Brain Evaluation

The Real Culprit of Heading

Recent research suggests that the problem of heading is actually the number of sustained concussions.  In a study of 38 amateur soccer players, those who headed the ball more than 1,320 times per year (which works out to just a few times per day) had more problems.  Microscopic white matter injuries consistent with a traumatic brain injury were detected using diffusion tensor imaging.  The advice of experts is to minimize heading especially for children whose brains are more vulnerable.  The warning is for practice drills when players head the ball back and forth thirty or forty or more times without a break.   Neurology Today 1-5-2012.

 

Imaging Abnormalities found in Mild Brain Injury

Neurology Today July 2 2011, referred to the first longitudinal brain scan study to measure mild brain injury found in Persian Gulf Vets. Diffusion tensor imaging with MRI is being used to detect brain changes resulting from blast injuries and events that take place around the explosion.

Research has documented for some type the impact upon the brain in the form of axonal injury that affects the frontal processes which are more vulnerable.  Blast injuries are not like the typical brain injury where the brain bounces around in its bony shell.  Blast injuries carry a force that can affect the brain in a more pervasive, albeit subtle manner.  The blast injuries are particularly vulnerable to impacting the frontal processes, revealing executive reasoning deficits.  The right orbitofrontal was found to be one of the areas affected which would result in a significant change in emotions.  Damage internal to the brain has widespread impact to brain pathways due to primary and secondary effects.

Nutrition and TBI

The Institute of Medicine released a report indicating the benefit and evidence based guidelines of providing adequate protein and calories immediately after the brain trauma has occurred.  Promising areas were identified but not recommended for B vitamin choline, creatine, n-3 fatty acids (EPA and DHA) and Zinc as the most promising. Neurology Today June 2, 2011

TBI associated with Major Depression

Traumatic brain injury may lead to major depression. Finding of new study that half of those diagnosed with TBI had a major depression (Neurology Today, July 1, 2010).  The patients also reported a high level of anxiety.  Both of these issues affected their quality of life and contributed to more functional impairment one year post injury.  The study suggests that major depression is very common after traumatic brain injury and associated with significant disability. There can be a brain triggered depression following TBI that is too deep and too severe for psychotherapy and/or medication to make a tremendous difference which needs to be recognized as a treatment variable.  Treatment should involve the whole family as a result, in the recognition that the brain injured person does not have a great amount of control over their depressed thoughts and as such cannot make changes on their own without support.  Cognitive therapies are very critical in the need to establish open communication to address the internal thinking processes of the brain injured person that are often not reality based.  The tendency is to think that things are far, far worse than they actually are or need to be. Recognize that you may or may not be able to talk the person out of their thoughts or dark beliefs and be ready to be creative in offering alternative treatments such as brain training and other methods to address the “crooked thinking”.

The concept that damage to the brain can occur beyond the site of injury when TBI or traumatic brain injury is involved

There still seems to be question in the field as to the impact of TBI and some professionals who still believe that the injury is at the site noted on the MRI or CT scan and nothing more.  The research that has been completed in the past decade clearly shows that injury can be beyond the site of injury and also beyond the time period of the injury. Recent research points to the presence of altered functional connectivity in the motor network after TBI damage noting damage that extends beyond the size and location of the injuries to affect remote brain networks.  The point that the individual is able to make adaptations that is not equivalent to their pre-injury optimal level. (Neurology 7-13-2010).  When people believe that injury from TBi is only related to the site of the injury without understanding the brain changes that occur as a result of impact to the brain, they miss severe primary issues.  One, they miss the impact to graceful aging and research that clearly depicts an association to dementia.  Second, they miss the person’s difficulty adding insult to injury as they negate the impact of the changes in their life post injury.  Recently, a young man indicated that his life had changed dramatically following a car accident but no one understood that he may have had a problem, suggested that he be evaluated with neuropsychological testing or that there was any problem following this accident.  As a result events happened in his life that he did not understand and is still recovering from and the question of whether he had a brain injury remains unasked and unanswered.

The phenomenon of Epileptogenesis and TBI

Epileptogenesis is the process occurring over a number of years by which a previously normal brain becomes prone to recurrent seizures

Professionals have long indicated and still indicate that if there are no problems within the first six months to one year then there is no impact from a traumatic brain injury. Lawsuits are won on this particular point.  However recent research totally debunks this theory pointing to the possible presence of problems up to 35 years post injury.  The highest risk for late posttraumatic seizures was found in those patients with multiple or bilateral contusions, subdural hematomas requiring surgery, an early posttraumatic seizure multiple cranial surgical procedures or a large midline shift associated with the injury.  Raymont et. al (Neurology 7-20-2010) studied a group of veteran soldiers who had served in Vietnam enrolled in the Vietnam Head Injury Study,  Among 199 patients in this cohort, the prevalence of epilepsy was 43.7 percent.  Data showed that the latency to the first seizure after the injury can be beyond ten years post injury.  In one case the emergence was 35 years post injury.  Complex partial seizures were the most common at 31 percent.

Sports concussion is linked to chronic traumatic encephalopathy.

The brains of athletes who had sustained multiple injuries and died at a young age (30’s and 40’s) were found to have abnormalities characteristic of Alzheimer’s disease.  John Grimsley, linebacker for seven seasons with the Houston Oilers died accidently in February 2008. He was 45 years old. When his brain was analyzed he had all of the pathological signs of Chronic Traumatic Encephalopathy (CTE).  CTE is a phenomenon first seen amongst professional boxers who appeared to be “punch drunk” after repeated blows to the head. Another term is that of dementia pugilistica. Symptoms of CTE include memory disturbance, confusion, gait problems, speech abnormalities and moodiness.  Apparently John Grimsley had noticeable problems with short term memory prior to his death.  The Center for the Study of Traumatic Encephalopathy at Boston University School of Medicine signed a collaborative agreement with the Sports Legacy Institute to study the brains of professional athletes. The goal is to understand the effects of chronic head trauma, repeated concussions and the risk of dementia. This is truly a wake- up call to re-examine the competitive nature of sports whereby competing athletes strive to win at all costs even if it means their brain, the very essence of their existence.  The question for paid athletes is whether the money they receive is worth their brain. Key issues are the use of available guidelines aimed at protecting athletes from acute concussions and warning of re-entering the game too early before total healing has occurred.  Also important is identifying other risk factors which make some athletes more vulnerable than others. Football is only one of many sports where athletes are at risk for brain injury via a concussion; whether it is falling on the ice, on a roller skating rink, butting heads, bouncing a ball on one’s head, the list goes on.  Full article found in Neurology Today, October 2, 2008

Why are Children More Vulnerable to Brain Injury?

Research tells us that the child's brain may be sixty times more sensitive to excitatory amino acids than the adult brain.  This leaves the child more at risk for the cascade of events that occur following injury to the brain on a cellular basis.  The hyper-sensitivity of the developing brain makes it more susceptible to injury and the effects of injury on the brain. Molecular changes occur allowing more calcium to enter the cell and more potassium to leave the cell. The energy machine in the cell is affected, the mitochondria. In this manner, things change on a cellular level hindering the cell's ability to create energy when more energy is needed for the healing process. The cell is deprived of energy and more injury (ischemia) occurs.  A secondary injury process is created by the changes that occur within the brain following injury to the brain.  Children are more vulnerable for this process to occur. The younger they are, the more vulnerable they are.  More calcium in the cells affects the tone of the vessels supplying blood, oxygen and nutrients to the brain.  Blood flow is altered, the term dysautoregulation,  resulting in more injury. Brain changes leave the child at risk for difficulty recovering from future brain injuries and greater sensitivity to additional brain injury. A second small injury to the brain has a greater effect which increases with each additional injury. Cell death occurs when the brain can no longer adapt to the cell's energy needs. Cells that die are not replaced. Cell death creates more changes in the brain, increasing the cascade of events. The snow ball effect becomes irreversible. 

Traumatic Brain Injury in Sports

Recent statistics. Estimated 1.6 to 3.8 million sports and recreational related concussions occur yearly in the US. You can have an injury with a loss of consciousness or without a loss of consciousness. More people do not have a loss of consciousness in fact only an estimated 8 to 19 percent do lose consciousness. 

So when do you know that you have a problem? When the child acts different emotionally.  Anger attacks, more reactive to everything that is said, more sad, clearly not the same child.  When math facts are too hard to memorize. When spelling words are not correctly recalled writing a sentence two weeks after the spelling test. When school becomes more frustrating. When there are more emotional reactions in school. When there are less friends. When the school calls you with problems. When reading gets harder. When tests are studied for and the information is not recalled when taking the test. The list is endless. Look for any kind of change and trust your gut.

What can be done? Get a neuropsychological evaluation. An evaluation of how the child is functioning using paper and pencil tests to measure the brain. The neuropsychologist and the neurologist form a team to diagnose the brain but the first step is neuropsychological testing. 

The problem is not the concussion, the problem is lack of diagnosis.

There are free "Heads Up" tool kits for physicians, high school coaches and youth sports coaches:

www.cdc.gov/ncipc/tib/Physician_Tool_Kit

www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm

www.cdc.gov/ConcussioninYouthSports

Pain is a Daily Symptom of Traumatic Brain Injury

Pain is a daily occurrence following TBI, whether it is neck and shoulder or headaches.  The pain often does not subside at all or takes months to resolve post-injury.  What happens when a person is in pain all of the time? It changes their personality, their sex life, their physical appearance, their sleep, their enjoyment of the day. They wait for the day to be over. They dread the hour signaling that the day is beginning. No one seems to understand the pain or know how to relieve it.  The question becomes if anyone can withstand the impact of pain on a daily basis.  Often these individuals turn to drugs or alcohol.  Professionals treating the TBI patient needs to be dedicated to relieving the pain instead of telling the patient they "need to live with it". NO one should have to live in pain. There are options, hypnosis is one. Finding the source of the pain is another. The Center for Disease Control suggests referral to a specialist in TBI when severe symptoms do not improve within three to five days. Pain is a severe symptom.