An interview with Russell Sheldrick: Clinical Neuropsychology

Brooke 00:00:24 - 00:00:36

Hello and welcome to another edition of our brain injury bites. This one I'm really excited about because we’ve actually got my treating clinical neuropsychologist, Russell Sheldrick. Hello, Russell.

Russell 00:00:36 - 00:00:39

Hi Brooke. Good to see you. Thank you for inviting me.

Brooke 00:00:39 - 00:00:46

Good to see you too. It's actually the first time I've seen you since before the pandemic started, so it's nice to see your face.

Russell 00:00:46 - 00:00:54

And you too, we've had a few conversations over the past few years, but, you know, sadly the pandemic in the way of meeting face to face, didn't it?

Ashwini 00:00:54 - 00:01:07

Well, thank you for joining. It's nice to meet you. Obviously, I haven't met you before. It would be really lovely actually, Russell, if you could just give us a little bit of an introduction as to who you are, what you do on a day-to-day basis, etcetera.

Russell 00:01:07 - 00:02:14

My title is consultant clinical neuropsychologist, which is quite a mouthful, but we're friendly people in this profession and I work with patients who’ve had traumatic brain injury, brain hemorrhage patients, brain tumour patients and a whole host of other neurological. Through my clinical work, probably the majority of it is one to one direct work with patients and their families. But I also get involved in work with groups of patients as well as and this in an area I’m getting more and more interested in and work with relatives and carers and institutions as they see and support patients of neurological conditions.

And I have to say it is very privileged work. It really is a privilege working with people with neurological conditions and just extremely fulfilling and satisfying to be alongside people in their recovery journey as they rebuild lives up from either injury or disease. And yeah, it can be very inspiring work.

Ashwini 00:02:14 - 00:02:35

I can imagine, I can imagine. And I guess when you're working not only with the patients themselves, but also their family members, you get a real insight into who that person was, how they've changed. But then also that journey as they begin to recover some of what was there before. That in itself must be hugely, hugely rewarding.

Russell 00:02:35 - 00:03:16

Yes, as I say when it goes well it's very inspiring as well as you see people taking very courageous steps and putting a lot of effort in because invariably there are challenges in that journey. It's not always a very easy process. There are ups and downs. There are situations where you have to manage your expectations of recovery. But when it all fits into place and we typically work not just in isolation as a profession, but with other professions alongside us. Yes, it's great to see it when it comes together.

Brooke 00:03:16 - 00:04:03

You do wait a little while though. Because the first time I knew of. Well, don't know if I can remember the first time I knew of you because obviously, after a head injury you go for a period of post traumatic amnesia. My parents told me that because I worked in a bar at the time, I got a lot of visitors and I think my mum was, or my mum and my dad, were quite nervous about you when they first saw you because you were in the in the corner of the room, as these people were coming in to see me. And I kind of took over the ward with visitors. And they were thinking that you were really kind of upset with me. But you said that was really good initially to get that that stimulation from your friends.

Russell 00:04:03 - 00:04:49

So I can remember that Brooke and you know, in a ward environment when you first came into hospital following your traumatic brain injury, we do have to be very careful in managing the environment, not just for you as a patient, but for those around you as well. And sometimes if situations become overwhelming, there's too much noise or there's too much sort of busy activity around people can get distressed. But we were noticing that actually that was quite motivating for you. You know, you were relating to your friends and clearly getting A bit of dare I call it comfort, but just fun and a bit of normal life interaction with those people. So yeah, it was fine to let that continue.

Ashwini 00:04:49 - 00:05:04

My question to you would be at one point do you get involved? Clearly, you’re involved on a regular basis when patients are going through the rehab ward side of things. But do you have input sooner than that whilst still in the acute phases?

Brooke 00:05:04 - 00:05:10

I was told that you were waiting till I was out of post traumatic amnesia.

Russell 00:05:10 - 00:07:42

Tricky question to answer very directly and succinctly but here at the Manchester Centre for Clinical Neurosciences we have neuropsychology input nearly every stage of a patient’s journey. It's very little in the A and E stage but when a patient is admitted to the trauma ward, we have psychology input there. So that's looking at quick assessment of a person’s cognitive or information processing ability, if there's any behavioral disturbance that we need to work on while they’re in those early stages of recovery, psychology will get involved there, and sometimes there is a need for emotional support early on.

So from the early, very acute stages of the person’s recovery, there will be some psychology input available and that's decided on really by the team. If they feel the treating team on the ward needs some psychology support, they will request that and we do our best to respond.

I mean, Brooke, in your case, you had moved to what we call the acute rehabilitation ward and that's where I was working at the time, so I was the psychologist on that ward. So you and I met at a very early stage in your recovery journey.

Not everywhere in the country will have acute rehabilitation wards. It's typically that you're treated either surgically or medically and then you await a rehab bed elsewhere.

Here at the Neuroscience Centre in Manchester, we try to get rehab started as soon as possible. The evidence is that whilst the brains in this state of flux, if we get the right amount of stimulation and rehab exercise for that person’s stage of recovery, we are perhaps speeding up their recovery, improving their chances of a better recovery. That doesn't mean that we're busy with them 24/7 on that ward. Of course, rest is very, very important in the acute stages, but we do try to get going with our physiotherapy, occupational therapy, speech therapy if necessary, and provide an environment in which people are stimulated just enough to start improving in the very early days of their either brain injury or illness.

Ashwini 00:07:42 - 00:08:07

Just to give our listeners some idea, what does neuropsychological rehab look at that early stage, because I'm, guessing it's an evolving process. So as somebody recovers and gains more function the shape of rehab will change and the level of input. But in the early, early, acute trauma phases when there's still so much going on, what do you do with patients?

Russell 00:08:07 - 00:10:37

For a lot of patients some of it is about building insight into their condition. Some patients are in a state of unawareness about their condition, and therefore it's very hard for them to engage in tasks that they don't see as relevant. Why are you asking me to do these physical exercises? Why are you asking me to build up my independence in washing and dressing? They're insight can be compromised and therefore psychologists would have to work with them very sensitively to develop insight in a way which doesn't overwhelm them and cause a very negative reaction. So we have to be very emotionally sensitive, but quite firm in helping them understand why they are there, what's happened and what our plans are.

Another role is understanding their cognitive abilities. So, for example, if a physiotherapist wants to work on mobility and balance, and they're developing certain techniques to help the person improve in their mobility imbalance. If they have memory difficulties their rehab may get into a Groundhog Day kind of situation. Whereas if we understand the memory difficulties and we're working with cues to prompt a person's ability to remember key information about the exercises they have to do or the reasons why they're doing them, we've got a better. chance of building up progress rather than just going back to square one.

And another vital role while in the early stages is normalising people's feelings and reactions. So maybe as they develop insight as you can imagine, that could be really upsetting. So once their life was OK, reasonably OK. And next they're told, no, you've got these problems. This has happened to you. Remember, for some people, like Brooke described, in the state of post traumatic amnesia, they won't have any recollection of what happened to them. But as that insight builds up, it's quite understandable, they're going to feel quite worried, quite sad, putting it mildly. And therefore, we have to provide an environment in which we are recognising their emotions, normalising them, so yes of course, quite common to go through this, it's understandable.

Aswini 00:10:37 - 00:10:39

I guess it's like a grieving process in some circumstances.

Russell 00:10:39 - 00:11:12

It is. It can be, yes, yes. And obviously a lot of uncertainty at that time. Well if I’m like this now, does this mean I'm going to be like this for the rest of my life? We don't always have answers to that. What we have to say is we work on the assumption that we can make improvements in these areas, so you have us, the team and the health service process that is designed to help you work through some of those situations in and those feelings.

Brooke 00:11:12 - 0:12:02

I can really relate to that emotional side that you said. I remmeber first appointment I had with you or the first appointment I can remember. I remember going through this thing that I'd always forgetting people’s names and I was really conscious because like, you know, someone would tell you their name and two minutes later, they’d ask you their name and you’d have forgotten. And I just thought everyone was perceiving that I was being really rude. I didn't realise that everybody would understand that I had the brain injury and it was totally to be expected.

And I remember you told me your name was Russell and I thought right, I'm going to remember this guy's name. And I’m really sorry to Russell, but I've got a friend called Russell, so I just imagined you as like a really over exaggerated version of Russell. So that's how I remembered. I kept thinking about that all the time. So I really made a massive effort to remember your name.

Russell 00:12:02 - 00:12:52

You put a smile on my face because obviously you're not the first person to have gone through that ward who would struggle with staff members’ names. I remember again, you saying, I feel as if I'm being rude and I hope people don’t think I don’t care about them. And hopefully, well from what you said, I was able to reassure you that that's not the case.

But yeah, I’ve had various versions of techniques to remember my name, including one person who was struggling to remember it. I said, well, you know what, what does my name sound like? Can you come up with something that's in your imagination which will make it a bit funny or a bit odd and he said, yes, you're the man in the crisp packet. It’s the noise a crisp packet makes, isn't it, it rustles, so that's how he remembered my name.

Brooke 00:12:52 - 00:13:17

I then got involved with a charity that you’ll know very well – BASIC - which is the Brain and Spinal Injury Centre in Salford, which is just down the road. And there was a lady who's unfortunately passed away now, Mary Todd, and she used to run the memory class and she used to call herself ma Mary. So that's how everybody remembered that name. You do, you pick up all these little ways of remembering things to patch up these problems that you've now got.

Russell 00:13:17 - 00:13:40

And that's a role we as neuropsychologists have as well. We might have a few off the shelf techniques which we are trained to help people with. But we're also learning from a patient who may say I found it really useful to use this, you know. For example, a mental image of family member to help me remember someone’s name. So then we’d encourage other people to use those techniques as well.

Brooke 00:13:40 - 00:14:59

I remember you used to set me these memory exercises and one of them was to watch a film and start off from (and this is how bad it was at first) start off at like a minute and start a timer for a minute and then stop it. And then you have to write a synopsis of what happened in that last minute. And then you gradually increase it to two, three, five minutes.

And then I used to get overconfident as well, and it was like the first time we went as a celebration of me supposedly getting my memory back. We went to see the James Bond film - it was Casino Royale - and I remember my dad asking me afterwards did I enjoy it, and I said I haven’t got a clue what happened, but I did really enjoy it!

Yeah, I just couldn't follow a film for such a long time, and in some ways 15 years later, I still can’t now. But it's something that you definitely have to be aware of. It's lack of concentration, isn't it. But I think it's the more you practice, the more it kind of improves.

And I think something that's helped me massively for that is when I started driving because obviously you’re hyper focused when you're driving and driving to me was not like sitting down and doing a specific memory exercise, you're doing something that you enjoy but you're also improving your concentration skills as well.

Ashwini 00:14:59 - 00:15:38

And I think the exercise you told us about just there Russell in terms of you know what does my name sound like to you and try and come up with word association or the memory, I think it's you know, we've talked in the past about how people with traumatic brain injuries can display rather rigidity of thinking. So it's probably quite a useful exercise to try and encourage that sort of loosening of thought process and flexibility and thought process, because I guess, you know, at the end of the day you're dealing with a muscle and it is just creating that training and muscle memory.

Brooke 00:15:38 - 00:16:14

What do you think, Russell, about the textbook claim that brain injury, well, something I've seen a number of times was that brain injury kind of heals for two years and it plateaus after that, or maximum of three years. I think my personal take on that is, I guess maybe the physical healing does plateau, but I just don't think you can stop making improvements. I think when I made my main improvements was after three years.

Russell 00:16:14 - 00:17:52

Yeah, that's a really interesting point. And I think those studies which people often quote are saying it's a two year curve upwards for recovery. I think the most rapid period of recovery in certain basic functions takes place in the first two years.

But, there are so many other variable. You know, you think about it, it was a few years after your injury that you started talking about studies or work situations, returning to driving. So the brain is given a lot of other challenges throughout life, isn't it? Not just in the first two years and the brain has to adjust and adapt once these new challenges happen.

So for those people who are fortunate enough in having the drive to keep going and putting themselves in the way of new challenges, or having an environment, family, social situations which are constantly helping them move forward and think about what next, then yeah, you can still have very significant recovery.

What we don't know is, is that all the nerves and the nerve pathways growing back, or are we just developing new ways of doing things. If you like, work arounds which the brain is extremely good at doing. It’s a very dynamic organ. It's constantly rewiring. My brain's been rewiring through doing this podcast as I'm thinking what should I be saying, how does this come across. My nerves are firing in ways they haven't ever done before.

Brooke 00:17:52 - 00:17:58

And we're just two seasoned professional.

Ashwini 00:17:58 - 00:18:10

In fairness, I think I am as well. It is that kind of constant exercise of listen to what you're hearing and then you know, where can I go with this? And yeah, I suppose we do it on a daily basis without even thinking about it.

Brooke 00:18:10 - 00:18:56

I think from my experience, the only time I’ve stopped or my recovery is going backwards is when I've stopped, when I've kind of given up and trying, you know, stopped making an effort. I think what’s always been important is having something to aim, some sort of structure to your week and also maintain a good level of fitness. That's one thing I've been quite keen on at all times, and also keeping that in balance as well. Not trying to overwhelm myself, because life in itself can be exhausting. And for me when I'm tired, the dark thoughts come in and you know, the positivity drops and it can be quite a depressing state.

Russell 00:18:56 - 00:20:28

So quite a few things, if you don't mind me picking up on there and running with, Brooke and I think you also mentioned before about mental muscle, memory muscle. This is a concept which taxes a lot of neuroscience professionals - that if we just keep practising one specific task, are we actually building mental muscle? We may be doing. But we may simply be working out different ways of doing things within the brain, so using different strategies.

So Brooke, you might remember I asked you to do lots of concentration tasks. So these sheets of paper. where you had exercises to do, like read this and circle the number of times the word ‘the’ occurred in the text. You know, there's some people that say that that those kind of activities don't really achieve a great deal. And there's been a huge industry and brain training apps, haven't there, which is training your memory or concentration or your problem solving and I think I would never say those things aren't useful. But sometimes I think the benefit is that people realise I've got to work on these things. It's about developing insight. So if you have a memory problem but you're constantly working to improve your memory, it means you're more consciously improving your memory in everyday situations.

Brooke 00:20:28

Absolutely yes.

Russell 00:20:28 - 00:20:40

So some of that memory muscle stuff is about developing, almost like accepting some of these difficult as a part of your identity and doing something about it, you know working a way around it.

Brooke 00:20:40 - 00:21:11

So I think I don't think I really started to get better until, or make improvements, sorry, until I'd like after I've accepted or I don't know if it was acceptance or just, you know, started to understand that I had these problems that were going to hold me back. Not to say that that's stopped me doing anything but just understanding that I've got, you know, the understanding that I’ve got these things that will hold me back in life. And then I've got challenges to find my way around. You've got to do things in different ways.

Russell 00:21:11 - 00:22:36

And you mentioned before Brooke about, you know some of these challenges coming much later on. But it's always that balancing act, isn't it. Not trying to do too much. And not trying to do or not doing too little. So you gave a brilliant example of the exercise I'd encourage you to do - watching a programme for a brief period of time and then sitting down and writing a summary. Yes, to prompt your memory. And then off you went to see Casino Royale a week later. Great that you enjoyed it and it is a great film, you know, plenty of action to enjoy, but you know it'd been a stretch too far in terms of keeping up. The pace of the plot and the characters, etcetera.

One thing I think you taught me Brooke, was how that negotiation within yourself, that sort of seesawing of I want to do more, but I can't do too much is a constant, isn't it. Particular when you're ambitious, you wanting more recovery, you wanted to do more with your life.

It’s fantastic that you've got that motivation and that drive. But if you overdo it, you can be left feeling a little deflated. The analogy I always come up with recovery is the tortoise and the hare - the story about the tortoise and the hare racing and the tortoise gets the prize.

Brooke 00:22:36 - 00:22:52

One thing you've always said to me is be kinder to myself as well, haven't you? Because I've always been quite hard on myself. Probably because I've tried to do things that are unachievable, and then I give myself a really hard time that I can't do them.

Ashwini 00:22:52 - 00:22:54

Almost setting yourself up to fail.

Brooke 00:22:54 - 00:22:59

Yeah, yeah, absolutely, yeah.

Ashwini 00:00:23 - 00:00:40

You must come across patients who have really high expectations of where they want their recovery to go or you know, wanting to get back to exactly how they were beforehand. And it must be very difficult or challenging to manage those expectations. How do you go about that?

Russell 00:00:40 - 00:02:11

Brooke we used the word acceptance before. Acceptance is a fairly complicated term, but commonly think of acceptance as almost like put up and shut up, this is the way it is, just get on with it. But acceptance can almost be a release as well. It's like I know what I'm dealing with now and because I'm fully aware of the difficulties which might go that, I'm in a better position to adapt, to change, to modify and still move forward, and that's the work that we try and do with patients who often say, I just want to be back to how I was.

Usually the breakthroughs in terms of speeding up their recovery comes, this will sound quite cruel, at the point when they realise I'm not going to be like I was, life has changed. But if we've got the support right, if we've involved family, loved ones, services in letting them know we're here to help you move forward from this position and build up a satisfying, fulfilling, happy life, hopefully we can take some of that pain away.

But we've talked about grief before, haven't we, and the analogy extends there with grief. There’s an evitable sadness, isn’t there? We have lost a loved one. We cannot have bereavement counselling with the intention of just feeling happy all the time. There is a sadness about what has happened.

Ashwini 00:02:11 - 00:02:47

And it's a loss of identity. It's such an intrinsic part to somebody's self being, so it must be quite a process to manage. You mentioned the family as well. And I mean obviously and I think we've spoken about this before in terms of, you know, how family and friends can play a role in people's recovery. But how do you involve them as a clinician? What sort of things do you have friends and family doing with you or with your guidance to promote somebody's recovery?

Russell 00:02:47 - 00:05:19

Obviously, it always has to be with the patient, the person’s permission to involve family, but once we've identified that we need a team approach and family, loved ones, friends are part of the team to support this person, it really depends what the person's problems are. But let's say there are cognitive problems, so problems in processing information and thinking, and as a result of an assessment we've worked out that the person's memory problems are affected by their distractibility. So, they've struggled to pay attention and typically this is a mental function that we take for granted.

You think about times when you might be in a crowded room, say it's a party. There's lots of chatter going around, but you’re speaking to one person, your brain automatically is registering there's noise going around, but it filters that out so that you're concentrating on what the person is saying to you. Well, sometimes after an acquired brain injury those filters aren't working, so everything's crowding in on the person and is very overwhelming. So if we've assessed that to be a problem and this person’s struggling in busy family life, we have to work with that family to say, if you've got important communication, let's work out how that communication is given - What environment is it in?

So let's say for example it's a couple with several young children. If the partner, the person with the acquired brain injury has to communicate some important information, let's not do it at a time when you've got the three kids bouncing up and down, wanting to tell you about XY and Z simultaneously, because the person won’t cope with that. So some of it will be helping the family member understand the nature of their cognitive difficulties and set up an environment which helps the person to overcome those difficulties or function better should I say.

It might be that there's work to be done on changes in behaviour, so if a person’s more irritable or short tempered it’s to help the family and ask why that's happening? Maybe they're overwhelmed. Maybe they're sleep deprived, help them not to take it personally, but prompt them to do certain things which might help them calm down or feel, you know, you don't need to be threatened by me here. I'm here for you, reassure you and then hopefully.

Brooke 00:05:22 - 00:06:13

I can massively relate to that, especially in conversations. Obviously you can get overwhelmed by the noise in the room, the poor lighting and you know, the other conversations going on around you. I would just add to that that one thing that used to go through my head is that like people find me boring, they're getting bored of you, leave this person alone. And then you kind of make excuses to get out of the out of the conversation as quickly as possible. That's when my confidence was really at my lowest.

I’d say one thing I've learned to do is to make the situation ideal. Like, if you're going have a conversation, make sure it's in, like a quiet room. Unfortunately, what I wanted be, was I wanted to be back as a young person back in nightclubs and stuff, but the best possible environment for me would have been like Tuesday afternoon in a well lit coffee shop.

Russell 00:06:13 - 00:06:38

But that's learning about yourself, isn't it? That's a brilliant example of the accepting this is the way things are and adapting and realising well, I can still enjoy myself, I can still socialise, can still have a good time. I just have to do it in a slightly different way now so that is a brilliant example of what I was talking about there. Our role for some people is to help them accept and adapt and building those up in different ways.

Brooke 00:06:38 - 00:07:26

I would continue to do these things like put myself in those situations with such as, like, you know, late night bars or whatever. And I would continue to just make me exhausted and when I used to get so tired, especially when you mentioned those exercises where you counting the number of the, the word the is written. I remember the tiredness I used to get from that. It's like it's like a headache and you just used to get this fatigue, tiredness. It was just like an exhaustion that I've never, ever experienced before. Touch wood, it doesn't happen as much now. I mean it can be under very specific circumstances, but it was something that I've really had to do a few times before I realised that this is not working for me. Like you said, socialise in a different way and I think it’s so helpful to have somebody who understands.

Ashwini 00:07:26 - 00:08:21

I guess it’s educating your friends and family; I can't cope with what I used to do and coming back to the grief point

and working with families. I guess it's also, you know, a lot of them will be going through the same sort of grief, like losing the person that was and then adapting to the person that is now. Working with them, trying to find ways to come up with those strategies, as you've mentioned, for example, how to present information but at the same time, you know, realising that we're dealing with somebody who has changed and isn't likely to go back to 100% how they were before and that that can be tough, particularly I think we've spoken about this in previous episodes, particularly in relationships. You know it's a very different person to who they were before and that can be such a huge losson both sides.

Brooke 00:08:21 - 00:08:48

You can just become obsessed with yeah, obsessed with the person who you were before you will be fine. You can look through rose tinted glasses, can’t you and you just think I want to be that person. But you don't realise that what's actually happening now is your life’s not necessarily stopping, it's taking a different turn and other option can open up for you and other doors can open up and if you look in a positive way, it doesn't have to be all negative.

Russell 00:08:48 - 00:10:13

But it's an important concept you're both touching on there, which we call post traumatic growth. So obviously we're all very familiar with the concept of post traumatic stress and all the negatives, which come with a traumatic experience, but we're beginning to understand a little bit more about some of the developments, the positives which can come out of trauma, you know, greater insight, different priorities in life, different degrees of ambition for some people, better quality relationship because people have gone through a reevaluation of what's important to them in life and it's a topic which is a bit sensitive cause when people really are struggling in the early days, they probably don't want to hear somebody saying ohh, you know, these areas will improve and in some ways, you’ll be grateful for these changes in your life. They’re not feeling it at that stage and you can't expect them to.

But for some people you've just got to be alert to the fact that it can be happening. And I think when it does, we have to acknowledge it. We have to celebrate it. Like I mentioned before, there's great inspiration in some of these situations for a lot of people, and for a lot of tragedy and difficulty obviously. But I think it's important to be open minded to some of the developments and the positive changes which can come out of certain situations.

Ashwini 00:10:13 - 00:10:39

And I guess also celebrating those positive changes, the milestones, however small they may be, celebrating those successes can then sort of, I guess create a more positive recovery journey because you can see the progress as it goes through. It's not about you know, running that marathon straight away. It is those small steps and it's like your one minute, 2 minute, 5 minute film thing.

Brooke 00:10:39 - 00:11:12

Acknowledging it as well, because one thing you do have is you have poor memory now and you just don't realise how far you've come on because you know you see yourself every day and you just forget it, don't you? I remember if I'd seen somebody that hadn't seen for like, say, six months, then that they would, well, this is in the early stages, they would say how much better I was and how much they’d noticed I’d improved. But if you just do it, you see yourself each day, you just you just don't see that there's any improvement at all.

Russell 00:11:12 - 00:12:11

And one exercise I encourage people to do sometimes with the help of family and friends is to keep a diary with their progress. If you're working, for example on memory function or concentration, typically what people will do, especially early stages, is compare themselves how they are now, but with the neurological condition to how they were before they had the trauma or became ill.

And with this diary, we said, OK, compare yourself how you are now to how you were just after you became ill or had the accident and then compare yourself to how you were couple of weeks ago. So you’ve always got this awareness. Ohh no, things are moving. It might be tortoise pace, but hey, it's moving in the right direction.

And that's a really useful exercise to do and it's nice for families to get involved in that as well because like you mentioned, the family are going through their own grief but for them to see actually things can get better.

Ashwini 00:12:11 - 00:12:51

It's a very interesting perspective. It's a different way of looking at it. I guess because if you're comparing yourself to how you were pre trauma pre, whatever the incident was before the incident before the trauma you were up there and now you're perhaps down here and it's like that massive mountain to get to. Whereas if you kind of start almost from the bottom of post trauma, this is where you were and then this is where you are now and you know, look at all this space that you've grown just in that short time it's just reframing the narrative in a way and getting people to look at things more positively, I find that really interesting.

Brooke 00:12:51 - 00:13:22

Somebody said to me once that I should video myself and I really wish I had have done. But you're just, you're always thinking that you're as recovered as you're going to get. But to record myself, you know, record myself speaking because my mouth used to lean. Well, I guess I used to be weaker on one side. But I used to speak appallingly and I used to stammer, I used to stutter and I really wish I had some sort of recording of those times.

Russell 00:13:22 - 00:13:43

But Brooke, you're aware of it and you know in some ways, because you've worked so hard on this recovery, you if you like, you've got your mental trace of how things have gone for you because of the amount of effort you have put into overcome these difficult, it's been phenomenal.

I remember those days well, you know, sat in the decrepit office in the old part of the building...

Brooke 00:13:43 - 00:13:59

I was going to say that old office. I always remember going up the stairs in quite a stressed state and then I would always come back quite happy. The trip down the stairs was always happier than the trip up, so credit to you, Russell.

Ashwini 00:13:59 - 00:14:00

Sign of a job well done

Russell 00:14:00 - 00:14:27

But some of those sessions, you could only manage about 10 minutes of me. But there are many people who might say, yeah, 10 minutes of you Russell is more than enough! But in terms of your fatigue and your ability to think through what we were talking about. Some of those early sessions were very limited weren’t they? But again, with building up stamina, you managed to do them, just.

Brooke 00:14:27 - 00:14:41

There's always this big picture in your waiting room. And it said something like ‘don't look back, you're not going that way.’ I thought that was really good.

Ashwini 00:14:41 - 00:15:04

I'd like to sort of go on a slightly different tack, if I may. I just want to talk about some of the different tests that you do when you first start working with somebody. What those tests are, what kind of information they give you. Appreciate you can't necessarily go into too much detail about some of them because of the nature of the tests, but you know how that feeds into your planning then for somebody's rehabilitation pathway and also just the kind of any tips you might have for anybody who is about to undergo a neuropsychological test battery because they can be quite intensive.

Russell 00:15:14 - 00:19:14

Our assessment process, first of all, people always meet a qualified clinician who will interview them, perhaps with relatives, people who know them all around. And they'll have full medical history as well, so we know quite a bit about the person, what they've been through before we meet with them. And then we'll sit them down and have an hour or so with them talking about how they feel, what problems they have, and through that we're observing certain things like we'll be making observations about their memory for names, for example, their confidence in speech, do they have any word finding problems, whether they are struggling to understand some of the questions we're asking, we’re getting a measure of their comprehension.

Those things that we're observing during interview and based on what we know about their condition, our initial observations, and what we find out in. Interview, we'll then come up with a fuller assessment plan.

So typical areas of cognition that we would be looking at are concentration and attention, so is a person distractible, are they easily knocked off course, can they attend to a couple of things at the same time. We will be looking at memory and memory is a very complex phenomenon, so we've got short term and long term memory, we’ve got visual and verbal and auditory memory. You've got recognition memory. So if you recognise something, it shows the information's gone in there you just struggled to get it out spontaneously or free recall memory, so I've introduced a lot of complex concepts there, but I just want to get across that assessing somebody's memory will involve several tests so that we work out where is the breakdown for them. And then we look into what we call the executive functions. So these are functions of the frontal lobes of the brain involved in problem solving, abstract thinking, creativity, a whole range of analytical, mainly problem solving based functions and we've got tests for each of these areas and we've got test for language function and test for visuospatial functioning as well.

So without wanting to go into too much detail, a typical concentration and attention task might be getting somebody to listen to a series of beeps and we're asking them simply to listen to this string of beeps and count how many there are and then, because we’re pushing people a bit and perhaps a little bit cheeky, bit naughty with people we'll introduce a distraction so I want you to count this beep but ignore this other one that's a different pitch, it might be a higher pitch. So then we think can they distract themselves from other things or does that overwhelm them. So that might be one concentration and attention task.

Examples of memory tests might be lists of words that we get people to hear, and then they have to repeat back as many as they can remember. And we do this over several sets of the words to see if they're learning as time goes on. And we might do the same with visual diagrams as well. See if they can copy simple line diagrams and see if they learn those over time as well.

Memory tests, we might get them to try and remember bits of information and then test them with two options. Did I say that the woman’s name is Mrs. Green or did I say it was Mrs. Brown and then, I know, ohh, it was Mrs. Green. You've recognised it, The information's in there, but I'm not so sure you would have got it with free recall spontaneously, you might have needed a prompt.

Various problem solving tasks that we would do separately to that, so little like construction problems, building a tower out of little disks of wood, move it from one place to another according to certain rules. So these are higher level problem solving tasks which we get people to do.

Ashwini 00:19:20 - 00:19:41

You know, it's interesting. I was talking to a colleague the other day and I was just saying how I would absolutely love to undergo a neuropsychological battery. I'm absolutely fascinated when I read about these things and just think, you know, it'd be really good to have an understanding of where I am now, also because you know thinking a little bit morbidly if anything were ever to happen, it would be really good baseline to understand.

Brooke 00:19:41 - 00:19:45

I absolutely hated it!

Ashwini 00:19:45 - 00:19:58

I think they just take me back to, like, doing a lot of verbal reasoning exercises when I was younger. I don't know, my mum had me doing bond papers for years! Anyway, I digress!

Russell 00:19:58 - 00:21:20

That’s one thing you say to people is it'll feel a bit like being back at school and doing some classroom tests and tasks. So part of your question is how do people prepare for them? Well, I would say a way less preparation is better, because if you get yourself anxious about it or you get worried about what if it shows this, what if it show that, then when it comes to doing the tests we’re not always getting the picture of how your neurological condition has affected your performance. We're possibly getting an effect of how your anxiety or these worries are affecting you because if you're trying to list remember a list of words, but you're simultaneously thinking I'm really bad at this and what will this mean and you’re not listen to the list of words.

We do try our best to relax people try and make them as comfortable, try and reassure them if they've got specific worries, make sure that you know they've got a cup of water or let them know that we can take a break at any point if they want, always feeding back to us how they're experiencing it. We can't really sure and say oh, you're doing great because we simply don't know that - they're being tested. But in terms of their engagement with it, we'll just try and let them know, yeah, that's fine, you're doing exactly what we want.

Ashwini 00:21:20 - 00:21:41

I guess my question in relation to preparation was more things like you know, making sure you get a good night's sleep, perhaps having the testing at a time of day that works better for you, a bit like Brooke’s Tuesday afternoon in a quiet coffee shop thing, you know, just not when you've had a really bad night and you've not slept or not like late on in the evening, that kind of thing, finding the optimum time.

Brooke 00:21:41 - 00:21:57

A good trick is to go for a nap just before - 20-minute nap. I heard this on GMTV or whatever r it's called these days. It's that caffeine takes 20 minutes to kick in, so I usually have a cup of coffee, 20 minute nap and I'm good to go.

Russell 00:21:57 - 00:22:04

There you go, you heard it from Brooke first! Brooke is teaching us ace all of our cognitive test.

Brooke 00:22:04 - 00:22:11

But don't drink caffeine after 12 because then you'll regret at 4:00 o'clock in the morning when you thinking why can’t I sleep!

Ashwini 00:22:11 - 00:23:03

Well, I think that's been really, really interesting. And so much food for thought for our listeners. A lot of it also, you know, touches on but expands upon what we've discussed in in previous episodes. Thank you very, very much for taking time out of your day to join us and I know I'm sure what I won't speak for Brooke, but I'm sure he's been very happy to see you again.

Brooke 00:23:03 Speaker 2

Thank you, Russell, yeah. It’s the first time I've see you in three years.

Russell 00:23:07 - 00:23:14

Let's see if we can meet up properly and see you Brooke. Thank you for inviting us, it’s been a pleasure.