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Jack Sisson's TBI Blog

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Earlier this week, Gregg Zoroya in USA TODAY wrote:
Scientists trying to understand traumatic brain injury from bomb blasts are finding the wound more insidious than they once thought.

They find that even when there are no outward signs of injury from the blast, cells deep within the brain can be altered, their metabolism changed, causing them to die, says Geoff Ling, an advance-research scientist with the Pentagon.

The new findings are the result of blast experiments in recent years on animals, followed by microscopic examination of brain tissue. The findings could mean that the number of brain-injured soldiers and Marines — many of whom appear unhurt after exposure to a blast — may be far greater than reported, says Ibolja Cernak, a scientist with the Johns Hopkins University Applied Physics Laboratory.

This cellular death leads to symptoms that may not surface for months or years, Cernak says. The symptoms can include memory deficit, headaches, vertigo, anxiety and apathy or lethargy. "These soldiers could have hidden injuries with long-term consequences," he says.

Physicians and scientists are calling TBI the "signature wound" of the Iraq war because of its increasing prevalence among troops.
Continue reading the article.

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On Friday, Sept. 28, 2007, The Brown Daily Herald published the following story about a Brown University alumnus who, after suffering a TBI in 2004, started a foundation for brain injury patients. From the article:

A month after his graduation, Charlie Maddock '04 was hit by a car and suffered an often-fatal traumatic brain injury. Two years later, in 2006, he founded the Charles Maddock Foundation, a nonprofit foundation that supports patients who have suffered brain trauma.

Maddock was crossing the street in New York City when he was hit by a taxi cab and crashed through its windshield. He received several severe physical injuries, including a fractured jaw and shattered pelvis. The most critical injury, however, was the trauma to his brain, which swelled due to the impact of hitting the cab.

Maddock was taken to New York Presbyterian Hospital, where he underwent surgery to reduce the intracranial pressure in his skull.

According to the National Center for Injury Prevention and Control, approximately 1.4 million people sustain a traumatic brain injury, or TBI, in the United States annually. Of that number, 50,000 die. Other long-term effects of TBI can include epilepsy and a greater risk of Alzheimer's and Parkinson's diseases.

"I was one of the lucky ones," Maddock told The Herald.

After leaving the hospital, Maddock still had the difficult task of rehabilitating from the physical and emotional pain of his TBI. The affliction is often called an "invisible epidemic," Maddock said, because people who survive a TBI are forever changed.
The story later notes:
TBI has recently received national media due to the increasing amount of head injuries for soldiers stationed in Iraq. About 10 to 20 percent of the 35,000 screened "health returnees" from Iraq and Afghanistan had "experienced a mild TBI during deployment," the New York Times reported in July.
And:
TBI has also made the national news FOX Newsbecause of the large number of NFL players with head trauma. In June 2007, late Pittsburgh Steelers offensive lineman Justin Strzelczyk was found to have signs of a condition associated with the elderly or boxers with dementia. Strzelczyk is the fourth NFL player to be found with this condition, which is thought to be caused by repeated concussions on the football field.

Read the article.

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Ever since O.J. Simpson almost assuredly got away with murder, Jack has wondered if all of those years of football contributed to brain injury. We know that brain injury alone doesn't necessarily make one violent, but coupled with existing mental illness and/or child abuse, you end up fitting the model for one of Jonathan H. Pincus's violent killers.
Pincus and his colleague Dr. Dorothy Lewis, a child psychiatrist, developed the view that murderers, and especially the most notorious kind, such as serial killers, are the product of the combination of child abuse with neurological damage and psychiatric illness. The three factors interact, as childhood abuse creates enormous anger, while neurologic and psychiatric diseases of the brain damage the capacity to stop urges to violence. A supplementary disinhibiting factor is the abuse of alcohol and drugs, involved in an estimated 70 percent of violent crimes.
You can read more here.

So, with all of that in mind, here's an article from "Slate" that explores the same question -- could football have contributed to O.J.'s behavior?

Slate by Chadwick Matlin, Sept. 21, 2007 -- With the murder trial, the "hypothetical" outline of how he would have killed his ex-wife, and now his "sting operation" in a Las Vegas hotel room, it's hard to remember that O.J. Simpson used to play football. He was actually pretty good at it, running away with the Heisman Trophy in 1968 and making the Pro Bowl five times in his NFL career. As a pro, Simpson carried the ball more than 2,400 times. As the evidence mounts that football can cause massive head trauma, it's worth wondering: Could O.J.'s erratic behavior have something to do with taking too many gridiron collisions?

After former Eagles defensive back Andre Waters committed suicide last year, the Waters family sent pieces of his brain to a forensic pathologist. The doctor reported that damage sustained while playing football had made Waters' brain similar to that of "an octogenarian Alzheimer's patient." According to his doctors, Hall of Fame center Mike Webster suffered frontal lobe damage due to repeated head injuries; he was suffering from dementia when he died at age 50. A post-mortem analysis of Chris Benoit, the professional wrestler who killed his wife and son and then committed suicide, revealed massive brain damage. Diaries were also found with cryptic, disturbing passages that suggested Benoit's behavior wasn't a result of steroid-induced rage, but rather a gradual decline into violence and dementia.

All of these athletes sustained traumatic brain injuries that killed brain cells and left them permanently impaired. Dr. David Hovda, a neurosurgeon at UCLA told me that any altered consciousness—seeing stars, dizziness, or feeling dazed after a hit—is considered a mild TBI. Even a mild concussion causes damage. With football's macho culture, players often pick themselves up and stay in the game, leaving themselves open to more serious harm. But repeated TBIs can lead to an altered frontal and temporal lobe, which can cause heightened anxiety and a loss of emotional control. Football players tend to damage their temporal lobe, which controls feeding, fighting, fleeing, and the person's sex drive.
Keep reading.

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Fighting Brain Injury in Iraq
The war in Iraq is bringing a well-documented but hardly understood battlefield injury into the limelight: traumatic brain injury (TBI). In an effort to learn more about the injury, the U.S. Army awarded Simbex, of Lebanon, NH, a million-dollar contract to develop sensor-studded helmets for combat soldiers. The army is currently testing the helmet technology, which could be deployed as early as December of this year.
Keep reading.

DOD, VA medical programs too complex for those with brain-damage

The bureaucracies that are supposed to help brain-injured war veterans are too complex for them to navigate, a panel of military and medical experts concluded at a meeting Tuesday.http://www.bcrc.com/

Specifically, the departments of Veterans Affairs and Defense need better coordination of their programs, according to the panel, which was part of a daylong Washington Defense Forum sponsored by the U.S. Naval Institute and the Military Officers Association of America.

The panel included two military officers, a doctor, a lobbyist and the chief executive officer of the Brain Injury Association of America.

"The systems in the VA and DOD seem to be against what brain injury can handle," said Susan Connor, chief executive officer the Brain Injury Association. "Because the frontal lobe controls memory, thinking, judgment and processing ... if you shove paperwork in front of someone with sustained brain injury or put them in a large group with scripted instructions, they can't follow it."
Keep reading.

Nonfatal TBIs From Sports and Recreation Activities
Each year in the United States, an estimated 38 million children and adolescents participate in organized sports,1 and approximately 170 million adults participate in some type of physical activity not related to work.2 The health benefits of these activities are tempered by the risk for injury, including traumatic brain injury (TBI). CDC estimates that 1.1 million persons with TBIs are treated and released from U.S. hospital emergency departments (EDs) each year, and an additional 235,000 are hospitalized for these injuries.3 TBIs can result in long-term, negative health effects (e.g., memory loss and behavioral changes).3 To characterize sports- and recreation-related (SR-related) TBIs among patients treated in U.S. hospital EDs, CDC analyzed data from the National Electronic Injury Surveillance System–All Injury Program (NEISS-AIP) for the period 2001-2005. This report summarizes the results of that analysis, which indicated that an estimated 207,830 patients with nonfatal SR-related TBIs were treated in EDs each year during this period. The highest rates of SR-related TBI ED visits for both males and females occurred among those aged 10-14 years. Increased awareness of TBI risks, prevention strategies, and the importance of timely identification and management is essential for reducing the incidence, severity, and long-term negative health effects of this type of injury.
Keep reading.

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"Executive Function" is a term used to describe a set of mental processes that helps us connect past experience with present action. We use executive function when we perform such activities as planning, organizing, strategizing and paying attention to details. Some of the problems associated with compromised Executive Function include:

*difficult to plan projects
*hard to estimate how much time projects will take
*difficult to communicate details in an organized, sequential manner
*hard to memorize and retrieve information from memory
*difficult to remember information while doing something with it, like remembering a phone number while dialing it.

According to the Encyclopedia of Mental Disorders:
Executive functions are high-level abilities that influence more basic abilities like attention, memory and motor skills. Most people who study these abilities agree that the frontal lobes of the brain play a major role in executive function. People with frontal lobe injuries have difficulty with the higher level processing that underlies executive functions. Because of its complexity, the frontal cortex develops more slowly than other parts of the brain, and not surprisingly, many executive functions do not fully develop until adolescence. Some executive functions also appear to decline in old age, and some executive function deficits may be useful in early detection of mild dementia.
Read the complete entry here.

Executive Function covers so many areas, it would be nearly impossible for one test to cover all of them. However, there are many tests and batteries of tests that professionals use to measure Executive Function and/or its loss. One of these is the Delis-Kaplan Executive Function System (D-KEFS; Delis, Kaplan, & Kramer, 2001). This system was designed exclusively for the assessment of executive functions, including:

*flexibility of thinking,
*inhibition,
*problem solving,
*planning,
*impulse control,
*concept formation,
*abstract thinking, and
*creativity.

The system utilizes a "cognitive-process approach," and it is composed of nine stand-alone tests. These tests provide a standardized assessment of executive functions in children and adults between the ages of 8 and 89. Proponents of the D-KEFS believe it also holds much promise as a research tool for increasing knowledge of frontal-lobe functions.

We'll look at some other tests of Executive Function, including the Wisconsin Card Sorting Task, in another post.

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Many neuropsych tests assess a person's memory or degree of memory loss. But what is memory exactly? Rutgers University (specifically their Memory Disorders Project)puts out an excellent newsletter called Memory Loss and the Brain. Their Web site features online versions of the newsletter as well as an extended Glossary and a good list of Resources with links.The following is from the Glossary:
Memory refers to the storage, retention and recall of information including past experiences, knowledge and thoughts. Memory for specific information can vary greatly according to the individual and the individual's state of mind. It can also vary according to the content of the information itself; thus information which is novel or exciting tends to be better remembered than information which is uninteresting or ordinary. Failure of memory can normally result from failure to adequately store the memory in the first place, failure to retain the information (forgetting), and failure to retrieve the information later.

The precise biological mechanisms of memory are not fully understood, but most scientists believe that memory results from changes in connections or connection strengths between neurons in the brain.

Sensory memory refers to the fact that, after experiencing a stimulus, information about that stimulus is briefly held in memory in the exact form it was received, until it can be further processed.

Short-term memory refers to memories which last for a few minutes.
Intermediate-term or working memory is sometimes considered a synonym for short-term memory. However, memory researchers often consider this a specialized term referring for information about the current task. Thus, even though a specific phone number may occupy short-term memory, working memory contains the information that lets you remember that you are in the process of phoning the gas company to complain about a recent billing error.

Long-term memory is memory that lasts for years or longer. It contains everything we know about the world, including semantic and factual information as well as autobiographical experience.


Read it all here.

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Tide Global Learning

Verbal memory refers to memory of words and verbal items. Since we process most verbal information with the left side of our brain, damage to that side of the brain can impair verbal memory and even the ability to talk and understand speech.

The California Verbal Learning Test is one way to assess verbal memory. The tester reads aloud “Monday’s shopping list,” which is a list containing sixteen items, each belonging to one of four categories. So there might be four fruits, four vegetables, four spices, etc. The person being tested then tries to remember as many items as possible.

The tester will repeat this exercise several times, making note of how many items the person being tested remembers, and also whether he is using the categories. For example, if the test subject remembers only three vegetables but guesses that the remaining item is a vegetable, then he probably understands categories. If he guesses something entirely different, like chocolate syrup, then he probably doesn’t understand the categories.

Sometimes a tester will read from a second list, “Tuesday’s shopping list,” to see if the person can keep items from the two lists separate, or if he confuses the lists. Then, for 20 minutes or so, the tester distracts the person by giving him other things to do, and then asks him to try to remember Monday’s list.

Women often perform better on this test, especially with the categories. And, according to Memory Loss and the Brain , “patients with different kinds of brain damage or disorder also show reliable patterns of performance. For example, patients with Alzheimer's Disease tend to be unable to make use of category information (and might recall: Apples, Bananas, Oranges, Chicken) while patients with Parkinson's Disease tend to make repetition errors (for example: Apples, Bananas, Oranges, Bananas).”

One other thing to consider is that some people naturally process information differently than others -- verbally (with words) versus visually (with pictures). A person who tends to think visually may not do well on a verbal memory test, and vice versa. Comprehensive memory tests will consider both types of memory to get a more thorough assessment of a person’s ability to remember.

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A 2006 Jason Polan cartoon from The New Yorker features two gerbils in conversation. In the background is one of those wire wheels you find in hamster/gerbil cages, and one of the two gerbils is saying with maybe a little more self-satisfaction than is warranted, "I usually do two hours of cardio and then four more of cardio and then two more of cardio." (You can see the cartoon, and obtain a copy of it in various forms, at The Cartoon Bank.)

It turns out that maybe the smug little creature was onto something after all (from "Lobes of Steel" in Play, The New York Times's "sports magazine"):
The Morris water maze is the rodent equivalent of an I.Q. test: mice are placed in a tank filled with water dyed an opaque color. Beneath a small area of the surface is a platform, which the mice can’t see. Despite what you’ve heard about rodents and sinking ships, mice hate water; those that blunder upon the platform climb onto it immediately. Scientists have long agreed that a mouse’s spatial memory can be inferred by how quickly the animal finds its way in subsequent dunkings. A “smart” mouse remembers the platform and swims right to it.

In the late 1990s, one group of mice at the Salk Institute for Biological Studies, near San Diego, blew away the others in the Morris maze. The difference between the smart mice and those that floundered? Exercise. The brainy mice had running wheels in their cages, and the others didn’t.
Oh, well, that's mice, you say. People are a lot different, right? Er, not necessarily:
[Scientists] have been finding more evidence that the human brain is not only capable of renewing itself but that exercise speeds the process.
[...]
This spring, neuroscientists at Columbia University in New York City published a study in which a group of men and women, ranging in age from 21 to 45, began working out for one hour four times a week. After 12 weeks, the test subjects, predictably, became more fit. Their VO2 max, the standard measure of how much oxygen a person takes in while exercising, rose significantly.

But something else happened as a result of all those workouts: blood flowed at a much higher volume to a part of the brain responsible for neurogenesis. Functional M.R.I.’s showed that a portion of each person’s hippocampus received almost twice the blood volume as it did before. Scientists suspect that the blood pumping into that part of the brain was helping to produce fresh neurons.
The article doesn't address research (if there has been any) on the effects of exercise in the TBI-afflicted. But it doesn't seem like much of a stretch (no pun intended) to imagine that working out can help, and perhaps help a lot. (We've seen this with Jack himself, who had dropped tennis for a while but has recently gotten back into it -- as TLS mentioned in a post back in July.)

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A neuropsychological evaluation (NPE or neuropsych test)) examines brain function and impairment. An NPE helps neuropsychologists determine and localize organic brain impairment. Utilizing test results helps the neuropsychologist develop rehabilitation programs for cognitively impaired patients.

We should remember that the training and experience of the person conducting the test can affect the reliability of the findings. We should also note that NPEs are not appropriate for everyone with cognitive deficits. Visit
eMedicine for more information about NPE.

There are many neuropsych tests being used today. These include:

*California Verbal Learning Test
*Delis-Kaplan Executive Function System
*Hayling and Brixton tests
*Rey-Osterrieth Complex Figure
*Memory Assessment Scales
*Wechsler Memory Scale
*Luria-Nebraska Battery
*Halstead-Reitan Battery

We'll be looking at these (and many more) in upcoming posts to this blog. All will be under the Neuropsych Test header.

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