“My son can now eat, speak, watch a movie without falling asleep,” explained his mother. “He can drink from a cup. He can express pain. He can cry and he can laugh.” This had not been the case for the last six years, a time when the man was fed though a tube, rarely showed signs of awareness, and used thumb or eye movements to communicate. The man was beaten violently in the head during a robbery in 1999, and the doctors said he would remain in a vegetative state for the rest of his life, if he even survived at all.
Doctors brought the 38 year old man out of the coma using an experimental electrode procedure called deep brain stimulation. “Drive” was delivered to specific and crucial areas of the brain. A similar procedure has been used for years with Parkinson’s patients, but in different brain areas.
]]> While the man still cannot walk and still must be spoon-fed, the changes are remarkable. Dr. Ross Zafonte, of the University of Pittsburgh, warns that “we need to know more,” but that the procedure is “very interesting and holds great promise.”A person can "break their back or neck" yet not sustain a spinal cord injury if only the bones around the spinal cord (the vertebrae) are damaged, but the spinal cord is not affected. In these situations, the individual may not experience paralysis after the bones are stabilized.
What is the spinal cord and the vertebra? The spinal cord is about 18 inches long and extends from the base of the brain, down the middle of the back, to about the waist. The nerves that lie within the spinal cord are upper motor neurons (UMNs) and their function is to carry the messages back and forth from the brain to the spinal nerves along the spinal tract. The spinal nerves that branch out from the spinal cord to the other parts of the body are called lower motor neurons (LMNs). These spinal nerves exit and enter at each vertebral level and communicate with specific areas of the body. The sensory portions of the LMN carry messages about sensation from the skin and other body parts and organs to the brain. The motor portions of the LMN send messages from the brain to the various body parts to initiate actions such as muscle movement.
The spinal cord is the major bundle of nerves that carry nerve impulses to and from the brain to the rest of the body. The brain and the spinal cord constitute the Central Nervous System. Motor and sensory nerves outside the central nervous system constitute the Peripheral Nervous System, and another diffuse system of nerves that control involuntary functions such as blood pressure and temperature regulation are the Sympathetic and Parasympathetic Nervous Systems.
]]> The spinal cord is surrounded by rings of bone called vertebra. These bones constitute the spinal column (back bones). In general, the higher in the spinal column the injury occurs, the more dysfunction a person will experience. The vertebra are named according to their location. The eight vertebra in the neck are called the Cervical Vertebra. The top vertebra is called C-1, the next is C-2, etc. Cervical SCI's usually cause loss of function in the arms and legs, resulting in quadriplegia. The twelve vertebra in the chest are called the Thoracic Vertebra. The first thoracic vertebra, T-1, is the vertebra where the top rib attaches.Injuries in the thoracic region usually affect the chest and the legs and result in paraplegia. The vertebra in the lower back between the thoracic vertebra, where the ribs attach, and the pelvis (hip bone), are the Lumbar Vertebra. The sacral vertebra run from the Pelvis to the end of the spinal column. Injuries to the five Lumbar vertebra (L-1 thru L-5) and similarly to the five Sacral Vertebra (S-1 thru S-5) generally result in some loss of functioning in the hips and legs.
What are the effects of SCI? The effects of SCI depend on the type of injury and the level of the injury. SCI can be divided into two types of injury - complete and incomplete. A complete injury means that there is no function below the level of the injury; no sensation and no voluntary movement. Both sides of the body are equally affected. An incomplete injury means that there is some functioning below the primary level of the injury. A person with an incomplete injury may be able to move one limb more than another, may be able to feel parts of the body that cannot be moved, or may have more functioning on one side of the body than the other. With the advances in acute treatment of SCI, incomplete injuries are becoming more common.
The level of injury is very helpful in predicting what parts of the body might be affected by paralysis and loss of function. Remember that in incomplete injuries there will be some variation in these prognoses.
Cervical (neck) injuries usually result in quadriplegia. Spinal map Injuries above the C-4 level may require a ventilator for the person to breathe. C-5 injuries often result in shoulder and biceps control, but no control at the wrist or hand. C-6 injuries generally yield wrist control, but no hand function. Individuals with C-7 and T-1 injuries can straighten their arms but still may have dexterity problems with the hand and fingers. Injuries at the thoracic level and below result in paraplegia, with the hands not affected. At T-1 to T-8 there is most often control of the hands, but poor trunk control as the result of lack of abdominal muscle control. Lower T-injuries (T-9 to T-12) allow good trunk control and good abdominal muscle control. Sitting balance is very good. Lumbar and Sacral injuries yield decreasing control of the hip flexors and legs.
Besides a loss of sensation or motor functioning, individuals with SCI also experience other changes. For example, they may experience dysfunction of the bowel and bladder. Sexual functioning is frequently effected. Men with SCI may have their fertility affected, while women's fertility is generally not affected. Very high injuries (C-1, C-2) can result in a loss of many involuntary functions including the ability to breathe, necessitating breathing aids such as mechanical ventilators or diaphragmatic pacemakers. Other effects of SCI may include low blood pressure, inability to regulate blood pressure effectively, reduced control of body temperature, inability to sweat below the level of injury, and chronic pain
How many people have SCI? Who are they? Approximately 450,000 people live with SCI in the US. There are about 10,000 new SCI's every year; the majority of them (82%) involve males between the ages of 16-30. These injuries result from motor vehicle accidents (36%), violence (28.9%), or falls (21.2%).Quadriplegia is slightly more common than paraplegia.
This article was written by Eisenberg, Gilchrist & Morton attorney Christopher J. Rogers. Click here to read his bio.
]]>Instead of focusing on the area where the pain is felt-as most doctors and researchers have in the past-the new findings reveal the pain we feel may be rooted in the brain. That is, our repeated memories of a painful event may actually cause us to feel “physical pain.” The research team concludes that chronic pain’s source may be memories that are trapped in the prefrontal cortex of the brain, a complex area responsible for learning and some emotions. Essentially, “our brain seems to remember the injury as if it were fresh and can’t forget it."
]]> The researchers have developed a drug that targets pain in the brain, a deviation from traditional drugs that target the body’s sensory input of pain (for instance, the back, or a foot, etc.). According to researcher Vania Apkarian, “In some ways, you can think of chronic pain as the inability to turn off the memory of the pain. What’s exciting is that we now may be relieving what has clinically been the most difficult to treat-the suffering or the emotional component of pain.”Experimentation on rats has shown the drug to be effective. If the drug is approved for human use, the researchers expect individuals will still report the sensation of feeling pain, but that the pain’s emotional and cognitive consequences will be reduced.
These findings are not limited to chronic pain management. Research has (again) shown the power of the brain to regulate our daily experience. In this case, researchers have examined pain, something which seems very bodily, and illustrated our mind’s involvement in the process.
Click here to read the entire article.
]]>In a recent commentary on MSNBC.com, chief science and health correspondent Robert Bazell writes, “Much of the medical care for wounded Iraq vets remains a national shame. The mental problems caused by either brain injury or post-traumatic stress will be a legacy of this war for decades.” Bazell blames the government’s unwillingness to pay the cost of treating so many wounded veterans as the key root of this growing problem. Many of these wounded veterans are not simple cases of broken limbs or shrapnel wounds- some statistics suggest 60-65% of all wounded soldiers have an acquired brain injury. Our military technology allows troops to be better armed and protected, but we have learned one major lesson: no matter how strong the body or vehicle armor is, “the brain- which gets shaken like jelly- is frequently damaged.”
]]> In a previous article, Bazell outlines the subtle brain damage from which troops suffer, as well as the pressure to continue fighting. Surely, media attention has put TBI in the spotlight. Furthermore, it has helped push the Bush administration to reform the system, such as a move to require all veterans to be screened for mental problems, as well as improved hospital facilities and care at home and abroad.The problem is, no matter the amount of light the media shines on TBI, these injuries continue to occur, both to soldiers and Americans of all walks of life. Perhaps, the media can begin to highlight the ways to prevent TBI, as well as highlighting the victims and their stories. Perhaps, a newfound vigilance to prevent these injuries can be “this war’s legacy.”
Click here to read Bazell’s entire commentary.
]]>Psychologists describe the animal brain as modular; that is, specific areas/systems are responsible for specific functions. For example, the occipital lobe of the brain is responsible for vision, the limbic system for emotion, and the motor cortex for muscle movement. Some psychologists have referred to this modularity as a “Swiss Army Knife model.” Like each tool in the knife, brain modules are somewhat independent; however, these modules, or tools, interact to create a larger entity.
In traumatic brain injury (TBI) cases, certain modules may be affected, while others remain completely normal. An injury to the frontal lobe may greatly affect an individual’s planning and problem solving (and thus greatly affecting that individual’s pre-injury routine), but may have no effect on the individual’s vision. Conversely, brain damage in the Occipital lobe may render an individual blind, but have little effect on frontal lobe functioning.
An oft-cited case is that of railroad worker Phineas Gage. While helping to the build a railroad in 1848, Gage’s head was severely struck by a three-foot iron (traveling so fast that it went in one side and out the other!). The iron struck mostly Gage’s frontal lobe. As his physical recovery continued to improve post-accident, Gage’s personality seemed to have drastically changed. The fact that a three-foot rod could so greatly affect personality but not affect functions such as sight and speech helped solidify the notion of a modular brain.
The Swiss Army Model is a useful way of understanding brain functions. However, one must always keep in mind the complexity of the human brain and its networking. Not only does current research continue to illuminate modules and specific pathways, but more and more we are discovering how hard it is to separate one module from another.
As Dr. Lehr concludes, problem areas in TBI rehabilitation often affect each other (networked modules). In his example, re-establishing balance and eliminating dizziness may help to improve concentration and attention, in turn improving planning and problem solving. In many cases such as this one, it becomes impossible to separate the individual tools of the Swiss Army Knife.
]]>“The nature and incidence of psychiatric and emotional problems in adults suffering Traumatic Brain Injury was recently illuminated in a study reporting a thirty year follow-up of brain injured individuals. As has been reported in short term studies of emotional dysfunction following Traumatic Brain Injury, this study demonstrates that a significant number of individuals struggle long term with psychiatric disorders following Traumatic Brain Injury. Forty-eight percent of these individuals experienced an Axis I disorder that began after the Traumatic Brain Injury. Sixty-two percent had an Axis I disorder anytime during their lives. The most common disorders after Traumatic Brain Injury were major depression (27%), alcohol abuse or dependence (12%), panic disorder (8%), specific phobia (8%) and psychosis (7%). Fourteen subjects or 23% had at least one personality disorder. The most prevalent individual personality disorders were avoidant (15%), paranoid (8%), and schizoid (7%). Interested readers are referred directly to the article by Koponen and colleagues (American Journal of Psychiatry, August 2002, Volume 159, pages 1315-1321).
]]> It is reasonable to conclude that Traumatic Brain Injury causes decades-lasting vulnerability to psychiatric illness in many individuals. In these individuals, appropriate care and treatment of emotional and behavioral problems may well speak to the difference between poor or adverse outcome. Clearly, additional research is needed to determine to what extent these adverse outcomes can be mitigated by early identification and appropriate diagnosis as well as psychosocial and medical intervention on a long-term, supportive basis. Further studies are also needed specifically of individuals with mild Traumatic Brain Injury. In clinical settings, it often appears that the long term adverse emotional and psychiatric problems these individuals experience may also be related to difficulty with chronic pain and stress.These data highlight the importance of emotional, behavioral and psychiatric assessment as part of a comprehensive neuropsychological battery. It is my experience that for many individuals recovering from Traumatic Brain Injury, long-term prognosis and functioning is often better predicted by emotional regulation and psychiatric stability than eventual level of cognitive and neuropsychological function.”
This advice from Dr. Goldstein once again illustrates the far-reaching implications of a TBI. Treaters must target neuropsycholigical rehabilitation and functioning, but at the same time remain aware of other psychological impairments caused either physically by the actual injury or acquired during the recovery aftermath.
]]>Other developments have accompanied the study, including a NY Times report that the suicide of ex-NFL player Andre Waters in November was partially caused by his earlier concussions. NFL commissioner Roger Goodell has since announced widespread regulations for the league vis-a-vis concussions, including mandatory neuropsychological evaluations for all players, and a system where players can report a coach’s attempts to “override the wishes of a concussed player or medical personnel.”
Football is just one of many sports which include a risk of head or brain injury. According to the Brain Injury Association of Utah (BIAU), college and pro football players suffer higher rates of head injury than youth football players, because of their size and the increased speed of the game. The BIAU urges parents to teach their children to always play touch football when unsupervised, as well as to always wear a helmet. http://www.biau.org/facts/facts_prevention.html#football
Click here to read the entire NY Times article.
]]>Research on the relation between PTSD and legal litigation remains in its infancy. Neuropsychologist Sam Goldstein explains that some studies have shown an increase in severity of PTSD symptoms in populations experiencing legal litigation. Studies have also demonstrated that financial compensation post-litigation does not decrease the severity of PTSD symptoms. Thus, while the litigation process may act as a secondary stressor adding to a victim’s ongoing traumatization, it does not appear the litigation process acts as a cure to this traumatization.
Further, PTSD symptoms tend to increase and decrease in severity over time. The unpredictability of these flows, along with the lack of a clear illustration of a specific causal link between individual experience and PTSD symptoms, make it difficult for forensic psychologists to predict “why, how, and for how long PTSD symptoms will present, evolve, and maintain.”
Click here to read Dr. Goldstein’s legal update.
]]>A recent Newsweek article focuses on children and teenagers’ use of ATVs. Doctors say that children don’t have the cognitive skills, size, or strength required to operate these machines. Dr. Denise Dowd, a member of the American Academy of Pediatrics’ injury prevention-committee, explains, “One can argue that ATVs are even more difficult to drive than a car,” citing the need to repeatedly shift weight during operation. The article highlights the experience of then 15-year-old B.J. Smith. Traveling at 60 miles per hour, Smith clipped a dog with his front tires. Smith then flew around 25 feet in the air, hitting his head on a sidewalk as he landed on the ground. "His brain was so swollen they had to cut out a piece of his skull," recalls his mother. "He's my only child. It was absolutely horrible." Today, Smith lives with the consequences of a TBI.
]]> Consumer critics argue more limitations must be placed on ATV use. Backing them are some staggering numbers. Children under the age of 16 account for two-thirds of ATV-related deaths and injuries. A recent study in Ohio concluded $30 million is spent by emergency rooms each year dealing with 10,000 ATV-related hospital visits, and that is just in one state.Some states have passed regulations prohibiting young children from riding and requiring riders to wear helmets. One state (North Carolina) now requires safety training for all ATV riders. The Brain Injury Association of Utah advises parents to make sure their children follow ATV safety precautions. These precautions include avoiding paved roads, riding during daylight hours, and never riding with more than one person on an ATV. As ATV sales continue to increase in this country, lawmakers must continue to pass accident prevention regulations. Regardless of what the lawmakers say, parents must insure their children are safely using ATVs, in order to avoid injuries such as Smith’s.
Click here to read the entire Newsweek article.
]]>“Neuroplasticity is defined as the capacity of brain cells to fight the chemical and structural changes that occur following trauma that can eventually kill them if not controlled. Neuroplasticity also refers to the ability of brain cells to modify their activity in response to change in the environment, to store information from the environment and to permit the organism to move about and survive. Thus, all functioning brains to some extent operate under the principle of neuroplasticity throughout life.”
Dr. Goldstein notes that “the once held belief that recovery from brain injury is limited to the first one to two years following injury has now been met with considerable challenge. Further, the idea that remediation of function can only be accomplished in the first eighteen months post accident is increasingly being challenged. The idea that the development of compensatory strategies many years post accident leading to improved daily functioning may have no direct impact on the structure and biochemistry of the brain is also increasingly in question. A significant number of studies have now demonstrated that many people can make significant physical, cognitive and behavioral recovery as long as five years or more post brain injury. As Stein noted in 1995, ‘There is no rule of neuroscience that the processes of functional recovery must occur rapidly or that treatment should be terminated after a fixed period of time because the early results are unsatisfactory.’”
]]> Advances in “Neuro-rehabilitative therapy, in particular cognitive rehabilitation, may well facilitate the brain's plasticity. This theory has been demonstrated not only from the patient's perspective and observations of others, but even through SPECT and PET scanning. It also appears that neuro re-organization can be enhanced through specific training. Though compensatory strategies can be helpful post brain injury, plasticity research suggests that the appropriate timing of teaching these strategies is a critical and complex issue. If strategies are implemented too early, those potentially available, compensatory parts of the brain may not be capable of effectively taking over function. This may explain the significant problems many mild to low moderate brain injured patients experience when they return, often within a few days post injury, to every day activities, particularly work. Thus, too much activity too early post injury may lead to increased adverse outcome.”Click here to read Dr. Goldstein’s entire article.
]]>In Cognitive rehabilitation, two areas are stressed: reacquiring cognitive skills, and learning to use strategies to compensate for lost skills. As physical therapy would be used to repair a damaged muscle, cognitive therapy can be used to repair a damaged cognitive system. Therapists may help TBI patients complete exercises or tasks in order to improve skills. In cases where these skills cannot be reacquired, the therapist may teach the patient specific therapies across inter-related cognitive categories, such as memory, attention, and organization. For example, a patient may be urged to use checklists and “to-do” lists to improve organization in their daily routine.
]]> In November 2006, the Brain Injury Association of America (BIAA) released an official position statement on cognitive rehabilitation. In it, the authors outline their recommendations for offering cognitive rehabilitation, along with evidence for its efficacy.As the BIAA statement illustrates, “Persons with brain injury may also engage in services aimed at improving emotional, behavioral, and psychosocial functioning” in addition to cognitive services. The advantage of the perspective system in psychology is the ability to combine treatments in order to find the most effective program possible. For instance, cognitive and behavioral therapies can be combined with drug therapy (a biological approach), along with many other options. As doctors both improve current treatment areas and find even more ways to diversify treatment plans, expect recovery to improve for persons with brain injury.
]]>According to Dr. Jean Langlois, one of the toolkit’s authors, “Recent research has shown that diagnosing mild TBIs as soon as possible is critically important because without proper management, recovery can take longer, and people who are still recovering are at higher risk of having a second, more serious injury. We believe that the ACE assessment tool will provide a needed diagnostic tool for physicians because it provides the most up-to-date information on how to recognize and treat concussion.”
Concussions, often referred to as mild traumatic brain injuries (MTBI), are by far the most common form of traumatic brain injury. The CDC estimates that 75-90% of all TBI are of the mild type. However, just because a TBI is mild does not mean there will not be serious consequences. According to the American Academy of Neurology, permanent brain injury can occur if the acute symptoms of concussion last for more than 15 minutes. Furthermore, concussions can lead to future problems, such as amnesia and post-concussion syndrome, as well as increasing the risk of stroke and Alzheimer’s disease.
The Heads Up: Brain Injury in Your Practice tool kit is available free of charge, by clicking here.
To read the entire CDC press release, click here.
]]>The Brain Injury Association of America estimates there are 1.4 million TBI each year in the United States, which translates to .5% of the entire population. This means roughly one in every 200 Americans will undergo some type of TBI each year in the United States.
But there is good news: tbirecoverycenter.org summarizes recent advances in medical technology for the treatment of TBI. These advances span diverse areas of medical science, including bone marrow cell transplant, oxygen therapy, hormone therapy, and drug therapy. Researchers hope these and other treatment options one day increase the rate of recovery for TBI survivors.
Dr. Sam Goldstein (samgoldstein.com), a neuropsychologist in Salt Lake City, Utah, remains optimistic that medical and technological advances can limit the negative effects of TBI.“There are exciting advances on all fronts in prevention, treatment and rehabilitation for people with TBI. Rehabilitation specialists have made significant headway in the combination of medications and therapies, both cognitive and behavioral, to help TBI patients return to a near-normal life. Further, preventive measures such as the design of helmets for sports and airbags in cars has dramatically reduced the number of TBI.”
The human brain is so complex and delicate that it is likely impossible to eliminate all short and long term effects of these injuries. Dr. Goldstein urges individuals to be as safe as possible at all times, for the only way we will ever be completely able to treat TBI is when we are able prevent them from happening in the first place.
]]>…Asbestos does not impact any two people in the same manner. In addition, asbestos has a latency period of at least five to ten years and can remain dormant for up to 40 years. It therefore can be difficult to prove when the exposure occurred that caused the asbestos injury.
…To prove that asbestos caused an injury, the first task is to determine each potential source of exposure. This can mean a review of over 40 years of a worker’s life. This can be accomplished by interviews, but often also involves a review of Social Security, union, tax, and other records.
Read the entire article here.
This article was written by Robert G. Gilchrist
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