My husband, Norm, has lived in a long term care home since acquiring his brain injury six years ago. Each holiday, be it Easter, St. Patrick’s Day, Halloween or Christmas, the facility decorates the common areas, in attempt to give residents and their families a more festive experience.
To be honest, since Norm’s accident, I really haven’t felt like celebrating the holidays. Norm and I don’t have kids so why bother? It seems as though I am just going through the motions.
Thankfully, Norm and I have good people around us. We get a crew together to decorate Norm’s room each year. His brother, sister-in-law and friends come to help. They help bring out the holiday spirit – which is hard, as Norm doesn’t show many emotions.
As much as possible, we try to keep things the same as before the accident. Christmas Eve we go to our parish church for mass. On Christmas Day we go to Norm’s brother’s to open presents and see the rest of the family. In the afternoon, Norm and I head over to our friends to wish them a Merry Christmas.
Despite this, our trips are more complicated now and planning is essential. When Norm and I go anywhere, I have to book the mobility van that is at his long term care facility. If the van is booked, I have to phone the taxi company. I have to strap Norm in with seat belts for safety. When we go out for Christmas dinner, to a restaurant or to friends, I have to make sure that Norm has a pureed meal to eat.
At the end of the day, I think having family and friends around is all Norms needs as when they are around, he just beams.
After her husband’s injury, Theresa went back to school to become a Personal Support Worker. She has taken courses in brain injury, and is now a full time caregiver. You can follow her on Instagram, HERE
I’d like to take a moment here to note that persons of any gender may be either perpetrators of or victims of IPV. The majority of the studies I will be summarizing are regarding female survivors of IPV perpetrated by males. As more research becomes available we may gain further insight into other relationship dynamics.
Survivors of IPV
Anyone who has experienced injuries to the head and/or neck (including being shaken), should be assessed for a brain injury.
This includes people who have experienced strangulation, since brain injury can occur from lack of oxygen to the brain. People who are living with brain injury are at an increased risk of depression or anxiety and tend to experience frequent headaches, fatigue and dizziness. Many experience cognitive issues such as impaired memory and concentration as well as difficulty planning and making decisions.
Understanding these symptoms are the effects of the brain injury, and getting help dealing with them, may help a survivor make decisions regarding their living situation and plan to gain independence from a violent partner. It may also validate their experiences, knowing there are real health issues going on, and they are not ‘just making things up.’
The good news is that research is starting to focus specifically on how females recover from brain injuries and how brain injuries from IPV and other forms of assault may be different from those sustained in other ways (such as a car accident).
As such, survivors of IPV who have sustained a brain injury (and feel they are able to so) may wish to participate in research in order to help further our findings with the goal of increasing the information base for other survivors.
Social Support is Crucial
Social isolation and loss of relationships are too common after brain injury, and those who have strong social support networks in place post ABI are more likely to have better outcomes than those who do not.
A reliable support system may be even more important for women with a brain injury as the result of intimate partner violence. Not only will they be dealing with the effects of a brain injury, but they may be leaving a violent partner, and / or dealing with the emotional and psychological impacts of having survived intimate partner violence.
Women may require financial support, legal information and a safe place to stay (with their children, if applicable) and temporary or ongoing caregiving.
While it is important to screen for brain injuries from IPV, it is complicated by issues regarding how safe a patient feels disclosing IPV. Some patients may fear retaliation if their partner finds out they’ve talked about the abuse and some may fear for the safety and custody of their children.
Research findings from other studies often help direct future research. I would caution that while past studies can be helpful, the literature may be missing more than we realize when it comes to survivors of IPV, for the following reasons.
Some survivors may choose not to participate in research or discuss their experiences. Depending on how risky they feel disclosing the IPV may be, survivors may not be seeking out medical assistance after injuries or they may not be forthcoming with details about how it happened.
Loss of follow-ups
If survivors seek medical attention, they may not return for follow-ups depending on whether or not they are trying to avoid alerting their partner about their medical visits.
Lack of details about injury
Unlike traumatic brain injuries from sports injuries or vehicular accidents where there are witnesses or first responders to provide information about the incident, survivors of IPV may have to rely solely on their own memories of the event (which can be difficult for anyone with a brain injury). They may not know how long they were unconscious or how many blows to the head they have sustained. Having accurate details about an injury can be helpful for research, especially when it comes to understanding post-injury recovery patterns and outcomes. While definitely not the fault of the survivor, having missing data may make it difficult to reach conclusions about the recovery of this population.
Incomplete representation of population
A study by the World Health Organization (WHO) found there are different societal standards for what constitutes IPV in countries where women have fewer rights. Therefore IPV may be underreported in other cultures or countries where males are viewed as having the right to punish their wives. Ideally there should also be more representation in the research from other relationship dynamics, such as those with trans partners, same-sex relationships, relationships where the female is the perpetrator and the male is the victim and relationships where both partners are violent.
Now, this is not to discount the value of research being done in this area. It is a historically under-represented group in the brain injury literature and researchers are now making great strides to shed light on how brain injury may differ for this population. It is hopeful that with continued research, we can tailor rehabilitation and support for this group with the aim of improving their recovery and quality of life.
Alana is a researcher who recently completed her Master of Science degree at the Rehabilitation Sciences Institute at University of Toronto. She has been studying brain injury for several years in topics including but not limited to: substance misuse, recovery, neurofeedback, sleep, and hospital-to-school transitions. Her aim for her blog posts is to continue to learn about and promote learning about brain injury research, hopefully making it easier for interested persons (brain injury survivors, caregivers, loved ones, clinicians etc.) to access relevant information.
In the current climate of concussion clinics, many tools are being used to assess this type of serious injury, also known as traumatic brain injury (TBI), or acquired brain injury.
Assessments can include physical and mental status examination, Glasgow Coma Scale, Immediate Post-Concussion and Cognitive Testing (ImPACT) computer-based system, Balance Evaluation Scoring System (BESS), Inertial Sway measuring devices, and Optogait assessments. 1-3
Each assessment method is designed to evaluate the different aspects of the complex physical, cognitive and emotional disturbances that can result from a concussion.4
Establishing a ‘baseline’ with patients before a concussion occurs is useful in evaluating a person post-concussion to determine how the injury has affected them.1, 3, 5 This is not always possible given how and when a brain injury can occur. An Assessment baseline can always be performed when commencing treatment and as an introduction to a rehabilitation program, and to compare against when re-evaluating a patient’s progress throughout their program.
One tool we are using to establish a patient’s baseline is the Optogait, which is considered a ‘gold-standard’ device for measuring gait (how a person walks), balance and movement symmetry.6-9
The simple 30-60 second test of walking on a treadmill can be recorded by a computer system using lasers to establish the individual characteristics of the patient’s gait, which can then be remeasured throughout the rehabilitation program. This test gives objective data on all aspects of the gait cycle, as well as stability, balance and movement symmetry.
The amount you move when standing still (your postural sway), can also be measured by 3D accelerometers (which track acceleration), gyroscopes (which track orientation), and magnetometers (which, according to the journal, Karger, ‘measure the’ magnetic fields emitted by the brain, generated by neuronal activity).10 These tools allow a much precise measurement of sway – up to 1,000 times per second more – compared to the current manual testing.
We also determine the speed of cognitive processing during walking by testing patients walking while counting backwards. The movements of the eyes and head together (Vestibular Ocular Reflex) are also tested in order to determine concussive symptoms.
These tests are useful when a patient may feel that their concussion symptoms have resolved, but in fact, their cognitive processing is still poor.
The Gyko component of the protocol also tests sway, which is the movement of the centre of mass, and upper vs. lower body plus compensatory movement patterns made by the brain to return to a normal set point when standing and walking.
These tests are blended nicely with the Optogait March in Place Tests (eyes open/eyes closed), and Gyko system to determine changes in physical functioning with changes in body position.
Most recently, a validation study was conducted to utilize the Optogait® equipment for evaluation of march-in-place tests traditionally used for vestibular (inner ear) testing, called the Fukuda or Uterberger Stepping Test. 3, 13-15
Using objective physical characteristics of the pathophysiology of TBI, the data collection with the OPTOGAIT equipment cannot be easily altered by the patient, thus you cannot under-estimate your symptoms with testing of gait, postural sway, or marching in place tests with your eyes open or closed.
This testing protocol provides an objective, evidence based protocol for both assessing, documenting and treating acquired brain injury.
Hirsch MA, Grafton L, Runyon MS, et al. The Effect of Cognitive Task Complexity on Postural Sway in Adults Following Concussion. Archives of Physical Medicine and Rehabilitation. 2015;96(10):e51.
Gaudet CE, Weyandt LL. Immediate Post-Concussion and Cognitive Testing (ImPACT): a systematic review of the prevalence and assessment of invalid performance. The Clinical neuropsychologist. 2017;31(1):43-58.
Engelson MA, Bruns R, Nightingale CJ, et al. Validation of the OptoGait System for Monitoring Treatment and Recovery of Post-Concussion Athletes. Journal of chiropractic medicine.
Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. British journal of sports medicine. 2013;47(1):15-26.
Alberts JL, Hirsch JR, Koop MM, et al. Using Accelerometer and Gyroscopic Measures to Quantify Postural Stability. Journal of athletic training. 2015;50(6):578-588.
Lienhard K, Schneider D, Maffiuletti NA. Validity of the Optogait photoelectric system for the assessment of spatiotemporal gait parameters. Medical Engineering & Physics. 2013;35(4):500-504.
Lee MM, Song CH, Lee KJ, Jung SW, Shin DC, Shin SH. Concurrent Validity and Test-retest Reliability of the OPTOGait Photoelectric Cell System for the Assessment of Spatio-temporal Parameters of the Gait of Young Adults. Journal of physical therapy science. 2014;26(1):81-85.
Gomez Bernal A, Becerro-de-Bengoa-Vallejo R, Losa-Iglesias ME. Reliability of the OptoGait portable photoelectric cell system for the quantification of spatial-temporal parameters of gait in young adults. Gait & Posture. 2016;50:196-200.
Ammann R, Wyss T. Comaparison of Three Gold-Standards to Measure Ground Contact Time in Runners. SPORTWISSENSCHAFTLICHE. 2011.
Neville C, Ludlow C, Rieger B. Measuring postural stability with an inertial sensor: validity and sensitivity. Medical devices (Auckland, NZ). 2015;8:447-455.
Iosa M, Morone G, Bini F, Fusco A, Paolucci S, Marinozzi F. The connection between anthropometry and gait harmony unveiled through the lens of the golden ratio. Neuroscience letters. 2016;612:138-144.
Iosa M, Bini F, Marinozzi F, et al. Stability and Harmony of Gait in Patients with Subacute Stroke. Journal of Medical and Biological Engineering. 2016;36(5):635-643.
Zhang YB, Wang WQ. Reliability of the Fukuda stepping test to determine the side of vestibular dysfunction. The Journal of international medical research. 2011;39(4):1432-1437.
Honaker JA, Boismier TE, Shepard NP, Shepard NT. Fukuda stepping test: sensitivity and specificity. Journal of the American Academy of Audiology. 2009;20(5):311-314; quiz 335.
Grommes C, Conway D. The stepping test: a step back in history. Journal of the history of the neurosciences. 2011;20(1):29-33.
Maerlender AC, Masterson CJ, James TD, et al. Test–retest, retest, and retest: Growth curve models of repeat testing with Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). Journal of clinical and experimental neuropsychology. 2016;38(8):869-874.
Schatz P, Glatts C. “Sandbagging” baseline test performance on ImPACT, without detection, is more difficult than it appears. Archives of clinical neuropsychology : the official journal of the National Academy of Neuropsychologists. 2013;28(3):236-244.
One in five Canadians will experience a concussion from sport in their lifetime. Suffering a concussion can lead to a range of debilitating symptoms such as constant fatigue, changes in mood, headaches and difficulty concentrating.
Returning to work after a concussion can be challenging and if not done properly may slow recovery. There are activities and techniques that allow for the smoothest transition back to normal life and the best chance for a full recovery.
The following are some tips on how to recover from a concussion and return back to work while maintaining your health.
There are good days and bad days and accepting that things will take time is important to maintaining a high level of mental health.
Say yes to help & support
The Centre of Disease Control and Prevention recommends gathering support as an important part of recovery and may help lift the burden of a concussion off an individual’s shoulders. Support can come from many places: a partner, a family member, a healthcare professional or a manager at work.
Having open channels of communication can lead to a greater understanding and empathy during recovery. It is easier for your peers to understand your situation and support you through the process if they know what has happened.
For example, a manager who knows their co-worker has recently experienced a concussion should lessen the workload initially as the individual begins the transition from rest back to work and this may help decrease their symptoms and stress.
Once someone has experienced a concussion it is important to recognize what triggers his or her symptoms. Every concussion is different and these triggers may range from person to person. The backlight on a computer screen may cause headaches, exercise may cause nausea, and conversations may cause fatigue.
Every individual has a different set of factors that will influence their symptoms. If an activity makes symptoms worse, then it is important to stop that activity and rest. For instance, if conversations’ are overwhelming, take a break from social engagements.
Manage your energy
It may sound simple, but managing symptoms and energy amongst all of the different aspects in your life can be a real challenge. Once the symptoms are resolved someone may wish to return to work. Returning with a decreased workload, taking scheduled breaks and being cognisant and respecting symptoms are helpful to ensure that transition goes smoothly.
Accepting that an injury has happened, and that it will take some time to recover from, is another important aspect to consider when living with a concussion.
There are good days and bad days and accepting that things will take time is important to maintaining a high level of mental health. The recovery process and managing setbacks can be incredibly frustrating, and patience can be one of the most important aspects of a recovery.
A person should focus on the activities that they can control and feel like they are making progress on, as opposed to the activities that are out of their control. Light exercise (As long as a person does not experience worsening symptoms), a balanced diet, and getting enough sleep are part of the foundation to achieve health and could be part of a recovery plan.
Having a concussion can initially be draining and frustrating. Having the support from work and peers, being aware, managing symptoms, and accepting that recovery takes time can go a long way towards making the transition back to normal life successful.
LCD screens surround us. Many people stare at computer screens throughout their workdays, taking breaks only to check social media on their smartphones.
While there are far fewer concussions in the world than there are screens, the frequency with which these injuries occur has been increasingly acknowledged in the mainstream media. Athletes such as Sydney Crosby, Steve Young, and Eric Lindros just to name a few, have brought the severity of Post Concussion Syndrome (PCS) to the forefront of public discourse.
A person who suffers from PCS will experience symptoms such as dizziness, nausea and headaches for an extended period of time after the initial injury. This can last for weeks or months, and there is no clear answer as to how it can be minimized.
The few treatment options that health professionals agree to are: rest, and a complete break from LCD screens.
While all cognitive activity can worsen the severity of headaches and dizziness in people with concussions, there are several reasons why the use of LCD screens in particular can exacerbate these symptoms:
Images that appear on LCD screens are made up of pixels that refresh at a rate of 60 times per second, even when the content on the screen is not changing.
The rapid movement of these pixels means when we look at screens for too long, we strain our eye muscles.
For someone who has suffered a brain injury, this strain can be detrimental.
Further, the backlighting of LCD screens can cause cognitive fatigue, headaches, dizziness and nausea in concussion patients.
22-year-old Maggie Callaghan, a varsity athlete who has suffered several sports related concussions over the past few years says she tried to avoid computer screens all together for weeks after her first concussion.
“I couldn’t look at a screen for more than a few minutes without feeling intense pain behind my eyes that would quickly evolve into a full blown migraine” Callaghan said. “I tried to avoid computer screens altogether for as long as I could.”
Maggie is one of many young concussion victims for whom the inability to study using a computer screen resulted in severe stress.
“It sort of becomes a cycle,” says Joe Ross, a 20-year-old student who, like Maggie, has suffered from concussions. “You feel sick when you use your computer to do school work, but when you aren’t able to keep up with your school work you feel anxious which can be harmful to the recovery process.”
Anxiety is just one of many mental health problems that disproportionately affects concussion patients. In fact, two out of three concussion patients experience depression following their recovery.
The social isolation that comes from being unable to communicate using computer and phone screens, as well as the stress associated with being unable to complete day-to-day tasks, are thought to be two of the primary causes of depression in concussion victims.
As difficult as it can be for students to abstain from using screens following their concussions, the struggle to recover from PCS without the use of computers can be even more intense for working adults.
“The recovery process would have been even more stressful if I had been working in a professional environment at the time of my concussions,” says Maggie. “So many jobs involve, if not completely revolve around, using computers. Being unable to work and not knowing when I would get better would be seriously nerve-wracking.”
Currently, treatment options for PCS do very little to account for the importance of screens in the average person’s everyday life. Patients have to work hard to engage in society and keep up with school or work without the use of their computer screens.
This can often be one of the most unexpected challenges of dealing with PCS.
So where does this leave people needing to return to a pre-concussion life while dealing with PCS?
While there are no solutions, one recent pilot study commissioned by the Canadian Concussion Centre indicated that people experiencing PCS were able to use a non-LCD screen, thus enabling a quicker return to school or work life.
Colin Harding is the CEO & Co-founder of Iris Technologies – aCanadianhealthcaretechnologycompanythatisimprovingthelivesofpeople whohavesufferedfromamildtraumaticbraininjury (MTBI) orlivewithchronicmigraines.
Meet Elizabeth Farquharson – the final hero we’re showcasing in our Heroes of Brain Injury Series – we can’t wait to see her and all the heroes on October 1st!
Our ABI hero Elizabeth Farquharson doesn’t need to run as fast of the speed of light to impress us, she’s worked in the field of brain injury for over two decades and is still going strong! Find out more about this amazing hero of brain injury below!
BY: JENN BOWLER
Tell us a bit about your work:
I have been a physiotherapist for 34 years and working in brain injury for about 20 of those years at Sunnybrook Hospital, as a clinician and more recently as a coordinator of care for trauma patients. I am a member of the ABI Network Transitions Committee and also have been involved in development of best practice guidelines for brain injury through the Ontario Neurotrauma Foundation. Despite the often devastating nature of trauma and brain injury, it has been a very rewarding career and I am often in awe of the patients and families that I have worked with. I admire the way people have managed to conquer so many obstacles and continue along chosen paths or find new meanings and different ways of doing things.
Why do you participate in the BIST 5K?
The BIST 5K is a way to support our brain injured patients and families and for our trauma ward to come together in a social event that is fun and inclusive. This year will be my fifth year participating!
I have run one year and walked all the other times – hoping one day there will be a prize for the slowest! I love that the BIST 5K doesn’t care how you do it; only that you do it. There are people cheering you over the finish line regardless of how fast or slow you are!
What does being a hero of brain injury mean to you?
It means doing your best to provide the best patient care that you can. It means supporting and advocating for your patients and families and being involved in that journey of recovery. Even if I’m only involved for a short time while they are part of the early acute care phase at Sunnybrook, it is still a privilege and honour to work with brain injured clients and families and see their progress and resilience. It is so rewarding when these individuals come back to visit us at the hospital, and we are able to follow their journeys.
What is your favourite part about Race Day?
It’s a lot of fun and I love meeting different people from survivors of brain injury to the whole spectrum of care involved in recovery. I love the park, the fresh air, the healthy competition and the family involvement!
Jenn Bowler is a social worker in the Trauma Program at Sunnybrook Health Sciences Centre and is a member of the BIST 5K Run, Walk, & Roll Committee.