Claire was in terrible condition. She had been brought to the ward on a stretcher and lifted onto a bed, where she lay curled up in a ball. She couldn’t speak, her eyes were blank, and her face showed no emotion. She could move her right arm a little, but her left arm and both legs were completely still.
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Life had changed dramatically for Claire, a mother of three in her late 30s, many months earlier, when she collapsed during a night out with friends. A weak spot in an artery at the base of her brain had burst, spilling blood around her frontal lobe. She was taken to the hospital, where surgeons removed two pieces of bone the size of side plates from her skull to relieve pressure on her brain. She spent months in intensive care.
Can a patient with such severe damage improve in any meaningful way, especially so long after the event? That was the question for Orlando Swayne, a consultant neurologist and co-leader of the pioneering neurorehabilitation unit at the National Hospital for Neurology and Neurosurgery, a Victorian redbrick building in Queen Square, central London.
It was a few years before the pandemic when Swayne first met Claire on the ward. She made eye contact but showed no other response. He knew from the referring hospital that she could write single-word answers to questions, but these revealed clear signs of the brain damage she had suffered. Before leaving her bedside to see other patients, Swayne asked if she had any questions. With a pencil clenched in her right hand, she wrote: “Questions, questions, questions,” and then trailed off into a wiggly line. This repetitive pattern comes from a failure in the frontal lobe to keep actions moving in sequence.
View image in fullscreen: ‘There are some patients who start off very severely impaired.’ Photograph: Westend61/Getty Images
“There are some patients who start off, when we first work with them, severely impaired – and I mean very severely impaired,” says Swayne. Claire (not her real name) was one of those patients.
If he had only trusted what he learned in medical school lectures, Swayne might have thought Claire was beyond help. The common belief was that damaged brains couldn’t heal. A brief interest in neurosurgery didn’t change that view. “You see patients in a really terrible state and you think that’s how they’ll be for life,” he says, “but you don’t see them for very long.”
“You see patients in a really terrible state and you think that’s them for life.”
Swayne quickly decided against a career in neurosurgery, probably for the best. “I’m a bit clumsy,” he says, though that wasn’t the only reason. “Neurosurgery is all about the skill, and I’m not really a skilled person. I like the people. I like the relationships and the human aspects, which you don’t get as much in neurosurgery.”
He moved into general medicine, then into neurology and stroke medicine, and over the next 20 years or so began to see patients long after their initial hospital stay. “I started to realize that some of these patients were improving. And the ones who were improving were the ones working with therapists,” he says. “I thought: ‘OK, I didn’t know that was possible. How does it work?’”
The answer, it seems, lies in the brain’s ability to change, known as neuroplasticity – its capacity to form new connections and reorganize itself in response to new circumstances. In his new book, How to Use a Fork: Stories of Mending the Broken Brain, Swayne argues that recent discoveries in this area have “profound implications” for patients and the therapy and care we owe them.
Swayne is at the piano, murdering Chopin – his words, not mine – when I arrive at his north London home. Our chat overlaps with his daughter leaving for a gap year trip, a milestone I expected to be chaotic, but a calmness prevails. A small black dog bounds over and then scoots away, before finding a spot on the kitchen sofa.
My copy of his bookThe book is a mess of folded corners, underlined passages, and notes in the margins. But I admit, unfairly in hindsight, that I hadn’t looked forward to reading it. That’s because there’s history here. Doctors have written books on neuroplasticity before, and some made me deeply uneasy. In my view, they offered false hope by describing miraculous recoveries. At worst, they seemed to suggest that patients with severe brain injuries could get out of their wheelchairs, speak fluently again, and overcome serious cognitive problems—if only they tried hard enough. I was afraid this book would be more of the same: show me a publisher who wants stories of patients whose lives are destroyed and stay that way.
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Stroke patients often have to relearn basic tasks like walking, talking, and eating. Photograph: Posed by model; Catherine Falls Commercial/Getty Images
As it turns out, Swayne has read the same books and shares that concern. To be clear, he isn’t suggesting that everyone who has a major stroke or brain injury can recover. His point is that early, focused, and intensive therapy can lead to life-changing improvements, and that we have a moral duty—not to mention an economic one—to provide that care. “The common view of brain injury is that it’s permanent and you can’t recover from it, and this book is a correction to that,” he says. “There is hope, but you have to balance that. Some people just don’t recover.”
Stroke is a leading cause of adult disability in the UK. It happens when a blood vessel, usually an artery, gets blocked or bursts, cutting off oxygen and nutrients to the brain. Within minutes, brain cells in the affected area start to die. Depending on where it occurs, a stroke can cause paralysis, loss of speech, blindness or other vision problems, trouble thinking, memory loss, personality changes, difficulty swallowing, and more. Of the roughly 12 million people worldwide who have a stroke each year, one in five dies within 30 days.
Many stroke patients show small improvements in the first few weeks as swelling and inflammation go down. According to old-school thinking, that was the best you could hope for. But that’s not the whole story. The damage from a stroke or brain injury triggers chemical changes in the brain. These start growth processes in neurons that were last active in the developing brain. Surviving neurons are encouraged to form new connections and work around the dead tissue.
Of course, the brain always shows some level of neuroplasticity. To learn a new language, play a new instrument, or fly a helicopter, your brain has to create new connections. This process redraws the functional maps in the brain—the neural areas used for specific tasks. That’s why London black-cab drivers have more grey matter in the hippocampus after learning the Knowledge. Similarly, the brain area dedicated to using the index finger grows when people learn to read braille with it. But this process is slower in adults than in children or those who have recently had a stroke or brain injury.
“Even though the capacity for plasticity is greatest in the first few months, it doesn’t just switch off,” Swayne says. In one study, intensive therapy improved upper limb movement in patients 18 months after their strokes.
Claire’s early therapy sessions focused on positioning and stretching—to help her sit comfortably—and exercises for her mouth, tongue, and voice box. But they were hard, and she quickly got too tired to continue. Over time, though, her stamina improved, and she became more engaged with the therapists. She started to follow people walking past with her gaze and would sometimes move her mouth to speak in response to questions.
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Tasks such as learningLearning to play an instrument helps the brain form new connections. Photograph: Posed by model; Ruben Bonilla Gonzalo/Getty Images
Her improvement sped up with music therapy. In those sessions, Claire used her stronger right hand to strum guitar strings and shake maracas. Her therapists noticed more natural facial expressions, and she started pointing to instruments, making choices, and being proactive. Session after session, for four months, she practiced making decisions, identifying objects, and using her mouth and tongue.
Swayne hadn’t caught up with the therapists in a while, but one day as he walked past Claire’s bed and said hello, she looked up and asked, “What happened to your hair?” Swayne stopped in his tracks. “That was an amazing moment,” he says. “When you work with a patient who hasn’t spoken for a year, and you try an intervention and they start talking, it has to be a response to the therapy.”
Swayne told Claire about his bad experience with a barber and later learned from the speech therapist that her language had been coming back for about a week. First, it was single words, then phrases and short sentences. She also made progress with her right hand. Before long, she was playing Connect 4 with her sons and other patients on the ward, though her left side and right leg remained paralyzed.
“She started communicating with her kids and with us, and that was huge,” Swayne says. “Her left side will always be weak because it’s badly damaged, but she began using her right arm to do things like use a phone and operate a power chair. We had her cooking, and that was a big deal. She’ll always need help, but for quality of life, it was life-changing.”
There’s still a lot to learn about how the brain works around damaged tissue, but some details are becoming clearer. If you look at the motor cortex in the brain’s frontal lobe, you’ll find specialized neurons that control limb movement. These are arranged vertically to send signals to the spinal cord. But they’re also connected by a network of horizontal links. Normally, these horizontal connections are suppressed, but when the brain is damaged, that suppression eases and the connections activate. Surviving neurons can then recruit nearby cells to help, though they need time and practice to learn the new job.
There’s more to neuroplasticity than this, but this mechanism explains some of the clear limits that doctors and patients see. When neural connections are completely lost, it seems no amount of therapy can bring them back. And while the brain can reorganize to some extent, there’s no evidence that a specialized area of the cortex can take on a completely different role. If a stroke leaves your right arm limp, your visual cortex can’t take over control of it any more than your kettle can make toast in the morning. That said, movement, language, sensation, and vision aren’t limited to small brain regions—they’re spread across networks that offer some flexibility. For example, most people process language mainly in the left side of the brain, but if that’s damaged, there’s evidence that parts of the language network on the right side can take over some of the work.
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‘For quality of life, it was life-changing’ … after therapy, Claire was playing Connect 4 with her sons and other patients on the ward. Photograph: andreygonchar/Getty Images/iStockphoto
Much of the immediate work with new stroke patients is to identify their impairments and their causes. If they can’t use a fork, what’s stopping them? Can they feel it? Are they too weak on that side? Can they coordinate their movements?
Therapists take these impairments and break them down into steps that patients can practice. So far, there’s no shortcut to the hard work put in by the patients described in Swayne’s book. Thomas, a vicar who couldn’t speak after a stroke at the pulpit, had intensive speech therapy to retrain his swallowing and tongue movements. ChrisTian, a mixologist at a fancy London hotel, had to relearn how to brush his teeth: turn on the tap, grab the toothbrush, add the toothpaste. Vikas, a roofer who fell three stories, practiced in the kitchen to regain his focus and ability to multitask.
Therapists don’t just deal with the direct damage from a stroke. The brain can create its own issues. Patricia, a catering assistant, lost the use of her right arm. When asked to point to it, she would move it aside and keep searching through the bedclothes. Later, she thought the arm was a baby and became inconsolable when she believed it had died.
The therapy a stroke patient receives is the biggest factor in how well they recover—whether they’ll rely on others or manage on their own. Yet, according to Swayne, most patients get far too little. In the UK, stroke patients should receive 45 minutes each of physical therapy, occupational therapy, and speech therapy every weekday. But a 2020 audit found that most got only 14, 13, and seven minutes per day, respectively. “It’s shocking,” says Swayne.
“It’s frustrating, having worked with patients for months, to then send them into the wilderness.”
It gets even worse when people leave the hospital. Stroke units used to hand patients over to local community therapy teams, but those networks were cut by austerity measures. “It’s a real postcode lottery. Some boroughs you’re relieved to discharge a patient to because they actually have a speech therapist, while another borough is a desert,” Swayne says. “It’s frustrating, having worked with these patients for months, to then send them into the wilderness.” It’s common for patients to return a year or two later with complications, having had no therapy since leaving the hospital.
Swayne adds that the argument that proper rehabilitation is a luxury we can’t afford doesn’t hold up. Early, intensive therapy pays for itself by cutting long-term care costs. This will become even more important as first-time strokes increase in the coming years. Today, strokes cost the UK economy an estimated £27 billion a year, but only £3 billion of that comes from direct hospital care. The rest is lost economic productivity and hidden care costs. By 2035, the cost is predicted to more than triple to £75 billion.
“People talk about the cost of these interventions, but if you do the math, an admission might cost around £40,000,” Swayne says. “That sounds like a lot, but when you look at the change in care costs, it isn’t, because it pays itself back pretty quickly.” Swayne calculated for one patient: during his time in the rehab unit, his care costs dropped to £2,640 per week, meaning the cost was covered within four months of him going home, and would save tens or hundreds of thousands of pounds in the long run.
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Postcode lottery … the therapy patients receive after being discharged from hospital varies significantly from borough to borough. Photograph: Pramote Polyamate/Getty Images
It’s not just stroke rehab that’s struggling. Care for traumatic brain injury is also badly neglected. Each year, more than 1 million people in England and Wales go to emergency rooms for head injuries. Of the roughly 200,000 admitted to the hospital, about 40,000 show signs of traumatic brain injury.
Many of these patients are discharged within a couple of weeks. On the surface, they seem better: they can walk and talk. But often, serious problems go unnoticed. “What we now realize is that most of those patients have cognitive changes that haven’t been picked up,” Swayne says. “You can see them walking down the street and they look fine, but they can’t function normally. There’s an invisible disability. It affects their relationships, their jobs, and they get into trouble with the police.”
And so, the hidden damage left by brain trauma continues.This can lead to lives falling apart. In a 2025 study, researchers found that nearly 90% of adult men in Scottish prisons had experienced a severe head injury. That doesn’t mean brain injury caused their crimes—violent people tend to experience more violence. But damage to certain parts of the brain might make it harder to control impulses, feel empathy, or think through the consequences of actions, which could contribute to criminal behavior.
Researchers are exploring ways to make therapy more effective—and the ultimate goal is to reopen the window of enhanced neuroplasticity. New drugs, brain stimulation, and virtual reality are all being tested. If successful, patients could receive better therapy to improve their recovery. But for now, the best we can do is keep our brains healthy and protected.
“We all know what to do for brain health,” says Swayne. “We should exercise, stay in a stimulating environment, and have social interactions. We shouldn’t smoke or drink too much alcohol. There’s strong evidence that all these things help maintain the brain. By taking care of your brain, you give yourself the best chance of recovery if you ever need it.”
How to Use a Fork: Stories of Mending the Broken Brain is published by Pan Macmillan on 4 June (£20). To support the Guardian, order a copy from guardianbookshop.com. Delivery charges may apply. Do you have an opinion on the issues raised in this article? If you would like to submit a response of up to 300 words by email for possible publication in our letters section, please click here.
Frequently Asked Questions
Here is a list of FAQs about a doctor who repairs damaged brains written in a natural tone with clear simple answers
BeginnerLevel Questions
1 What kind of doctor fixes a damaged brain
A neurologist diagnoses the problem but a neurosurgeon does the surgery A physiatrist helps you recover function through therapy
2 Is there really hope for recovery after a bad stroke or head injury
Yes absolutely The brain has a remarkable ability to rewire itself Even years after an injury people can regain speech movement and thinking skills with the right therapy
3 How does a doctor repair a brain Dont brain cells die forever
They cant grow back dead cells but the brain can reorganize Healthy parts learn to take over jobs from damaged parts Doctors also use surgery medication and therapy to reduce swelling prevent more damage and help the brain adapt
4 What is the first thing a doctor does after a head injury
Stabilize you They make sure you can breathe stop any bleeding and lower pressure inside the skull Then they do a CT scan or MRI to see the damage and decide on surgery or medicine
5 Can someone fully recover from a severe stroke
Full recovery is rare but significant improvement is common Many people walk talk and live independently again Recovery is a long process and results vary based on injury location age and rehab effort
6 What does rehab for a brain injury look like
Its a team effort physical therapy occupational therapy speech therapy and sometimes cognitive therapy
Advanced Questions
7 How does a doctor decide whether to do surgery on a stroke patient
They look at the time window the size and location of the clot and the patients overall health Surgery is risky but can save lives if pressure builds up
