Episode 7 – Traumatic brain injury — with Dr. Lyn Turkstra

MIND BEYOND THE MISSION EPISODE 7: TRAUMATIC BRAIN INJURY WITH DR. LYN TURKSTRA

Brian

We’re on again, and we’re going to be talking about traumatic brain injury. People are going to find that over the course of this podcast, for the years to come, it’s going to keep coming up. It’s a reoccurring theme. It is a coast-to-coast theme. It covers every grouping of people that join the Forces, and to be fair, all kinds of people in society, so that’s what we’re doing here today.

Obviously my partner in crime, Laryssa, is here and we’re joined by Dr. Lyn Turkstra, who is working out of McMaster University and is a speech pathologist. So let’s go there. Lyn, explain to people in your own words, what’s your background, and why is it that a Veteran and a Veteran Family peer support specialist – the two of us – are talking to a speech pathologist today?

Dr. Turkstra

Thanks very much, I’m really happy to be here. Thanks for inviting me. I have been working with people with traumatic brain injury for about 30 years, mostly with people with more severe injuries because those injuries often result in cognitive impairments that affect people’s ability to read, write, listen, speak and participate in all the communication activities they need in their lives. So I’ve been in the United States (US) for my whole working career until I came back to Canada.

In the US, when the US declared war in Iraq, they had zero budget for rehabilitation. They had zero expectations that people would need rehabilitation. By the end of the biggest bulk of the conflict, 50% of active duty service members were filing for disability. And so, starting in the early 2000’s, the US military reached out to those of us in the civilian sector to ask, how are we going to manage brain injury in a system that had no brain injury in it? Because in service, you would be med-boarded out to the VA.

So the US military had absolutely no infrastructure for rehabilitation. There’s no ranking officer in language pathology because why would they have one? So that’s when I started. It was mostly people with more severe injuries. In the early days, you might remember, there was quite a bit of pushback in the US military against the idea that you could have cognitive impairments.

Laryssa

You have a wealth of experience. I’m looking forward to our conversation with you today and where we’re going to go, but I think I want to start with some basics, if that’s okay. I’m going to ask some basic questions to build from there. What is a traumatic brain injury, and what’s the difference between a traumatic brain injury and a concussion, if there is a difference?

Dr. Turkstra

A traumatic brain injury is basically damage to the brain from applied force. That can come because you hit your head, or that can come because you hit your body and it jolts your head. It can be very mild so that people just have a very temporary change in their thinking or balance or have a headache or vomit, all the way up to very severe where a person could be in a coma. It’s really the range of consequences of force applied to the brain. It can also be so mild that people don’t pay much attention to it, but if you have a lot of those accumulated injuries over time, that can also cause damage to the brain.

Laryssa

Brian and I were chatting before and I think a term that people use is, “ring my bell,” “I got my bell rung,” and then they carry on. The next question – and I understand this might be hard for you to answer given what you just mentioned, that it could be something as mild as “getting your bell rung” to experiencing a coma or unconsciousness – but can you just give us an idea of some of the range of symptoms of traumatic brain injury for those who might be just learning about it or might be just suspecting, “Is this something I’m experiencing?”

Dr. Turkstra

There are symptoms at the moment and then there are long-term symptoms. So at the moment I would say the mildest thing would be that— we say some kind of a neurological symptom, meaning I had tunnel vision, felt nauseated, felt dizzy. You hear people say a lot [that they are] sensitive to light, sensitive to sound. That usually doesn’t show up immediately. It usually plays out over 24 hours. Especially from student-athletes, we hear a lot of people saying they didn’t really know anything was wrong, so they went back in the game, and then over the course of the day they had more and more symptoms.

Brian

In the theme of, “you learn something new every day,” as you were speaking about a minute ago, you mentioned that it could actually be a body blow.

Dr. Turkstra

Yes.

Brian

I’ve been looking at this for a while as a patient. I’ve been concerned about it for a while. I’ve never really actually thought that strikes to the body could actually be that way, and so I think here’s what some people go through is, are you telling me that a body blow that I take today can affect my ability to communicate five years down the road? That sounds like a bit of a stretch. Why is it not a stretch? Why is that a reasonable connection to make?

Dr. Turkstra

It’s physics. Basically the neurons, the main cells in your brain, are connected with each other by these really fine, fine arms: processes. They’re delicate. And if you shake them up, they can tear. You can shake them up by shaking a body. That’s where shaken baby syndrome came from; the idea that you don’t have to hit the head in a baby. If you shake the baby, it’s just physics. Where our head is, we say it’s like a popsicle or like a lollipop. Your head is this heavy thing that’s sitting on a neck that’s attached to your body [laughs]. If you think of—

Brian

Well, and bigger-headed people like me… [laughs]

Laryssa

I know that explains a lot for me! [laughs]

Brian

Not funny. [laughs]

Dr. Turkstra

There’s an expression we have in brain injury. We say it’s not just the injury, it’s the brain you bring.

Brian

Right.

Dr. Turkstra

So for example, we see more women with long-lasting consequences and that’s probably because of physics, because women have thinner necks. If you hit their body, their head will bobble. You might hear the bobble-headed doll expression.

Brian

Here’s an interesting thing to think about when it comes to women Veterans. You could say, when you look back at shell shock, when you look at what we used to call PTSD as we knew it in World War I, you could look back and go, well, the history of looking at these things goes back a century, or wherever it goes. I would add into that, since it’s only been about 30-35 years of full integration of women in the Canadian Forces, we haven’t studied a lot of women brains.

A lot of the helmet is probably designed based on studying men. And I’ve got to imagine that there’s a gap in knowledge about what’s going on with women Veterans and just women in particular when it comes to TBI. Is that a concern when it comes to your line of work, gathering information, making sure we’ve got balanced input?

Dr. Turkstra

It absolutely is. The history of research and brain injury is the history of research on men. In the civilian sector as well, it was men 3:1 who had brain injuries of all severities, but all of a sudden, you have women in active duty, you have teenage girls driving more. We saw youth soccer, we have female football players, and the difference is shrinking every year. There’s a bunch of us who do research really focused specifically on outcomes for women.

They’re hormonal differences between men and women. There are role differences often in everyday life between men and women. We actually don’t know very much at all about brain injury in women in the military and among Veterans.

Brian

In some ways it could be considered that this is a woman’s issue in so much as we just don’t know much, we don’t have the data, it’s not in.

Dr. Turkstra

That’s correct.

Laryssa

I’m just curious, then, how many women are misdiagnosed? We’ve had conversations between Brian and one of our other guests, Ryan Carey, about how from my spouse, who we suspect had traumatic brain injury for quite a while, he’s been medically released for more years than I care to mention. We knew for sure that he had post-traumatic stress disorder, but it was only until recently after we advocated and asked and asked and suspected that he was finally assessed, and I guess you could say diagnosed.

For many men, there seems to be a delay or a misdiagnosis for traumatic brain injury. So I’m wondering, even for women, are they being diagnosed with depression or other things? I guess it’s a two-sided question. In your observation, are many people diagnosed, or is there a delay in diagnosis, and what the implications might be on the women that you’re seeing as well?

Dr. Turkstra

We actually don’t know that—

Brian

How do we not know that?

Dr. Turkstra

diagnosis in women in the military [laughs]. Nobody asked the question. That’s how I don’t know that. Why did we only study intimate partner violence in women when we studied shaken babies 40 years ago, and men being violent 30 years ago, and we only started talking about women 10 years ago? I don’t know. That’s a really good question. I don’t know. I know if you look at who we see for cognitive rehabilitation, we see a lot of women, and they certainly will report not having been diagnosed. We’ve never compared men and women. It’s a really good question. I can’t imagine it’s better for women because I feel like if your family doc’s not asking, they’re not asking anybody.

Brian

There’s a couple of things I’ve had to snicker at over this last bit as we are going through here. One is you work in this space, you’ve been around this for a while, you work with Veterans. But as discussions have happened about some of the things that Veterans do or that soldiers, sailors and air personnel do, I noticed around the room, a lot of eyes get wide, like, “You do what?” But that’s the reality of it. These are hard jobs. They’re tough on the body. Why are we at this position sometimes of thinking it’s just tough on the body?

Dr. Turkstra

It’s a military mindset, right?

Brian

Right.

Dr. Turkstra

You tough it out. People are there to serve. They don’t want to let down their peers in any situation, in combat, in training. At least that’s what I’ve encountered. It’s difficult though because there’s been such a firewall between military and civilian information. If you think about, I think Laryssa, you were mentioning in your previous podcast about seeing the video. You guys were saying you see a video— I think Ryan was also mentioning, you see a video of what a blast is. I can tell you we don’t see those videos in the civilian sector. It was a good 10 or 15 years before I was allowed to see a video of what happens in a breach. We just didn’t know.

Brian

You think about it, you have no advantage when you are attacking a room. There’s math on this, attackers generally have a 3:1 disadvantage. The defender knows the ground. He defends, he prepares. A classic thing we used to find is you’d open a door and there might be a mattress up against the wall just to stop you from chucking things in. In other words, the attacker doesn’t get the chance to build defenses. The defender does. Then you start going into this urban environment, where it just creates all these more complications.

At the end of the day, we blow our way through things. That’s how you get in. To turn the tide a little bit in your favor, you want to concuss and disrupt and disorient everyone in that room so that by the time they know the difference between up and down, they’re on the ground, you are standing up, there’s four of you in the room, and they’re just completely overpowered. That’s what’s going on. I can tell you, hand on heart, tech will advance. Fifty years from now, we’re still going to be banging our way through things. We will have to. We’ve been doing it for hundreds of years. That’s going to continue.

So we’re going to need your skill set. Here’s one thing I want to ask you. There’s a lot of different ways we come towards an issue. You are a professional, you’re also a citizen, you hear things. When someone says, “My grandpa was in the war, and he doesn’t talk about it,” what does the speech pathologist in you hear?

Dr. Turkstra

Well, I think the first thing I would hear would be the psychological trauma. I think that’s where probably most people out in the general public would think, “Oh, the psychological trauma of the war.”

I think the thing that I would hear that would make me wonder about brain injury would be, “My brother/cousin/spouse/dad did military service, and is just not the same person they were, is having trouble managing everyday things that used to be difficult. Can’t tolerate it when there’s a lot of people in the room talking, has these outbursts of temper for reasons I don’t understand that seem really out of proportion, or seems really depressed.” Those are the things that would make me think, “I wonder if that person had a brain injury and it didn’t get picked up.”

Laryssa

I think in our experience, as I mentioned, my spouse has PTSD and I’m learning more. These conversations are really teaching me a lot, that there can be a little bit of overlap in symptoms. I think many Veterans don’t understand the differences or the overlap or the similarities, and certainly Family members don’t. Just as you were chatting, something that I picked up on with my spouse was that we’d be in a conversation and I would convey something to him, I’d say something to him, and there’d be a delay… and then he would respond.

I assumed that was part of PTSD, that he maybe was symptomatic and he was trying to deal with his symptoms or whatever the case is, but I learned that I give him information, he has to stop and process, and then formulate his answer, and then respond. It’s sounding like the more that I’m learning, maybe that wasn’t PTSD, maybe that’s traumatic brain injury.

Dr. Turkstra

That’s a very common complaint after a mild traumatic brain injury. I would say one of the most common findings across military and civilian sectors is slow thinking speed. You might hear slow speed of processing, that’s the term you’ll see in the research literature, but what you’re describing is exactly that. This delay in putting together what someone has said, and it shows up in lots of different ways.

It shows up in forgetting because you went on to the next thing, and I was still thinking about the first thing, so I missed the next thing you said. It shows up in, “I can’t follow you in a conversation. I don’t want to be around a lot of people because when they’re all talking, I can’t keep up.”

Brian

We’ve done some discussions before about communication. I wonder if there are circumstances with the damaged mind, with the wounded brain, that I might actually have the thoughts in my head, but I can’t actually spit those out into words? That happens to me, but I’m wondering is that part of this, or is that just a Brian problem?

Dr. Turkstra

[laughs] I can’t say if it’s just a Brian problem. I will say that word-finding problems are up there in the top three things people complain about, and it might be part of the same issue of speed. You’re trying to process what the person’s saying, you’re trying to get your own thoughts in order, you’re trying to find the right words, and it’s not happening fast enough. For a lot of people, if they have extra time, they can find the words. It’s in the moment, and then you get frustrated. The more frustrated you get, the worse it gets.

Brian

So what can we do about this?

Dr. Turkstra

I work in cognitive rehabilitation. It’s unfortunately named because cognitive rehabilitation sounds like we’re fixing your thinking, but there isn’t a lot of evidence that this sort of training your memory helps people in everyday life. There have been a few studies looking at things like brain games and do they actually help, but they don’t seem to transfer to solving your everyday problem.

People get better at the games, for sure. When you’re playing the game, you might realize, “Oh, you know what? I’m better if I turn the TV off in the background while I’m playing the game.” So playing the game might teach you there’s a strategy you could use, but what’s really helpful is learning strategies to help just manage your everyday thinking. That’s where people like me, speech language pathologists, also occupational therapists, can really make a big difference.

Laryssa

That’s so hopeful to me because I’m thinking about the experience of someone with a brain injury and TBI, lots of them can be younger. Experiencing memory loss, not being able to find the words, knowing that their thinking is slowed down, that must be pretty scary for a younger person thinking, “I’m kind of losing it here.” To hear that there are ways to mitigate that, that you can learn strategies, I think that would be so hopeful for so many people. What would you recommend, how does a Veteran or a Family member, how do they know what questions to ask to be able to obtain those types of services and support?

Dr. Turkstra

I think it’s really good to ask, if you’re going to your family doctor to just say, “I’m having trouble with everyday thinking. Can I be referred for cognitive rehabilitation?” We have such a strained healthcare system at the moment that it’s difficult to get it, but if people don’t ask for it, we’ll never get it. Also, the brain injury associations are amazing. The National Brain Injury Association of Canada, the provincial brain injury associations, they’re a great resource for referral out to people in the community.

Brian

One of the things I’m happy to hear in this discussion is you’re not necessarily saying it’s these massive endeavors people can’t do, you’re picking up on the fact that it’s the daily living. I remember one day for me when I was very recently back from overseas and people were trying to figure out what’s wrong with me. I was trying to figure out what was wrong with me. I had to change a tire on the highway on the driver’s side.

As I pull over, it’s somewhat dangerous, cars are flying by. No problem. No problem at all. Slapped that tire on, do it, handled it quite fine. But where I was going—I was going to a shop to get a frame done. It was for a photo or something like that. When I got in there and they started asking me, “What kind of matte do you want? Do you want it this big, that big, this contrast, this colour?” that took me down.

It was the fact that I was being asked three or four questions at once… not in the brain space that I was in. Some people might look at that and go, “Well, that changing the tire by the side of the highway thing is what would be the most bothersome.” Actually, no. For me, I was quite calm there, but I was almost breaking down in tears as I’m trying to figure out this minor, minor task. Is that common with people that have had a physical injury to the brain?

Dr. Turkstra

Yes. It’s unfortunately very common and so easy to address in some ways if you understand what the problem is. For you, Brian, you wouldn’t have the perspective to step away and say, “Oh I see, I understand the factors that make this situation bad and this situation easy.” And so I feel like that’s another part of where talking to someone like me can be helpful because it can make something that seems overwhelming and complicated really pretty simple.

For example, people should write things down for you. You know what I mean? Sure, you can do a lot of exercises to say, “Oh, now I can listen to multi-steps.” That’s another common thing. People will say, “I can’t take multiple steps of information at once.” Okay, well, perhaps your Family member can just write it down.

Brian

I also think we talk a lot about communication. I feel that I’m the person that could still handle a stressful situation, but I also can tell you that I’m the person that when there’s a fight between two of my kids, I’m not the best to handle it. When it’s planning just the grocery shopping trip, I would feel more comfortable handling stress than I would feel just running my day-to-day life. I actually don’t know where the PTSD part of Brian ends and the TBI part of Brian begins. I have no idea, and I’ve been at this for a while.

Laryssa

I’m doing some introspection, thank you very much, as we’re chatting and Brian, you sharing your experience about trying to make all the decisions for picking the picture frame matte and how I’m presenting information to my spouse. And to be honest, sometimes I get frustrated with it because what seems to me like what should be a simple to-do or a simple task, or I’m just giving information… maybe I’m overwhelming my spouse in that process, and then potentially he’s shutting down or getting worked up, maybe. Who knows?

I think it’s important to be able to give strategies to Families and education to Families as well. I don’t know if you have any recommendations or strategies for Families, Dr. Turkstra. Maybe it is not just about information for Brian on how he best communicates, but for Families or even in day-to-day things. I really appreciated what you said about making short lists. I don’t know if you have anything else to offer.

Dr. Turkstra

Absolutely. We’re doing this cognitive rehab study in the US right now with the VA and the Department of Defense. We’re about 50 people in, so about 50 patients have received this cognitive rehab. We have transcripts of these therapy sessions, and we’re looking now at what the service members and Veterans are saying about their lives with this mild TBI. What we’ve really noticed is a lot of the process of treatment is them educating their Family members on what works for them.

Some of it is them recognizing that what Family members are trying to do can be helpful. Just to give you an example, I was looking at a session the other day where a Veteran was saying, “My wife makes a calendar, but I never really feel like I need it.” Then he just forgets to pick up the kids. Part of that process is, you know what, that calendar is actually pretty helpful. We could see by the end of the therapy that the Family together is using the calendar. We see a lot of stress and conflict with Families where either the Family doesn’t recognize the problem, or the Family does, and the person doesn’t recognize the problem.

Brian

At home, my wife and I, we’re a blended Family. There are four kids, and they’re at different schools. Then you had the elementary and the high school. When my kids hear this, they already know where I’m going to go with this. I’m going to talk about Wednesday morning. One school’s got late start, the other’s got early start, the other one’s got early dismissal, this one’s got a late dismissal, and then they stagger. This one does it every one in two weeks a month and this one is on the three and the four.

It got to a point where it’s like, “Honey, Wednesday, you got it. I’ll do all this other stuff. I’ll pick up the dog turds in the backyard.” I’ll just do things that aren’t Wednesday. This is not a complicated thing, by the way. I used to run a platoon of 34 people with some pretty in-depth who’s where, and he’s at the medic, and these folks are on leave, and you just constantly feel like you’re the band conductor with these folks, and you get good at it. And now I can’t figure out who’s going where on a Wednesday. I’m not a dumb guy. I can manage things, and yet, I find myself sometimes falling apart now.

And then my workday starts after I’ve just dropped the wrong kid at the wrong school at the wrong time. I’m not telling you about years ago, I’m telling you about right now. I celebrated when my last kid got into high school because there were less Wednesdays to try to figure out who’s going where and, good God, I dropped him off the wrong place. This happens. I don’t have a lack of care or love for my kids. I just screw it up all the time.

Dr. Turkstra

That’s such a great example of the difference between before and after you’ve had an injury or multiple injuries. We think about it like a jar full of pennies that when you have an injury, you need all your pennies. I don’t want to say marbles because that sounds like you’re losing your marbles [laughs]. You need everything in that jar, you have brain injury, and you’ve scooped out a bunch of those pennies.

For us, what cognitive rehabilitation does is help you make the best use of the pennies you have to take some tasks that were costly before, make them automatic. If you can offload your multitasking to a calendar that’s on the wall, you have more brain resources left to think about other things in your life, but if you’re spending all those pennies trying to figure out where the heck your kids are going to school, you don’t have a lot left.

Brian

Then what happens relationship-wise? What would you think if Steve goes to the wrong place that he’s supposed to have gone every day?

Laryssa

I appreciate what you said is that you are an intelligent guy, and you’re a loving father, and you’re committed to your kids.

Brian

Great looking, too.

Laryssa

I didn’t go there. I just realized it’s recorded that I said that you’re intelligent [laughter]. Even as you were saying that, I know that about you, but as a Family member, maybe as the spouse, I would be frustrated. Like isn’t it important enough to you that you would remember where to pick your children up in each place? Yes, potentially it could create frustration within the Family dynamic. It could create maybe resentment within the Family dynamic.

I think that’s where it’s so important to include and educate Family members along the way because that resentment could be, “Oh, now I have to do everything on Wednesday.” I love what you were talking about, Dr. Turkstra, about that program that you were chatting about where the Veterans, you encourage them to include and discuss it with their Families, and hopefully giving them the tools and strategies on how to do that because how do you have that conversation? So yes, absolutely I can see where it can impact Family dynamics and relationships, not just between the spousal partners, but what are the children thinking? “Dad forgot me at the school,” that kind of thing.

Dr. Turkstra

I want to go back to something you said about PTSD versus TBI and symptoms. I don’t think we’ll ever resolve that.

Brian

That doesn’t give me too much hope, doc. [laughs]

Dr. Turkstra

No, there’s a follow-up hopeful comment. There’s been a massive effort in research to come up with biomarkers that will separate PTSD versus mild TBI. In the complicated lives that Canadian Armed Forces members and RCMP members live and their training, I don’t know that it will ever be possible to disentangle them. They have similar effects on the brain. However, we have treatment strategies for both. The model in a lot of the VA in the United States is to say, “Let’s try one and see if it helps, and then we’ll try the other.”

We know we have effective treatments. If the PTS treatment isn’t resolving the person’s everyday cognitive challenges, we’ll do cognitive rehab. If the cognitive challenges are the big ones, we’ll start with that, and then we’ll see if that alleviates the stress.

Brian

You guys might look at me like I walked in on the wrong podcast here, but one of the reasons soldiers cringe when they’re watching movies about war and things like that, you always see these big fireballs, and really what they’ve done is they made something go “bang,” and they put a bag of gas under it, and they simulate that that’s an explosion. Explosions are black, gray, or whatever colour that they kicked up from the ground. If the ground was red, then there’ll be some red in the sky, there’ll be a little bit of fire, but really what’s happening is blast and fragmentation.

Along with that is the fact that sometimes people will look and say, “Well, we have less of this than we used to.” And I’ll leave budget discussions to some other people. One of the reasons is because explosives have gotten better, the science has gotten better. As we advance our understandings, we’re going to advance our protective equipment, we’re also going to advance our ability to do harm to bodies with this equipment. That’s not going to stop.

So… a message of hope, while it sounds like I might not be doing that here, but what I find hopeful is I look at a knee injury: ice pack. I look at a tendon problem: might be another technique. But there are actual things that can be done to help people once they’re diagnosed with these problems. I really never felt that that was the case. I felt that something wrong in my head is permanent, which is why I certainly didn’t want to talk about it. But there are things. What are those things that can be done once someone is diagnosed with one of these issues?

Dr. Turkstra

Many things. Cognitive rehabilitation is an umbrella term that refers to a whole bunch of things that you can do to help. For what I do, we do a lot of strategy training. What are strategies to help you manage your everyday cognitive challenges? How can we support you? I think our motto in the US military and Veterans base is from Home Depot, “You can do it, we can help.”

Brian

Nice.

Laryssa

As we’re ending our conversation, thank you so much. I’ve learned so much. I have some considerations to make when I’m supporting my spouse. He’ll be happy to hear, I’m sure. Where can a Veteran or Family member get started? If they’re listening to this and it’s resonating with them, and they have more curiosity, or they want to pursue it, what are some first steps that they can take? What are some resources that they may be able to tap into as well?

Dr. Turkstra

I mentioned the brain injury associations. I think that’s a really great first stop. You can just Google “brain injury association” of whatever province you happen to be in. If you’re hearing this in 2023, you can always email me about our ongoing cognitive rehab study for Veterans, which is talklab@mcmaster.ca. They’re all good starting points.

Brian

For me, it does give me a lot of vision to the future because there’s more people like you. There’s only one Dr. Lyn, but there are people on this file, there are people looking into what happens. That accident is affecting my ability to learn, but there’s people looking at it, and there’s something that we can do when we know what’s wrong with you. That’s the key.

I hope people in your profession, but also on the clinical side, start to realize when you encounter a Veteran, please start thinking about this right away. Don’t wait until I’m 9, 10 years into treatment before it crosses your mind that we might have something going on. I’m of the belief that a couple of years in the Forces, we should be pretty much assuming that you’ve been knocked around a little bit. That’s only going to get worse as science progresses because it’s going to do both things. It’s going to make better helmets, it’s going to make better bombs. We’re going to keep working. We’re going to keep working together, but thank you for joining us here on the podcast.

Laryssa

Yes, thank you so much.

Dr. Turkstra

Thank you very much.