></p><p class="fine-print"><em><span>Audrey McKinlay and Mark Linden do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>About one in ten children who have suffered concussion are thought to have long-term problems.Mark Linden, Lecturer School of Nursing and Midwifery, Queen's University BelfastAnn Glang, Research Professor and Center Director, University of OregonAudrey McKinlay, Adjunct Professor of Neuroscience, University of CanterburyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1169822019-05-24T10:44:42Z2019-05-24T10:44:42ZPeople with traumatic brain injury, who often lose empathy, can regain it with treatment<figure><img src="https://images.theconversation.com/files/275953/original/file-20190522-187165-7bot3u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Understanding the facial cues from another person is a component of empathy.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sad-man-listening-advice-colleague-during-690911812?src=YLMUcA7ngh2FRkp9dGmLiw-1-76">Pressmaster/Shutterstock.com</a></span></figcaption></figure><p>Most people can easily determine when a loved one is feeling sad or anxious. This recognition will often trigger the person to offer a comforting gesture or even have a <a href="https://en.wikipedia.org/wiki/Emotional_contagion">contagious emotional</a> reaction, causing them to also feel sad or anxious, too. </p>
<p>These important actions are referred to as emotion recognition and empathy, and they are fundamental to establishing human emotional connections and relationships.</p>
<p>But imagine waking up one morning and your loved one lost the ability to recognize and empathize with your feelings. For the last couple of decades, researchers have been showing this to be a common outcome for people who have suffered a traumatic brain injury. The inability to <a href="https://psycnet.apa.org/record/2011-06479-001">recognize</a> and <a href="https://www.cambridge.org/core/journals/journal-of-the-international-neuropsychological-society/article/inability-to-empathize-following-traumatic-brain-injury/A3AA1F6B946F6A71F156BF76D3E7FE2A">empathize</a> with others’ emotions after brain injury has a resounding impact on family and friends and has sparked research leading to promising treatments.</p>
<p>I started studying emotion recognition and empathy in 2005, and this is exactly how the wife of my first research participant described it happened for her husband who was in a car accident and suffered a traumatic brain injury, or TBI. Once a very affectionate partner who responded to all of her emotional needs, he now failed to recognize her sadness or comfort her when she lost her father. Conversely, he was unable to feel the emotional contagion of her joy when she received recognition at work. This once very strong couple later divorced.</p>
<h2>Crashes, blasts and falls that affect millions</h2>
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<img alt="" src="https://images.theconversation.com/files/275952/original/file-20190522-187153-1wmlwep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/275952/original/file-20190522-187153-1wmlwep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/275952/original/file-20190522-187153-1wmlwep.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/275952/original/file-20190522-187153-1wmlwep.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/275952/original/file-20190522-187153-1wmlwep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/275952/original/file-20190522-187153-1wmlwep.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/275952/original/file-20190522-187153-1wmlwep.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Falls are a common cause of traumatic brain injury, but car and motorcycle crashes also are major causes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/construction-worker-falling-off-ladder-inside-521522911?src=INAi_gpaECFoioEX2l7XOA-1-35">Andre Marcelo Santa Maria/Shutterstock.com</a></span>
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<p>A <a href="https://www.biausa.org/brain-injury/about-brain-injury/basics/overview">TBI</a> is when an external physical force leads to a disruption in brain function. Falls and motor vehicle accidents are the most common causes, but damage also results from many other injuries, including blast injuries that are frequently experienced by active duty military. </p>
<p>In 2014, almost <a href="https://www.cdc.gov/traumaticbraininjury/get_the_facts.html">3 million Americans</a> received some type of medical care or died from a TBI-related incident. Problems with attention, memory, planning, reasoning or problem solving are common. But often more troublesome are the frequent emotional and behavioral changes, such as increased anger and aggression. Emotional and behavioral changes have been linked with problems recognizing others’ emotions and an inability to share another’s feelings. </p>
<p>Prevalence rates of <a href="https://psycnet.apa.org/record/2011-06479-001">problems with emotion recognition</a> and <a href="https://www.cambridge.org/core/journals/journal-of-the-international-neuropsychological-society/article/inability-to-empathize-following-traumatic-brain-injury/A3AA1F6B946F6A71F156BF76D3E7FE2A">decreased empathy</a> after brain injury are 39% and 60%, respectively. </p>
<p>This is quite concerning for people with TBI and their family members, as this impairment has been related to worse <a href="https://www.tandfonline.com/doi/abs/10.1080/02699052.2018.1531301">social relations</a> after TBI. </p>
<h2>The first step of empathy</h2>
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<img alt="" src="https://images.theconversation.com/files/275955/original/file-20190522-187189-tut1fk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/275955/original/file-20190522-187189-tut1fk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/275955/original/file-20190522-187189-tut1fk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/275955/original/file-20190522-187189-tut1fk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/275955/original/file-20190522-187189-tut1fk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/275955/original/file-20190522-187189-tut1fk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/275955/original/file-20190522-187189-tut1fk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A boy responds to a girl’s look of pain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/little-boy-hugging-consoling-upset-girl-1164198340?src=YLMUcA7ngh2FRkp9dGmLiw-1-46">fizkes/Shutterstock.com</a></span>
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<p>It has been a longstanding <a href="https://journals.sagepub.com/doi/abs/10.1177/1534582304267187">theory</a> that a person must recognize others’ emotions in order to empathize with them.</p>
<p>However, despite the strong theoretical rationale, scientific experiments have had trouble finding strong support for this belief, in people <a href="https://journals.lww.com/headtraumarehab/Abstract/2014/01000/Relationships_Between_Alexithymia,_Affect.13.aspx">with</a> and <a href="https://www.safetylit.org/citations/index.php?fuseaction=citations.viewdetails&citationIds%5B%5D=citjournalarticle_261580_38">without</a> brain injury. </p>
<p>When I looked at how the past studies were conducted, I saw clear design flaws. Many of the former studies assessed emotion recognition and empathy in isolation of one another. Empathy was typically measured with unrelated subjective questionnaires. So it is not too surprising little relationship was found between two unrelated tests. </p>
<p>For example, researchers would administer an emotion recognition test, such as pictures of facial expressions. The researchers would then give participants a questionnaire about their general empathic tendencies. But the researchers did not test how the person with TBI felt in response to the facial expressions they had to identify. For example, did they feel sad when looking at a sad person? By not gauging a person’s feelings in response to the emotional expression in the picture, researchers were not measuring a direct empathic response to another’s feelings. </p>
<h2>A second step to empathy</h2>
<p>Due to the limitations of previous studies, my colleague, <a href="https://spectre.cqu.edu.au/profiles/view/10920"></a><a href="https://scholar.google.com/scholar?hl=en&as_sdt=0%2C15&q=barbra+zupan&btnG=&oq=barbra+z">Dr. Barbra Zupan</a>, and I decided to take a different approach. In our <a href="https://doi.org/10.1016/j.apmr.2018.07.431">recent publication</a>, we showed subjects with and without TBI emotional film clips and had them identify how the character in the clip felt and how they felt while watching the clip. </p>
<p>Since a shared emotional response is an element of empathy, when participants felt the same emotion they identified the character to be feeling, we defined that as an empathic response. We did not require them to recognize the character’s emotion accurately to be classified as an empathic response. Using this approach allowed us to measure the direct relationship between recognizing another’s emotion and having a shared empathic response. If we made accurate emotion recognition a requirement to be considered an empathic response, we would not have been able to measure this relationship. </p>
<p>We had several interesting findings. Based on past research showing <a href="https://www.cambridge.org/core/journals/journal-of-the-international-neuropsychological-society/article/inability-to-empathize-following-traumatic-brain-injury/A3AA1F6B946F6A71F156BF76D3E7FE2A">impaired empathy</a> after TBI, we expected the percent of empathic responses to be pretty low in our participants with TBI. While participants with TBI did not have as many empathic responses as their uninjured age and gender matched peers (79%), they did respond empathically 67% of the time. </p>
<p>Further, we found that accurate recognition of characters’ emotions was associated with a greater number of empathic responses. The empathic responses of participants with TBI more than doubled when they accurately identified the character’s emotion, compared to a misrecognized emotion (71% vs. 32%, respectively). </p>
<p>We think it is important to note that correct emotion recognition was not sufficient for an empathic response to occur in either group. That is, participants did not always respond empathically when they correctly recognized the emotion.</p>
<p>Our findings also suggest that participants with TBI had a harder time recognizing and empathizing with sad and fearful emotions, compared to happy emotions. This was indicated by their lower recognition and empathic responses when characters were acting sad and afraid. This means that when loved ones need comforting the most – when feeling fearful or sad – they are unlikely to get it from a partner with TBI.</p>
<h2>Helping those with TBI</h2>
<p>We think these findings have important clinical implications.</p>
<p>First, clinicians treating people with TBI should plan to evaluate emotion recognition and empathy in their patients and learn how to treat these impairments. Interviewing patients with TBI and their family members can help paint a picture of how a person has changed compared to his or her pre-injury self and lead to goals for rehabilitation. There are <a href="https://journals.lww.com/headtraumarehab/Abstract/2015/05000/A_Randomized_Controlled_Trial_of_Emotion.12.aspx">evidence-based approaches and free treatment tools</a>, designed by our group, that have now been deemed <a href="https://www.archives-pmr.org/article/S0003-9993(19)30194-7/abstract">practice standards</a> for improving emotion recognition skills. </p>
<p>When training emotion recognition after TBI, clinicians should also discuss with the patient ways they can respond empathically to loved ones. <a href="https://www.ingentaconnect.com/content/wk/htr/2017/00000032/00000005/art00010">Newer research</a> from another group in the Netherlands shows that this combination – both recognition and responding empathically – is effective and should involve the family member as part of treatment. </p>
<p>Also, clinicians should consider educating survivors of TBI and their families about these common changes after TBI, why it happens, what they might expect in terms of changes in behavior, and notifying them that it could improve with treatment. </p>
<p>Finally, family members could be directed to be more explicit about their emotions and what they would like from their loved one with a brain injury. Together, these efforts could improve outcomes after TBI and minimize the common relationship strains experienced after a brain injury.</p><img src="https://counter.theconversation.com/content/116982/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dawn Neumann has received funding from the Cannon Research Center at Carolinas Rehabilitation, The Humanity Research Institute at Brock University, and the National Institute on Disability, Independent Living and Rehabilitation Research (grant no. H133G080043)</span></em></p>Millions of people suffer traumatic brain injuries, and many lose the ability to emotionally connect with others. A new study suggests there’s a way to help them regain their ability to connect.Dawn Neumann, Associate Professor of Physical Medicine & Rehabilitation, IUPUILicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1151282019-05-22T19:47:53Z2019-05-22T19:47:53ZAboriginal Australians want care after brain injury. But it must consider their cultural needs<figure><img src="https://images.theconversation.com/files/275068/original/file-20190517-69189-ps8p2p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Australia's first Aboriginal Brain Injury Coordinator, Rebecca Clinch, with brain injury survivor Justin Kickett.</span> <span class="attribution"><span class="source">Edith Cowan University</span>, <span class="license">Author provided</span></span></figcaption></figure><p><em>This article is the fourth part in a series, <a href="https://theconversation.com/au/topics/where-culture-meets-health-70226">Where culture meets health</a>.</em></p>
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<p>Aboriginal Australians continue to face serious health challenges. Life expectancy is about <a href="https://www.aihw.gov.au/getmedia/bbe476f3-a630-4a73-b79f-712aba55d643/aihw-ihw">10.7 years less</a> for Indigenous Australians than non-Indigenous Australians.</p>
<p>Brain injury occurs up to <a href="https://www.ncbi.nlm.nih.gov/pubmed/21493909">three times more often</a> in Aboriginal Australians than their non-Aboriginal counterparts. It also commonly occurs at a younger age, and is more likely among Aboriginal people living in <a href="https://journals.lww.com/headtraumarehab/fulltext/2018/11000/Missing_Voices___Profile,_Extent,_and_12_Month.7.aspx?casa_token=cAlzJJUcucoAAAAA:5Av23TAwiv2BjIQ6XiyOG31EuFzk3hu5NvW-aBUwLdt71Nb9X2g4SCdME3VZYfTes6gWqcqn1tr_UU3_OJDAZPg3BQ">rural and remote areas</a>.</p>
<p>Despite their greater need, Aboriginal people access rehabilitation services at <a href="https://particle.scitech.org.au/people/revitalising-rehab-for-aboriginal-brain-injury/">a lower rate</a> than the general population. </p>
<p>Barriers to accessing health services <a href="http://www.biomedcentral.com/1472-6963/13/460">can be related</a> to communication breakdowns, distance from facilities, and previous negative experiences with services.</p>
<p>Aboriginal people who have suffered brain injury are even more vulnerable to these barriers.</p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-traumatic-brain-injury-75546">Explainer: what is traumatic brain injury?</a>
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<p>Our research tells us the absence of Aboriginal people in rehabilitation services has often led largely non-Aboriginal practitioners to assume they don’t want therapy.</p>
<p>But based on our interviews with <a href="https://www.tandfonline.com/doi/abs/10.3109/09638288.2014.972581?casa_token=awEocv7M8BEAAAAA:_0YcC4_3oYP1WOSm8ChHKN70ph8-BHfipsJEZUGExH2nXh2DJeRscjvXkij-BnhwHfddiXoGKYvOzQ">Aboriginal brain injury survivors</a> in Western Australia, we’ve found they want more information and education about brain injury, and more practical support along their rehabilitation journey.</p>
<h2>Culturally secure health care</h2>
<p>The effects of colonisation, social exclusion, poverty and racism <a href="https://search.informit.com.au/documentSummary;dn=546572336923501;res=IELIND">continue to impact</a> many of our First Nations peoples today.</p>
<p>This is compounded by health services that may not have the tools to consistently recognise and respond to the cultural needs of Aboriginal people. </p>
<p>Aboriginal understandings of health and wellness, and how these understandings differ from Western biomedical models, need to be better reflected in practice.</p>
<p>The Aboriginal construct of health is a holistic model that perceives physical, psychological, spiritual, cultural, social, environmental and economic factors as affecting a person’s functioning.</p>
<p>Cultural security directly links understandings and actions. So providing culturally secure health care means all these factors are taken into account. Importantly, patients can practise their cultural norms and their care <a href="https://search.informit.com.au/documentSummary;dn=955665869609324;res=IELFSC">will not be compromised</a> as a result.</p>
<p>For example, under certain circumstances, interactions may only be considered culturally secure when conducted between people of the same gender, language group, or when aligned with kinship rules. Hospital limitations on the number of family members visiting at one time may lead to feelings of exclusion and infringement on family rights.</p>
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Read more:
<a href="https://theconversation.com/indigenous-health-programs-require-more-than-just-good-ideas-20104">Indigenous health programs require more than just good ideas</a>
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<h2>Our research</h2>
<p>We spoke to Aboriginal people who had <a href="https://www.tandfonline.com/doi/abs/10.3109/09638288.2014.972581?casa_token=awEocv7M8BEAAAAA:_0YcC4_3oYP1WOSm8ChHKN70ph8-BHfipsJEZUGExH2nXh2DJeRscjvXkij-BnhwHfddiXoGKYvOzQ">experienced brain injury</a> as a result of a stroke, or a traumatic injury such as a car accident, assault, or fall.</p>
<p>Our participants spoke frequently about poor communication with non-Aboriginal hospital staff. Many felt staff did not understand or empathise with their situation and the centrality of family and culture in their lives. Some expressed feeling vulnerable, alone and diminished in the hospital environment.</p>
<p>Several people reported being unable to understand technical explanations they were given regarding stroke, its treatment and recovery. Many Aboriginal stroke patients and families felt they received very little practical information about services available to them once they left hospital.</p>
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Read more:
<a href="https://theconversation.com/words-from-arnhem-land-aboriginal-health-messages-need-to-be-made-with-us-rather-than-for-us-100655">Words from Arnhem land: Aboriginal health messages need to be made with us rather than for us</a>
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<p>We also interviewed non-Aboriginal health service providers. They reported not feeling confident working with Aboriginal patients and families. </p>
<p>Reasons for this included a lack of skills in positively engaging and communicating with Aboriginal people, a fear of offending, and recognition that their largely Western knowledge base may not be appropriate when delivering medical care to Aboriginal patients.</p>
<h2>We need Aboriginal service providers on the ground</h2>
<p>The first point of contact after a brain injury is critical in determining the person’s ongoing rehabilitation journey. If information and support are made accessible from the outset, and cultural security guaranteed, follow-up and two-way engagement <a href="https://www.ncbi.nlm.nih.gov/pubmed/22530862">will be more likely</a>.</p>
<p>In our studies, patients often talked about feeling more comfortable with another Aboriginal person. Someone who understands their personal context including family, culture and community is uniquely placed to assist with the person’s journey to recovery.</p>
<p>As a result of our findings, the National Health and Medical Research Council funded <a href="https://www.ecu.edu.au/schools/medical-and-health-sciences/our-research/communication-disorders-research-group/projects/brain-injury-in-aboriginal-populations/healing-right-way-enhancing-rehabilitation-services-for-aboriginal-australians-after-brain-injury">Healing Right Way</a>, a project across Western Australia to improve the journey after brain injury for Aboriginal people and their families.</p>
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<img alt="" src="https://images.theconversation.com/files/275070/original/file-20190517-69186-1o7cndc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/275070/original/file-20190517-69186-1o7cndc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/275070/original/file-20190517-69186-1o7cndc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/275070/original/file-20190517-69186-1o7cndc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/275070/original/file-20190517-69186-1o7cndc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/275070/original/file-20190517-69186-1o7cndc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/275070/original/file-20190517-69186-1o7cndc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Aboriginal Brain Injury Coordinators provide education around brain injury and support patients during rehabilitation and recovery.</span>
<span class="attribution"><span class="source">Edith Cowan University</span>, <span class="license">Author provided</span></span>
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<p>Healing Right Way will employ eight Aboriginal Brain Injury Coordinators to support Aboriginal people for the first six months following their injury. These are the first such positions in Australia.</p>
<p>Typically nurses, the coordinators meet the patient and their family in hospital immediately after injury. They provide education around brain injury and subsequent rehabilitation and recovery, as well as psychological support. </p>
<p>They also liaise with other services and care providers such as GPs, specialists, and Aboriginal Community Controlled Health Services. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/indigenous-health-leaders-helped-give-us-a-plan-to-close-the-gap-and-we-must-back-it-54480">Indigenous health leaders helped give us a plan to close the gap, and we must back it</a>
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<p>Meanwhile, the project is providing training for hospital staff to enhance their skills and knowledge in delivering culturally secure care for Aboriginal people with brain injury.</p>
<h2>There are success stories</h2>
<p>Our research has revealed stories of “successfully” <a href="https://www.tandfonline.com/doi/abs/10.3109/17549507.2011.663790?casa_token=HYZ73LG3M7cAAAAA:FzG6ySsMd4b7egYofsJTiiIqWLjtNzIHoCrLugmz0mFoCiSGXIfasEVoALIMVtIzwj4FTV69lVSD6Q">living with brain injury</a>. </p>
<p>One man who suffered a severe stroke looked to family and community groups to support his recovery. He resumed painting, travelling, and socialising over time, despite being partially paralysed and having virtually no speech. This was enabled by a strong will and help from his sister who organised taxi vouchers, train trips and other supports.</p>
<p>These stories provide a rich basis from which to explore alternative possibilities in the rehabilitation process. Learning from Aboriginal brain injury survivors about how to re-engage with community and return to regular activities offers insights that can be shared with brain injury survivors in the future, and, importantly, with rehabilitation service providers.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-art-of-healing-five-medicinal-plants-used-by-aboriginal-australians-97249">The art of healing: five medicinal plants used by Aboriginal Australians</a>
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<p>The issues raised for Aboriginal people with brain injury are mirrored in First Nations people with a range of other conditions. </p>
<p>While examples of individual clinicians attempting to provide culturally secure services were evident in our research, system-wide practices doing the same were rare. </p>
<p>To build a more culturally secure approach for Aboriginal patients recovering from brain injury, there needs to be acknowledgement of patient experiences alongside a system willing to implement change.</p>
<p>The involvement and leadership of Aboriginal researchers, health professionals and consumers is essential.</p><img src="https://counter.theconversation.com/content/115128/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Beth Armstrong receives funding from National Health and Medical Research Council, Western Australian Department of Health, Royal Perth Hospital Medical Research Foundation, Australian Institute for Aboriginal and Torres Strait Islander Studies. </span></em></p><p class="fine-print"><em><span>Juli Coffin does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The absence of Indigenous Australians in rehabilitation services has created the belief they don’t want therapy. The reality is they want services which better meet their cultural needs.Beth Armstrong, Foundation Chair in Speech Pathology, Edith Cowan UniversityJuli Coffin, Ellison Professor of Aboriginal Research, Telethon Kids InstituteLicensed as Creative Commons – attribution, no derivatives.