Frontal Lobe Problems After Brain Injury

It's a real pleasure to be here today, and there is such a big audience out there. In addition to the professional side of things, it's probably worth mentioning that at least one, probably two members of my family also suffered traumatic brain injuries, so I have a bit of experience and understanding of the impact that can have on families, friends, and the systems around them.

Today, my objectives are to give a very brief overview of information relating to neuroanatomy and neurodevelopment, which I think are simple to understand and provide a good grounding for the topic we're going to talk about today. I'm going to talk a bit about the role of the frontal lobes in daily life, what kind of tasks they are involved with, and what skills are involved. Then, I will specifically focus on recognizing executive functioning difficulties following a traumatic brain injury, how that affects people, and what it looks like. Toward the end, I will provide a little bit of information about some strategies that we use in neurorehabilitation, with a focus on compensatory strategies rather than remediation-type strategies.

To start with a diagram, your brain is about the size of your two fists put together and is in two halves. The left half controls the right-hand side of our body, and the right-hand side of your brain controls the opposite side of our body. The cortex, the wrinkly bit that you see in these pictures, is divided into four regions which we call the lobes.

At the back of your head are the occipital lobes, primarily associated with vision, a very important sensory process for humans. Above that is the parietal lobe, which deals with touch and spatial relations, or how we position ourselves in reality. To the sides, as indicated by the name temporal, we have the region associated with hearing and also particularly implicated in memory consolidation and retrieval. Then at the front, you can see probably the biggest lobe; it covers a large area from the front of your forehead to about the middle of your skull.

So, the frontal lobes are particularly well-developed in humans compared to all other mammals. It's the bit that differentiates us from other creatures and is involved in some of the higher-level functions that we're able to do. It is continually developing through adolescence and is actually the last bit to fully develop, not until maybe our mid-20s. So, anybody who has any adolescents at home will understand, maybe at the end of the talk, how they are lacking some of the executive skills that are important in human behavior.

In terms of frontal lobe functioning, one of the most important areas to consider first is with respect to motor function. At the back of the frontal lobe is the primary motor cortex. This is a strip of brain where particular parts are associated with the movement of particular parts of the body. Moving further forward, there is a small area called Broca's area; this is related to speech production. It's in a double dissociation with another area further back in the brain called Wernicke's area, which is speech recognition. They work independently, so you can have good speech recognition while at the same time having impaired expression if you have a lesion or damage to Broca's area, and vice versa.

Beyond the motor cortex or premotor cortex, we have an area which is the focus of what we're talking about today: the prefrontal cortex, right at the front of our brains. This is a large area which is often considered the control center of our brains, the area where information from all other parts of our brains is integrated and made sense of. It is the conductor, a metaphor I like to use, in trying to make sense of the role of the prefrontal cortex in organizing and putting together all the information that comes in through the sensory parts of the brain.

Executive functions go beyond pure memory, attention, or language. They are involved in planning, organizing, and problem-solving—those high-order processes that distinguish us from other mammals. It is our ability to abstractly take information and use it to solve problems, our ability to time travel in our heads, and our ability to project forward into the future to consider what might happen in certain circumstances if we choose one path or another. It helps us to navigate our complicated social worlds and the ability to initiate and inhibit instinctual behaviors. The prefrontal cortex is most closely associated with our super-ego, an area where we make moral decisions.

The frontal lobe is right at the front, so it is the main area that often gets hit in a trauma, particularly in car accidents but also in assaults. It is the area that is likely to be involved in a traumatic brain injury, either through direct trauma or a contre-coup injury, where the brain is shaken in the head, rubbing up against the rough front surface of the skull.

There is a much older region of the brain, the subcortical region or the limbic system, which is associated with more primitive, basic instincts. It is the area where automatic processes are controlled, like your heart rate and breathing. These processes are done through unconscious control. The reason I mention this is because our frontal lobes, in particular, are involved in the inhibition and management of those basic impulses and drives. When we feel angry or driven, the reason we don't always immediately act on those instincts is because our frontal lobes are able to hold those feelings, look at them, step back, and consider whether acting on them is in our best interest.

Common symptoms of frontal lobe damage include difficulty focusing or concentrating—an inability to filter incoming information. Other issues include poor impulse control, where people might say exactly what they think without consideration of the social circumstances. Emotions become more difficult to manage, and mood swings can be more pronounced. Obviously, the ability to make decisions and solve problems can be impacted. Social interactions can become very problematic because when you lose the ability to step back and look at what is going on, social communication becomes difficult.

Initiation is another issue; a group of people with specific lesions to parts of the prefrontal cortex will struggle to initiate themselves. People might assume someone is depressed, but often they just lack any drive to do anything. People’s personalities may also become more exaggerated; whoever they were before, they are more of that now. Insight is also difficult for most of us, but that ability to see any changes in ourselves is particularly acute with executive functioning problems.

Executive problems are a hidden disability. People with these issues can often talk coherently and be very convincing, yet these problems are completely life and relationship-changing. We use the term 'The Frontal Lobe Paradox,' where an individual gives a good verbal account of themselves but, in the moment under pressure, is unable to follow through with what they say they can do. This often makes it difficult to hold down a job or manage day-to-day decisions and finances.

To conclude, strategies like routines, chunking information, and using apps are very helpful. These are compensatory strategies, and they take a significant amount of time to learn. Ideally, they should be done with the support of a professional rehabilitation team. Emotional adjustment to a brain injury is a lifelong journey, not just for the individual but for the friends and family around them. Accessing support, like Headway, is a fantastic first step, and having time for your own self-care as a family member is absolutely vital.