Claire was in a critical condition when she arrived at the hospital, transported on a stretcher and placed on a bed in a fetal position. She was unable to articulate any words, her expression vacant and her gaze dull. Although she could slightly move her right arm, her left arm and both legs remained completely still.
Her life took a drastic turn months prior, when a night out with friends ended in tragedy. An artery at the base of her brain had burst, causing blood to leak into her frontal lobe. Claire was rushed to the hospital, where surgeons performed a procedure that involved removing two sizable sections of bone from her skull to alleviate the pressure on her brain. Following the operation, she spent several months in intensive care.
The pressing question for Orlando Swayne, a consultant neurologist and co-leader of an innovative neurorehabilitation unit at the National Hospital for Neurology and Neurosurgery in central London, was whether someone with such severe disabilities could show any significant improvement, especially so much time after the incident.
Swayne first encountered Claire years before the pandemic while she was in the ward. Although she could make eye contact, there was no other visible response from her. He was informed by the referring hospital that she could respond to questions with single words, but her answers revealed the extent of her brain damage. Before attending to other patients, Swayne asked if she had any questions. Claire, holding a pencil in her right hand, wrote: “Questions, questions, questions,” before trailing off into an erratic line. This repetitive behavior indicated a dysfunction in her frontal lobe that hindered her ability to maintain sequential actions.
Swayne noted, “Some patients we start working with are extremely impaired – and I mean really severely so.” Claire, who is not her real name, was one of these patients.
Had Swayne relied solely on his medical school teachings, he might have dismissed Claire as hopeless. Conventional wisdom suggested that damaged brains were incapable of healing. His brief experience in neurosurgery did nothing to alter that perception. “You encounter patients in dire conditions and assume that’s their fate for life,” he explains, “but you don’t see them for very long.”
Ultimately, Swayne opted against a career in neurosurgery, attributing this decision partly to his lack of dexterity. “Neurosurgery is very much about skill, and I’m not particularly crafty,” he admits. “I prefer the human interactions and relationships, which are less prevalent in that field.”
He transitioned to general medicine and then to neurology and stroke medicine. Over the subsequent two decades, he began observing patients long after their initial hospital visits. “I started to notice that some of these patients were making progress. The ones who improved were those receiving therapy,” he remarks. “I thought: ‘Wow, I didn’t realize that was possible. How does that work?’”
The answer lies in the brain’s neuroplasticity—the capability to forge new connections and reorganize itself in response to changes. In his recent book, How to Use a Fork: Stories of Mending the Broken Brain, Swayne argues that emerging insights in this field have significant implications for patient therapy and care.
When I visited Swayne at his home in north London, he was attempting to play Chopin on the piano—his own description of his performance. Our conversation coincided with the moment his daughter was preparing to leave for a gap year, a situation I expected to be chaotic, but a sense of tranquility filled the room. A small black dog ran around before settling on the kitchen sofa.
My copy of Swayne’s book is marked with folded corners, underlined sections, and margin notes. I must admit, in hindsight, that I did not thoroughly enjoy reading it. There is a complex history surrounding this topic; previous medical texts on neuroplasticity have left me uneasy, as they often depict miraculous recoveries that seemed unrealistic. At worst, they suggested that individuals with severe brain injuries could achieve full recovery if they only tried hard enough. I braced myself for a similar narrative—dreading the idea that publishers would favor stories of patients whose lives remained irrevocably altered.
However, Swayne has also encountered these previous works and shares my concerns. He clarifies that he is not claiming that every individual who experiences a significant stroke or brain injury can fully recover. Instead, he emphasizes that early, focused, and intensive therapy can lead to transformative improvements, and there exists both a moral and economic imperative to provide such care. “The common belief regarding brain injury is that it is irreversible and that recovery is unattainable, and my work aims to challenge that perception,” he states. “There is hope, but it must be tempered with realism. Not everyone will regain their prior capabilities.”
Stroke is a leading cause of disability among adults in the UK, occurring when a blood vessel, usually an artery, either becomes blocked or ruptures, depriving the brain of vital oxygen and nutrients. Within minutes, brain cells in the affected area begin to die. Depending on the stroke’s location, it can lead to paralysis, speech loss, visual impairments, cognitive decline, personality changes, swallowing difficulties, and more. Annually, around 12 million individuals worldwide suffer a stroke, with one in five succumbing within 30 days.
Many stroke survivors experience minor improvements in the initial weeks as swelling and inflammation decrease. Traditional beliefs held that this was the extent of potential recovery. However, this perspective fails to encompass the entire picture. The damage inflicted by a stroke or brain injury triggers chemical alterations in the brain, initiating neuronal growth processes that were last active in the developing brain.
