How to Use a Fork, by Dr Orlando Swayne, is a sequence of real stories which will resonate with clinicians working in neuro and stroke rehabilitation, or the patients and relatives living with acquired brain injury. The book is formatted into 12 chapters, each focused first on an individual, discussing the mechanism of the brain injury and the impairments caused. The author then uses each different presentation and condition to explain the background of the impairments caused, from cognitive impairment, motor recovery, speech and spatial neglect. The chapters return to the same cases, and the reader gains a real understanding of the individual person and family.
The simple royal blue book cover, and a beautiful image of the neural pathway on hard cover captures the reader’s attention. Although the title on its own may be ambiguous without the added explanation on its application in brain injury, when my six-year-old daughter looked at the book when it arrived, she looked confused and questioned, ‘well surely everyone knows how to do that?’ However, the fork analogy starts to make sense in chapter 4, where the story of how to eat a sausage is told alongside an explanation of motor control.
I became aware of this book by a Guardian article published June 4th [1], entitled: The doctor who mends the broken brains: why there is room for hope after stroke or head injury. The article title is slightly misleading, there is no single person supporting patients in the recovery from brain injury and the book brilliantly describes each role, and how it is an intensive multidisciplinary team approach to rehabilitation, with high dose therapy and training, that drives recovery by engaging both the brains’ natural ability to recover and promotes neuroplasticity.
The author takes us on a tour of individuals within an inpatient Neurorehabilitation unit in London. In chapter 1 we meet Christian, the bartender, who had right middle cerebral artery stroke, then in chapter 2 we meet Priya, only a teenager, who presented with autoimmune encephalitis. The chapters then unfurl in a similar manner – in chapter 1, the case of Christian is used as a springboard to explain emergency stroke treatment, vascular supply to the brain and areas which are damaged due to the MCA occlusion. This chapter uses a parallel of the ‘Numskulls’ from the beano magazine operating within the human brain, and how stroke effectively wiped these out. This is one of many examples of how the author breaks down complex information into a readable format.
Within chapter 5, we meet Claire. She had a subarachnoid haemorrhage with extensive frontal lobe injury. During rehabilitation Claire slowly improves her ability to communicate. The author uses this case to expand on neuroplasticity, how the brain can remould and strengthen its connections, and how the neuroplasticity is driven by stimulation and intensive therapy input. We return to Claire’s case in chapter 6 where despite her intensive rehabilitation, she does not regain movement in her right arm. Her case is discussed alongside Danny, who after experiencing a pontine haemorrhage presented with both agitation and right sided weakness. We see how his arm function recovers, and the author describes reorganisation and plasticity in the brain which leads to this recovery.
In chapter 8, we meet Gary who also had a right MCA stroke resulting in significant sensory neglect. The author expands on the concept of neglect and imbalance of the attention networks between the brain’s two hemispheres. In chapter 9 we meet Tarek and Dritan, both presenting with left sided injuries and issues with speech. For these patients, music was a catalyst to improving engagement and progress in rehabilitation, as music can stimulate activity across multiple regions of the brain.
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In chapter 10, we have a quick whistlestop of the cross between neuropsychiatry and neurology with cases of delirium, delusions, drug use, depression and functional symptoms. The description of functional neurological disorders is brief; however, it is clear and easy to understand. It is joined with an explanation of the rehabilitation strategies used to compensate for excessive attention via distraction and shifting focus. This chapter felt more disjointed than others and it felt the author was trying to cover many topics in a short space.
In chapter 11, we then move to the severe brain injury spectrum and discussion of prolonged disorders of consciousness. We meet Philip and Bridget who both had a significant traumatic brain injury. The use of functional MRI in patients with significant brain injury is discussed, and how this has shown that patients with significant injury can sometimes demonstrate covert awareness. We also learn of the disability paradox, how many patients with significant disability report good quality of life, and how this can impact best interest decision making.
The final chapter explores the author’s own family, how his father survived cardiothoracic surgery and reflections on his mother’s health journey. This is a personal reflection on the impact significant medical events have, and the difference seeing this through the eyes of a family rather than as a health professional. We also get a roundup of outcomes from some of the patients we meet during the book.
The author notes the difficulty in the UK for patients with brain injury to access the necessary intensive multidisciplinary rehabilitation. He highlights that funding has been primarily used to drive vital changes in emergency care, but has often left rehabilitation in inpatient settings – and particularly community settings – underfunded and under resourced.
In conclusion, this is a beautifully presented and skillfully written book with excellent and clear explanations of impairments, recovery, plasticity and new technologies within rehabilitation. The author clearly enjoys developing a therapeutic relationship with each unique individual and their family. Occasions of humour are sprinkled through the book, aligning with the different personalities we meet throughout, highlighting how humour is so important when responding to adversity.
I have already recommended this book to my colleagues in Neurorehabilitation, and it is also accessible to readers without a medical background interested in brain injury recovery.
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