Articles Posted in Brain & Spinal Cord Injuries

The long-term consequences of traumatic brain injuries are always difficult to ascertain for clients as their rehabilitation progresses. One of our concerns has always been the future risk that a client suffering from TBI would later develop Alzheimer’s or other dementias. The medical literature has not established this association to a certainty. Recent data published by the Journal of Neuroscience, however, has significantly moved forward our understanding about this significant medical risk.

Using mice and post-mortem samples from human brains, scientists from Tufts University School of Medicine have found that even a single event of moderate to severe TBI can disrupt the proteins that protect the brain from the enzymes that cause Alzheimer’s disease. Serious TBI can lead to a dysfunction in the regulation of the enzyme BACE1, and elevation of that enzyme causes elevation of amyloid-beta, the key component of brain plaques associated with senility and Alzheimer’s disease. It is hoped that these findings will guide future research, as well as assist in the development of future drug targets to aid in the prevention of Alzheimer’s.

Moderate to severe TBI is often caused by the significant forces found in blunt force trauma, falls, and motor vehicle accidents. The CDC has reported that over 1.7 million people suffer such injury annually, although the majority suffer a milder form of TBI called a concussion. Even concussions and repeated but lesser head trauma is suspected to lead to Alzheimer’s, however. Alzheimer’s disease is reported to affect over 5 million Americans, and is the most common cause of dementia in those over the age of 65.

Although neuroscience has progressed in establishing the role various brain structures play in the executive functioning of the brain, there has not been solid evidence of the brain networks that support high-level cognition and general intelligence. In a new study released in the journal Brain, a fascinating picture is emerging that could support new understanding of the brain’s critical functions. Scientists gathered 182 volunteers with very localized brain injuries from penetrating head wounds, and subjected them to CT scans and an extensive battery of cognitive tests. What they found was that general intelligence was derived from a particularly circumscribed neural system. Several brain regions working in connection were found to be most important for general intelligence. These structures were primarily found behind the forehead (left prefrontal cortex), behind the ear (left temporal cortex), and the top rear of the head (left parietal cortex). The data also disclosed that brain regions for planning, self-control and other key elements of executive functioning overlapped those structures found important for general intelligence. This new evidence suggests that intelligence does’t derive from one brain region or the brain as a whole, but specific brain areas working together in a coordinated way.

Source:
A. K. Barbey, R. Colom, J. Solomon, F. Krueger, C. Forbes, J. Grafman. An integrative architecture for general intelligence and executive function revealed by lesion mapping. Brain, 2012; DOI: 10.1093/brain/aws021

A new and powerful imaging technique has been developed that will allow doctors to clearly see the brain’s neural connections that have been broken by traumatic brain injury and other neurological disorders. High Definition Fiber Tracking may now give doctors a means of objectively determining how brain tissue has been injured. Conventional CT or MRI scans often miss brain injuries because they show no brain changes, even though the patient continues to struggle with the devastating consequences of brain injury. HDFT is apparently able to reveal the brain’s wiring in such vivid detail that pinpoint breaks in fiber tracts that contain the brain’s critical neuronal connections can be found, thereby allowing doctors to identify any part of the brain that has lost its connectivity. HDFT is not widely available to patients, but may soon provide promising help in the diagnosis and treatment of those suffering from traumatic brain injury.

Source:

High-definition fiber tracking for assessment of neurological deficit in a case of traumatic brain injury: finding, visualizing, and interpreting small sites of damage.

Individuals who are severely or catastrophically injured must assert a one-time claim for all the economic losses they will experience over their remaining life expectancy on account of their injury. An injured person only gets one trial. The injured individual cannot go back to court in 5, 10 or 15 years because the assumptions that were used in his or her economic loss analysis proved too optimistic. This is a particularly important issue given the present economic downturn. Many statistics which economists have traditionally relied on to calculate economic loss have limited or diminished relevance today. For example, historical statistics concerning the availability of alternative work, and prevailing wages for such work, now overstate the opportunities that are actually available to an injured person in today’s economy. In addition, just focusing on the most recent economic data does not necessarily solve this problem. The traditional measure of unemployment does not include discouraged workers who are no longer actively looking for work, thus substantially overstating the actual health of the labor market. A final example involves historical statistics concerning work-life expectancy. An economist will typically project a severely or catastrophically injured person’s earnings over their statistical work-life expectancy. However, for numerous reasons, the historical data now underestimates the likely work-life expectancy of current workers. Work-life expectancy is now likely to be significantly longer than historical averages because of factors including (1) reduced and/or depleted retirement savings, (2) declining percentages of individuals with fixed pensions, and (3) the cost or complete unavailability of non-employer-sponsored health care coverage which causes individuals to work longer. The bottom line is that severely or catastrophically injured individuals need to hire counsel who are familiar with recent economic trends and who regularly work with economists are knowledgeable and current on issues affecting serious personal injury claims. See Employee Benefit Research Institute, 2010 Retirement Confidence Survey http://www.ebri.org/pdf/briefspdf/EBRI_IB_03-2010_No340_2010_RCS.pdf

One of the difficulties faced by our clients who have suffered “mild” traumatic brain injury (TBI) is that there has been no objective means of establishing that brain injury exists even though the clinical signs of dysfunction are present. This has often resulted in clients not getting the medical care that would help them with their rehabilitation, or they have suffered the undeserved claims by defense practioners that they were “malingering” or “magnifying” their symptoms.

Two new studies support the early data on the efficacy of a new MRI tool–diffusion tensor imaging–in the diagnosis of traumatic brain injury (TBI). Diffusion tensor imaging allows the care provider to visualize the brain’s white matter, which contains the fibers that connect nerve cells. Conventional MRI would commonly not reveal any differences between the patients with mild TBI and controls. DTI, however, is finding objective evidence on imaging that is consistent with a positive finding on neuropsychological testing.

One study at the University of New Mexico has found that diffusion tensor imaging can be used to reliably detect and track brain abnormalites in patients with mild TBI. The study compared patients with known mild TBI and found that conventional MRI did not reveal any differences between those with TBI and control subjects. The diffusion tensor imaging, however, demonstrated white matter abnormalities in the subjects known to have TBI. Thus, the technique was successful in finding objective evidence of injury when conventional MRI failed to do so. Another important finding was that, when the patients found to have such abnormalities were evaluted with diffusion tensor imaging 3-5 months later, a period by which recovery is expected, the diffusion tensor imaging was able to track these white matter changes, as well. The study concluded that diffusion tensor imaging can provide an objective biomarker that can assist in the classification and tracking of mild TBI injuries and their effects.

There has long been a debate in medicine, and consequently one in the law, about whether a concussion caused by trauma can lead to structural brain tissue damage and functional deficits. While many recover from such injuries without lasting deficits, it is estimated that over 30 percent suffer from the traditional hallmarks of traumatic brain injury, such as personality changes, deficits in short-term memory, or deficits in executive functions involved in the ability to make decisions, organize, or plan.

As recently reported in the journal Radiology, researchers at the Albert Einstein College of Medicine have now demonstrated objectively the areas of the brain injured when concussion occurs. The study subjected patients who had sustained concussions to tradition MRI and CT scans, which routinely demonstrated that no structural injury had occurred. When neuropsychological testing showed effects upon their executive functions, however, the patients were then given a more sophisticated type of MRI scan known as diffusion tensor imaging (DTI). DTI can detect subtle changes in the brain by measuring the diffusion of water in the brain’s white matter. The DTI studies in these patients showed the presence of major areas of structural damage located mainly in the brain’s prefrontal cortex, a part of the brain essential for normal executive function. It is this area of the brain that is susceptible to injury in concussion, and such structures are involved in the cognitive processes that cause the functional deficits the patients were experiencing.

It is unfortunately the case that many people suffering mild traumatic brain injury are not properly advised about the possibility of functional deficit by either their medical or legal practioners. It is often the case that problems do not disclose themselves until a patient returns to more full function after orthopedic injuries have healed. It is when they try to reengage life at their former level of function that deficits begin to take shape. Using DTI as an adjunct to clinical evaluation will likely help identify those patients who should receive rehabilitation earlier when it is more useful to the patient.

The Alaska Personal Injury Law Group recently posted an article about how the FDA and other federal agencies have systematically attempted to use preemption to make manufacturers immune from suit for injuries caused by their defective products. One point of discussion was how the FDA has weakened regulatory protection of consumers from dangerous, defective drugs. Now, just a few days later, an independent group of objective scientists has issued a new report chastising the FDA for its approval of bisphenol A, commonly referred to as BPA.

The new report was issued by the Science Board, a group of independent scientists that provides advice to the Commissioner of the FDA. The Science Board provided peer review of the FDA’s draft assessment of use of BPA in food contact applications. The Science Board concluded that the FDA position was seriously flawed.

BPA is an industrial chemical used to make polycarbonate plastic and an epoxy resin used in many consumer products. The FDA approved it for use in baby bottles and as a liner in food containers like baby formula cans. It is also used extensively in other food containers, in sport bottles such as Nalgene bottles, and as a liner in soda cans. In mid-2008, the National Toxicology Center issued an extensive report addressing the health risks resulting from exposure to BPA, including effects on brain and behavioral development in infants and small children, and the potential to cause cancer. In response, the FDA steadfastly maintained its position that BPA was safe.

The Science Board has now found multiple flaws in the FDA assessment. First and foremost, the FDA assessment failed to provide “reasonable and appropriate scientific support” for its finding that the public wasn’t at risk from BPA. Second, the FDA ignored many peer reviewed studies that found BPA presents serious health hazards. Instead, the FDA relied upon two studies funded by the chemical manufacturers’ association, only one of which was peer reviewed. The studies ignored by FDA show multiple risks, including impaired neural development, developmental changes in children, impaired reproductive tract development and diabetes. Third, the FDA assessment improperly analyzed the margin of safety (MOS) provided by the FDA standard for BPA exposure. The Science Board found extensive evidence that the FDA standard for allowable exposure levels was at least an order of magnitude too high, particularly for children.
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Most readers know that PTSD can be caused by intense trauma from accidents and injuries, but the question whether medical intervention itself can cause PTSD has not been extensively studied. Dr. Dimitry Davydow of the University of Washington’s School of Medicine reports in the Sept.-Oct. issue of General Hospital Psychiatry that as many as 22% of ICU patients will later suffer PTSD. This conclusion arose from the review of 15 medical studies and 1,745 ICU patients. The symptoms of PTSD include nightmares, sleep problems, flashbacks, irritability and anger, as well as emotional numbness. The risk of suffering PTSD increased if the patient had underlying mental illness, such as anxiety or depression, or was treated with certain sedatives that cause disorientation, confusion, or psychotic experiences.

Sources:

General Hospital Psychiatry, Vol. 30, at 421-34, Sept. Oct. 2008

If the march of history has shown us anything, it is that technological advances are often the result of armed conflict. We have seen that in striking detail in the Iraq and Afghanistan conflicts. One of the most unfortunate consequences of these conflicts is that they have dramatically highlighted the armed services’ inability to effectively screen and treat traumatic brain injury (TBI) and post traumatic stress disorder (PTSD) in returning soldiers. Another consequence is that the fact that soldiers have suffered TBI and PTSD in ever increasing numbers has forced research forward concerning these intractable disorders. In recent weeks, several articles of note crossed our desks here at the Alaska Personal Injury Law Group.

The Government Accounting Office (GAO) just released a report that underscored the Dept. of Veteran’s Affairs’ (VA) continuing inability to identify and provide services to affected veterans. This is true despite a pledge by the VA Secretary, Jim Nicholson, last April to promote new screenings for brain injury and a personal promise to see the changes through. The GAO reviewed nine VA medical centers, and found that there were problems in securing follow-up appointments after the veterans initially tested positive under the VA’s TBI screening tool. Two of the medical centers did not follow the screening tools protocol because they failed to use the symptom checklist, which they said was because they didn’t know the checklist existed or because they had inadequate staffing. The GAO also identified poor rural access to services resulting in a 50% decrease in the ability to provide care. It is estimated that as many as 20% of US combat troops who fought in Iraq and Afghanistan are believed to leave with signs of TBI.

At the end of January, the New England Journal of Medicine published a study submitted by specialists at the Walter Reed Army Institute of Research that added further to the controversy about how veterans should be screened and treated upon their return. Studying outcomes for over 2500 soldiers, the researchers found that soldiers with mild traumatic brain injury, particularly those who had suffered loss of consciousness, were significantly more likely to report poor general health, missed workdays, medical visits, and a high number of somatic and post-concussive symptoms than were soldiers with other injuries. After the data was adjusted, the researchers concluded that mild traumatic brain injury with loss of consciousness was strongly associated with PTSD and depression. Over 43% of soldiers reporting TBI with loss of consciousness met criteria for PTSD, compared with 27% of those with the lesser brain injury from an altered mental status following their injury. TBI with loss of consciousness was also significantly associated with major depression. The difficulties the soldiers faced may therefore be more attributable to the result of intense psychiatric reactions to battlefield events, rather than a structural injury to the brain. This may be good news in that there are treatments for PTSD and depression, and very few medical treatments available to those who have suffered a structural injury to the brain.

We have handled a number of cases at the Alaska Personal Injury Law Group where clients have developed balance and dizziness complaints after suffering a traumatic brain injury (TBI) in automobile crashes or similar assaults to the brain. It is not commonly known that these disorders flow from TBI, and attorneys often miss the connection. These disorders can develop in several ways, but a common mechanism is benign paroxysmal positional vertigo (BPPV). BPPV is a balance and dizziness disorder caused by a problem in the vestibular system of the inner ear which forms part of the body’s balance system. Small particles, or crystals, of the inner ear are dislodged with the trauma and this interferes with the normal function of the inner ear. This can cause episodic vertigo that can be quite disturbing to the client. If untreated, the episodes can recur for years and become part of the lasting and unfortunate legacy of TBI.

There are treatments for BPPV through a series of scripted movements by trained therapists designed to put these crystals back in their normal position. This is called a canalith repositioning maneuver, and significant improvement has been experienced by some clients.

To properly diagnose a patient regarding the many potential causes of balance and dizziness problems, a client often undergoes vestibular testing, but it has traditionally been aimed at finding a localized problem, a “site of lesion”. The major limitation of these site-of-lesion tests is that they assess structural and physiological changes within individual sensory or motor components in isolation, rather than in the functional context of balance control. A new type of testing has been developed called the Neurocom Balance Manager, which is designed to provide a comprehensive differential diagnosis of sensory, motor, and central functional impairments of balance control. Developed using methods created by NASA to study balance in astronauts, Neurocom uses a computerized dynamic posturography (CDP) system that professes to offer a more comprehensive means of diagnosing the patient, which hopefully will lead to more specific and helpful treatment.