Mild brain trauma metaphor - earthquake

The earthquake metaphor can simplify explanations about the consequences of mild brain trauma for patients who prefer such methods rather than scientific descriptions.

“A brain trauma can disrupt the organised transport of information through the brain regions, similarly to disrupted traffic in a major city affected by an earthquake. The infrastructure is no longer in place. Traffic from one end of the city can’t run smoothly via motorways and streets. Travellers have to find alternative, less affected paths or have to clear the rubble first. The usual means of transport don’t work. The chaos causes disorientation that may lead to wrong decision making. One might have lost the sense of direction and move around in circles. This costs time, requires an enormous effort and is emotionally challenging.

“Following a concussion, the information in your brain cannot run smoothly and quickly. There is so much more to observe and more new information to remember. Former routines or patterns are not usable. What one was able to remember in one load in the past has to be now encoded in smaller portions. However, each time a task is repeated, the new infrastructure improves and the chaos settles. It is nevertheless necessary to be economical with energy and allow a lot of time. If the process is hurried, then bodily resources become depleted.

“A person travelling through the ruins who is also worried or traumatised might become disorientated and stressed, with an additional sense of imminent danger. This person needs to learn to remain level-headed and address emotional difficulties.

“In contrast to a place ruined by an earthquake, the brain has the capacity to rebuild some of the infrastructure itself. This happens slowly by natural healing and can be encouraged by your positive and proactive health management.”

Explanations like these can evolve in conversations with the patient. It may be beneficial to use therapeutic aides (graphics, written notes, repetition, etc.) to support patients’ mental processing abilities. Patients’ intuitive understanding and their own words are always a good place to start.

Activity Planning and Desensitisation

Use the activity planner & well-being schedule and meta-strategy PROM

“Let’s explore how you can adapt your routines and activities to help with your headaches.

The rationale of preparing your activities is to ensure that you can achieve what you have planned. It’s about the power of the first small step and encouraging your sense of accomplishment. Such task management aims to focus your attention towards organising the situation and the task itself.

First identify a task that you would like to improve. Maybe it’s an activity that has caused frustration in the past.”

Use the meta-strategy PROM as described in the health management module.

Use a taskmaster approach:

“Identify the task or activity

Chose a ‘headache neutral’ task, i.e., a task that is less likely to trigger symptoms

Aim to make the task 100% achievable by breaking it down to the smallest manageable parts

List and grade the steps that link the parts together

Simplify the surroundings

Slow the pace right down

Enable calm and controlled task performance

Schedule a time for your task in your planner

Think about the things you need

Carry out the task and be aware of the process

Check that you got it right.”

Example: A patient might find it difficult to remember where their car is parked. They might have got lost in the past, which has caused anxiety or resulted in headaches. Now, the thought of parking the car triggers self-doubt, apprehension, fear of stress and headaches, actual headaches or avoidance of driving. They are encouraged to schedule suitable times for practising the taskmaster approach in order to learn to remember their car parking space.

Using this example for now, a patient is encouraged, at a planned time, to drive the car a few hundred yards from their home. They are instructed to mindfully pay attention to key features of the surroundings and, if appropriate, use memory aids (take a digital photo, use a satellite navigator or write the street name down). Through practice, they learn that every time they park their car, they have strategies to find it again. As a result, the anxiety should reduce. If headaches are experienced during the activity, then the task should be even more simplified and relaxation should be part of it (either before or during a break, or afterwards). Task accomplishment is the goal of this desensitisation activity.

Ending: headache monitoring and coping strategies

“Next session, you will have the opportunity to explore your headaches in more detail. Record the headache intensity and duration on one morning and one afternoon over a period of two hours. Use your headache diary.”

“Carry on with your relaxation practice each day.”

Headache therapy session 2: why do I have a headache?

Useful material

Activity planner & well-being schedule Peripheral and Central Sensitisation Figure 1.6.

Diathesis-Stress model of migraine and mild brain trauma Figure 1.7 Headache diary

Migraine and mild brain trauma worksheet

Mild brain trauma worksheet

My well-being actions worksheets 1 & 2

Pain Gate worksheet

The energy roller coaster worksheets

Objectives

  • • Review of activity planning and desensitisation
  • • Information about posttraumatic headaches and stress
  • • The Pain Gate: acute versus chronic headaches
  • • Actions that close the Pain Gate
  • • Migraine and mild brain trauma

Welcome

Review of activity planning

Use the activity planner & well-being schedule “Last time we explored how an injury to the brain disturbs the underlying mechanism of normal brain processing. You were encouraged to plan and carry out a graded activity. Regular experience of the fact that day-to-day activities can be performed successfully will retrain your brain to accept that most situations are safe. Your body and brain systems do not get overloaded with a graded approach. This is important in order to reduce the persistent state of ‘high alert’ or hypervigilance. Eventually, you should experience less stress and hopefully fewer headaches.”

“How did you get on with your scheduled activity regarding:

Grading of the activity Attentive awareness of the task Skill improvement Sense of accomplishment?”

Headache diary

What observations were made regarding headache episodes (intensity, lengths of headache episodes, coping with consequences, etc.)?

How was the day structured when headaches occurred?

What happened before and after the headache episodes?

How was the day structured on non-headache days?

Main therapy section

Headaches and stress

Use the mild brain trauma and Pain Gate worksheets to reflect on the interactions between headaches and stress.

Refer to Chapter 1 of this book for a theoretical recap of these topics. “Frequent headaches are often a symptom of chronic tension due to the physiological states of stress. Most people develop headaches due to intense and longer-lasting demands on the bodily systems. This can happen in relation to a challenging life event or strenuous mental or physical activity, especially if the situation persists for some time.

“The impact of the accident made your body more vulnerable and less able to absorb the same degree of demands as before. The headache is a symptom of a chronic mild brain trauma syndrome, i.e., a reaction of your body to overwhelming demands. It is not an indicator of a dangerous brain disorder.

“How can this be understood?

“Pain is a natural physical response. It signals the body’s healing functions following an acute lesion (i.e., physical injury). The initial injuries to your head and neck (e.g., bruises, muscle sprains) have now healed. Your chronic headache is no longer associated with an acute lesion. Headaches are very common in association with mild brain trauma. Persisting headaches are, in most cases, a result of ongoing hyper-arousal and the consequence of your body’s depleted energy resources. Your body’s ability to rebalance physical ability and environmental demand has fallen out of sync.

“Some types of headaches (e.g., allodynia) are related to disturbed processing of nerve signals. The strategies proposed in this programme can be helpful for many different types of headaches.”

 
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