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Brain Injury and the role of the Clinical Neuropsychologist

Accidents of various sorts can cause a serious head injury that requires treatment and rehabilitation. If it is serious enough it is likely to cause a brain injury. The most common cause is a road traffic accident (RTA) but other sorts of accident can cause a brain injury such as an accident at work (i.e. industrial accident) or as a result of a medical accident (e.g. anaesthetic accident).

A serious brain injury is likely to require medical attention and possibly a period of medical treatment. In hospital the doctor will use the Glasgow Coma Scale (GCS) to measure the severity of the injury. There may be a period of unconsciousness and if so this is often followed by a period of confusion or poor memory called post traumatic amnesia (PTA).

If there has been a mild brain injury the person may recover quite quickly however they sometimes experience physical and/or cognitive symptoms. These may include headaches, dizziness and tiredness as well as difficulties concentrating and remembering things as efficiently as usual. A mild brain injury may be referred to as a concussion and so if such symptoms continue for an extended period of time it may be said that the person is experiencing post-concussion syndrome (PCS). Some people find that they are not able to carry out their normal activities, such as work or leisure pastimes, until these symptoms resolve or become less severe.

When brain injury is more severe the symptoms may be more serious. Physical symptoms may include weakness or paralysis of one of more limbs, inco-ordination, double vision or slurred speech. Memory is likely to be poor and concentration may be difficult to sustain. In some instances speech is affected but more often the person is less efficient at communication, such as giving too much detail or wandering off the topic of conversation. As the frontal lobes are often affected and so executive functions are likely to affected including the ability to plan and regulate on-going actions. The person may act or react out of character from their usual self (i.e. altered personality) and in some instances the degree of change in their behaviour may be quite marked. Irritability, impatience and short-temper are not unusual, sometimes to the extent that they become aggressive. In many cases relatives and friends may notice that the person who has been injured does not seem to have a full appreciation of the effects that the brain injury has had upon them and the implications this may have for their future.

Treatment initially is focused on any urgent or acute problems (e.g. internal bleeding or broken bones). Once the person is considered medically stable and therefore no longer in need of medical treatment or intensive nursing care they may move to a rehabilitation unit. They are likely to have therapy from variety of professionals such as physiotherapy, occupational therapy and speech therapy. Such rehabilitation from a multi-disciplinary team is now the norm in most units, however not all teams include a clinical neuropsychologist.

A clinical neuropsychologist specialises in assessing the effects of a brain injury and advising on therapy and rehabilitation. During their assessment they are likely to use a variety of tests of cognitive function such as memory tests. A neuropsychological assessment may be carried out as part of the process of pursing compensation when a personal injury claim is pursued. In this case the neuropsychologist acts as an independent expert who provides a report for the court about the cognitive and psychological effects of the brain injury. They may also carry out an assessment to help guide the person's rehabilitation so that their input as well as the input from other therapists is designed to suit that person's individual difficulties.

The clinical neuropsychologist's role in rehabilitation may cover various areas. One mentioned above is assessment of the cognitive effects of the injury. They may provide information and discuss these effects with the person and/or their relatives. Some sort of psychological reaction to what has happened is common therefore they may offer treatment for anxiety, depression or other forms of psychological disturbance.

It is important to have some understanding of the distinctions between different related professionals who may become involved during rehabilitation. A counsellor or counselling psychologist can offer support but they do not have the specialist knowledge about neuropsychology. A neurologist may be involved, particularly if the person has suffered an epileptic seizure as a result of the injury. As a medical specialist they are more likely to be involved with any medical (i.e. neurological) problems. A psychiatrist or neuro-psychiatrist is another medical specialist who may become involved in treatment of psychological disorders such as anxiety, depression as well as suspiciousness and agitation. There is considerable overlap between all of these professionals, including the clinical neuropsychologist.

Rehabilitation following a brain injury takes various forms dependent on the stage of recovery and the nature of the predominant problems. Post-acute rehabilitation usually follows the initial hospital treatment and the treatment of physical as well as cognitive symptoms. 'Cognitive' or neuropsychological rehabilitation focuses on the cognitive problems and aims to increase the person's awareness of these and their ability to compensate for them using various strategies. Specialist rehabilitation programmes can also be found for severe behavioural disturbance and persisting coma.

Post traumatic stress disorder (PTSD) can develop after an accident. The most common treatments are medication that relieves symptoms such as anxiety or depression and Cognitive Behaviour Therapy (CBT). Eye Movement Desensitisation and Reprocessing (EMDR) is another approach that may be recommended for the treatment of PTSD. Both approaches have been shown to be effective in recovery from PTSD but depend on the commitment and participation of the person to achieve the best results. CBT and EMDR are provided by a variety of clinicians including clinical psychologists, counsellors, counselling psychologists and psychiatrists.

Dr Drew Alcott
Consultant Clinical Neuropsychologist

TERMS

Anoxia

Technically this refers to a total lack of oxygen of a period of time but in practice it is usually hypoxia that has occurred.

Brain injury

Brain injury refers to a broad category including strokes, head injury, or lack of oxygen (i.e. anoxia or hypoxia). The injury may be in the form of contusion, haemorrhage, poisoning (e.g. due to chemicals) or lack of oxygen or nutrients in the blood supply.

Clinical Neuropsychologist

A clinical neuropsychologist is a psychologist who specialises in assessing and treating people who have had a brain injury. In Britain they form a branch of clinical psychology, which is the study and treatment of psychological disturbance and disorder, such as anxiety and depression. They are different from a neurologist, who is a medical specialist that diagnoses and treats diseases of the nervous system (e.g. Parkinson's disease or multiple sclerosis)

CBT (Cognitive Behaviour Therapy)

CBT is the most commonly used psychological therapy approach in Britain. As its name indicates it combines 'cognitive' and 'behavioural' approaches. It is applied to a wide range of psychological disorders and there is substantial evidence of its effectiveness. The 'cognitive' component involves learning thinking strategies to counterbalance thoughts or ideas that are associated with the disturbance (e.g. alternative thoughts), whether it be anxiety, depression or other problem (e.g. post-trauma stress). The 'behavioural' component involves planned activities or experiences that help to reinforce the alternative thoughts.

Cognitive / Cognition

Cognition refers to mental functions such as memory and concentration. There are a wide range of cognitive functions relating to other mental abilities such as speaking, reading, recognising objects, remembering how to use an object or making a plan. The function considered to be the highest level of cognition is called executive function.

Coma

When someone is unconscious for a length of time they are said to be in a coma. The length of time they are in a coma depends on how serious the injury was to the head or the brain.

Concussion

Concussion is the medical term sometimes used to refer to a mild head injury, usually without a period of unconsciousness

Contusion

This is the technical term that refers to bruising to the brain.

Counsellor or Counselling Psychologist

Counselling is a general term applied to methods and an approach which is likely to focus on offering emotional support as well as support in making difficult decisions and plans.

Disability

Disabilities are the effect that impairments have on a person's ability to carry out normal activities of life (e.g. bathing and dressing, shopping, preparing meals, managing personal finances, pursuing sports or other pastimes and working)

EMDR (Eye Movement Desensitisation and Reprocessing)

EMDR is a method used by some clinicians to treatment PTSD. It involves a combination of repetitive eye movements whilst recalling and/or discussing traumatic experiences. Although there is evidence that people who have undergone EMDR have improved, there is controversy about which components of the therapy are necessary and which are not.

Executive Functions

The term 'executive functions' refers to the brain's ability to regulate and control its own activity. These functions allow us to choose a set of actions that are appropriate to the situation and carry these out in the correct order or sequence of steps. The term also refers to the monitoring process which ensures that chosen course of action is completed and if necessary adjusted or changed completely if things are not going as planned or intended.

Frontal lobes

The frontal lobes are the areas of the brain that lie immediately behind the forehead, above the eyes. They play a major role in the executive functions.

Glasgow Coma Scale (GCS)

The Glasgow Coma scale is a quick method used by doctors in hospital to measure the severity of a brain injury. It involves assessing how awake and alert they are, whether they are able to move their limbs and whether they can speak. The doctor rates the person's response in each of these three areas. The maximum score on the GSC is 15 and lowest score is 3. If the score is below 15 but higher than 9 it is classed as a 'mild' injury. Scores below 9 are classed as 'severe' injury.

Head Injury

The term head injury includes anything from minor injury, such as a bump to the head, to a very serious injury that results in a coma.

Haemorrhage

The term haemorrhage refers to bleeding within the head, either on the surface of the brain or within the brain tissue. Hence location of the haemorrhage may be indicated such as "intracerebral haemorrhage" (i.e. within the brain tissue) or "subarachnoid haemorrhage" (i.e. on the surface of the brain.

Hypoxia

A period of time during which there is not enough oxygen reaching the brain.

Impairments

The term 'impairment' refers to the reduction in function of an injured organ or system. In the case of brain injury impairments relate to cognitive functions, such as memory and executive function, as well as motor functions, such as muscle poor and co-ordination. A brain injury can impair other systems such as that involved in regulating hormones.

Multi-disciplinary team

The term 'MDT' refers to a team of therapists as well as nurses, doctors and psychologists in some settings.

Neurologist

Neurology is a branch of medicine that deals with neurological diseases and disorders such as Parkinson's disease, multiple sclerosis and epilepsy. Following a brain injury they may be involved in diagnosis relating to certain symptoms (e.g. double vision) and/or treatment of related disorder (e.g. post-traumatic epilepsy).

Post-concussion Syndrome

This is a medical term used to refer to a cluster of physical and cognitive symptoms that persist after a mild brain injury or concussion

Post Traumatic Amnesia (PTA)

A period of time following a brain injury when memory may be poor, sometimes to the extent that the person is confused and so not able to remember what has happened recently, including the fact that they are in hospital and not doing engaging in their usual activities, such as work. PTA usually gradually resolves and the person becomes able to remember recent events, even if their memory remains less efficient than usual. The length of PTA usually relates to the severity of the injury and so is often used to measure severity.

Post traumatic stress disorder (PTSD)

PTSD is a common psychological reaction to traumatic events in which life or limb is in jeopardy. Symptoms may include nightmares, irritability and anxiety. Often people will avoid things that remind them about the events such as discussing what happened, watching related news items or television programmes or driving if the trauma was a road accident.

Rehabilitation

Rehabilitation is the general term applied to any treatment or therapy that aims to help the person resume their usual activities to the fullest extent possible within the limits of any persisting impairments. Its primary aim is reduction of disability.

RTA

The abbreviation RTA refers to a road traffic accident, in other words a serious car crash. It may also be referred to as an MVA (i.e. motor vehicle accident). The person who has been involved in an RTA was not always in a car. They may have been riding a motorcycle, bicycle or been hit a vehicle whilst walking (i.e. as a pedestrian).

Why George Ide Phillips?

If you or someone dear to you has suffered a brain injury it is essential to consult a specialist solicitor. Early instruction to the right firm can result in you receiving the best treatment and rehabilitation that is available on the NHS or privately. Our brain injury team is nationally recognised by the independent "Chambers Guide to the Legal Profession 2007" as having a "...well recognised in brain injury cases".

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