by Sadia Hussain, BSc (Hons) Speech and Language Therapy
Claimants diagnosed with brain injuries, without physical disability and who retain subtle cognitive communication difficulties are commonly referred to as the walking wounded’. They present with understated communication difficulties, which are barely noticeable in general conversation but which become heightened in structured communication tasks.These tend to surface when a claimant is confronted with clerical, administrative and managerial functionsat work. Or, in their personal life, where socialising with friends and family becomes a struggle, rendering them to the risk of social isolation. As a Speech and Language Therapy (SLT) expert witness, I readily come across cases where a claimant’s inconspicuousc ommunication deficits cause permanent disruptions in their working life. In this article, I wil lshare three cases to highlight the communication challenges facing the ‘walking wounded’:
Case One: A claimant in her forties, involved in an accident at work, was diagnosed with a mild brain injury and discharged from hospital within days of heri njury. She was physically mobile and, although slightly confused at the time of the injury, was able to engage in conversation and unintentionally masked deeper cognitive impairment. After a short recovery period, she began a gradual return to work as a Human Resources Director, only to find that she was no longer able to perform her work duties. She particularly struggled to process complex information,chair boardroom meetings, make executive decisions,conduct interviews, deliver presentations and meet target deadlines. She had difficulty deciphering literal interpretation from sarcasm and missed the nuances of indirect conversation. This, in itself, caused her difficulties maintaining effective interactions with her colleagues and she found herself amidst a workbased conflict.
I was instructed as a SLT expert to determine whether a communication disorder existed, what it was caused by and how it affected her work. By comparing her pre-injury baseline to her current situation,it was evidently clear that she had acquired cognitive-communication and high level language difficulties. This had affected her function at work and, in particular, her ability to reason information,problem solve incongruities, interpret multifaceted situations, and deliver narratives. This was a direct result of her brain injury and she was unfit to continue within her current executive position. As part of my expert opinion it was recognised that she was only likely to cope with working part time hours, in a less demanding role, and with the support of a personal assistant to facilitate administration. In addition to this, she was recommended technological devices to support her memory, speed of processing and written communication.
Case Two: A gentleman, working as a sales manager,who suffered a stroke as a result of medical negligence.Given that he showed no obvious physical paralysis, it was deemed his symptoms had fully resolved,only for him to later discover he experiencedpersistent difficulties when reading. When he returnedto work his communication struggles magnifiedbeyond reading and he found it challenging toexplain his ideas coherently and use technical languagehe had been using for most of his working life.This caused him anxiety and he felt he could nolonger carry out his sales role and was forced to takeleave from work. During this period, I was instructedto provide a SLT opinion and my assessment showedhe was harbouring an array of difficulties rangingfrom verbal dyspraxia, mild dysphasia (language disorder)and cognitive-communication disorder. Giventhat these difficulties were permanent, the claimantand his employer came to a mutual agreement forhim to retire early and the cost of earnings was providedthrough a settlement. He re-considered vocationaloptions, choosing to go down the route ofvoluntary work with the help of SLT technologicalsupport, using a tablet device with communicationsoftware to support reading and writing skills.
Case Three: My final case is about a male university graduate, who incurred a brain injury during a diving expedition whilst serving in the navy. He was diagnosed with minor physical impairments and a severe case of PTSD (Post Traumatic Stress Disorder).PTSD symptoms masked significant cognitive-communication difficulties, which only became noticeable months later when his relationship came to an abruptend and he struggled to maintain his friendships. A once popular and sociable man, he found it difficult to cope in group situations, not being able to digest humour and hold conversations with friends.
Immediately upon my instruction, the scale of his difficulties were apparent, when he showed difficultyr ecalling several telephone conversations we had to arrange an appointment. However, more interestingly,the results of the assessment showed that most of his formal communication skills were within the normal range, apart from some mild anomia (word finding difficulties), memory impairment and some executive dysfunction. Collectively, these impacted his pragmatic ability to engage in conversation and his awareness of social situations. His once proficient musical skills had also been affected and he was no longer able to read music and play the piano. My recommendations included; vocational rehabilitation to aid a change in targeting social communication, to aid a change in career more suitable to his needs. He was also recommended support to increase his communication confidence and awareness in social situations. This was largely done through a support worker, SLT intervention and regular leisure activities.
In all three cases, communication deficits were inadvertently missed, but why did, and indeed does, this happen? To answer this question, I looked at two aspects including the level of SLT care afforded to individuals in the initial stages of brain injury and the complexity of the communication deficits involved.
Having worked in the acute setting, it is evident that the capacity of specialist SLT intervention to assess and diagnose less obvious cognitive-communication disorders in the initial stages of hospital admissions for individuals with brain injury is limited, especially with those who present with mild physical injuries.My experience is that the clinical priority is very often to assess and treat swallowing problems, which posea physical risk. When it comes to communication deficits, SLT’s have less capacity to do full assessments and rely on screens often done by other health professionals,who are most likely to pick up on more obvious dysphasia or dysarthria features rather than under the radar communication or social features.For example, ‘slurred speech’, ‘muddling up words’or ‘not following simple commands’ are typical features of impaired communication post brain injuryor stroke. The limited resource of SLTs in hospital settings has been publically recognised: ‘While the speech and language therapy profession has grown in the last 10 years, most of this has been outside the NHS, with managers reducing by 23% since 2010 (NHS digital).
’Cognitive communication operations involve the brain’s ‘executive functions’, including planning, organisation,flexible thinking and social behaviour.Brain injuries, usually involving frontal lobe damage,raise the potential for communication difficulties affectedby cognition, which Headway describe as: ‘Attention and concentration difficulties, memory problems, literal interpretation, reduced reasoning and problem-solving skills, cognitive fatigue, slowed speed of information processing, impaired social communication skills and reduced insight.
’It is evident that the components of cognitive-communication disorders and high level language are farranging and complex, which means they can be easily masked, misunderstood or missed. If an individualis able to converse fluently and can manage functional situations, the communication deficit is difficult to identify. It is also the case that some of the symptomslisted above only amplify when an individual is confronted by multi-layered tasks, which use these in combination. Such tasks are typically found outside personal routine and familiarity and usually arise in the work place. Unfortunately, later identification of such symptoms can cause a person grave anxiety and cause disruption in personal and working lives
As a SLT professional I can see that it’s imperative that identifying subtle communication changes earlier in the course of injury is necessary to avoid further complications. The only way I see this is possible is through increased awareness and educationfor brain injury sufferers and professionals of all levels (health, legal and social) who engage with such individuals.
About the author
Sadia Hussain has a BSc(Hons) Speech Sciences,MRCSLT (Member ofthe Royal College of Speech & LanguageTherapists)
Sadia works within the specialist field of neurological and spinal rehabilitation at the Royal Buckinghamshire Hospital and is an Associate Trainer with Somek & Associates Ltd.
Somek & Associates is one of the largest providers of Expert Witness services in the UK, and has overtwo hundred experts, which include occupational therapists (care experts), nurses, midwives,physiotherapists, speech and language therapists,and other allied health professions.