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About Gordon Johnson

http://gordonjohnson.com

Attorney Gordon Johnson is one of the nations leading brain injury advocates. He is Past-Chair of the TBILG, a national group of more than 150 brain injury advocates. He has spoken at numerous brain injury seminars and is the author of some of the most read brain injury web pages on the internet.

Posts by Gordon Johnson:

Brain Injuries Probable in Amtrak Derailment

Missouri Amtrak Derailment – Force of Impact Will Cause Brain Injury

Missouri Amtrak derailment will likely leave many with significant brain injury, as the biomechanics forces to the brain of being thrown around without a seat belt is a source of significant brain damage. See https://braininjuryhelp.com/brain-damage-biomechanics/

Monday, June 27, an Amtrak train carrying 243 passengers and 12 crew members collided with a dump truck at a train crossing in Missouri resulting in an Amtrak derailment. Three passengers and the driver of the truck were killed, and more than a hundred were injured. Overturned carriages at the aftermath confirmed a passenger’s recollection of the event as “hell on earth”.

“I was riding backwards, so that was a blessing because I didn’t fly forward on the impact, but all I heard was a bam, bang, boom,” he said. “And all of a sudden the train dropped down, which I thought was probably when it went off track.” https://www.npr.org/2022/06/28/1108391218/amtrak-train-derailed-missouri

The key word in this account is ‘impact’. While train derailments can occur due to other factors, in this case we have the initial point of impact with the dump truck and the forces involved in the train derailment that ensued.

“It overturned, fell to the left, and it skidded, skidded, skidded forever. I felt like it, anyway.” https://www.npr.org/2022/06/28/1108391218/amtrak-train-derailed-missouri

The National Transportation Safety Board dispatched a team of 15 to investigate the Amtrak derailment and download the “event recorder” to determine the engineer’s actions prior to impact, the speed of the train and any other clues which might shed light on the events which led to the derailment. According to the US Department of Transportation, there are approximately 5800 train-car crashes annually, the majority of which occur at train crossings. Approximately 600 deaths and 2300 injuries occur annually from these incidents.

Train transportation is one of the safest modes of transportation yet derailments occur more often than one might think. The Bureau of Transportation Statistics analyzes and compiles information about all modes of transportation in the United States for the United States Department of Transportation. Since 1990, there have been 54,539 accidents in which a train derailed. The statistics are difficult, however. They include incidents involving freight trains which do not include train passengers, deaths of drivers of vehicles, and incidents such as the 2002 derailment in North Dakota which involved hazardous materials which injured hundreds. Factoring out these other data sets, and focusing on the impact on train passengers alone, 131 people have died in train derailments from 1990 to 2021. https://cw33.com/news/nexstar-media-wire/how-often-do-trains-derail-more-than-you-think/

Our concern here is the impact of a train derailment, due to impact with a heavy vehicle, on the survivors of the crash. A very old adage in our profession is “if an accident is significant enough to break a bone, it is significant enough to cause brain damage.” And this is, in reality, an understatement. While the human body is a miracle of biological engineering, it was not designed to withstand the forces of modern transportation mishaps. While the external body may walk away relatively unscathed from an impact, the biomechanical forces within the body can produce damage and this is especially true in the brain.

The brain itself is housed within the skull and can be damaged at both the point where it impacts the interior of the skull and on the rebound from such an impact. These are known as coup and countercoup injuries and can occur at both the time of impact or due to a rollover type incident. This can result in cerebral contusions and/or more diffuse injury to the brain.  Additionally the different layers of the brain have different masses which travel at differing speeds during impact. When these layers move at different speeds, the axons which transverse these layers can be damaged.

 “Diffuse axonal injury is the shearing (tearing) of the brain’s long connecting nerve fibers (axons) that happens when the brain is injured as it shifts and rotates inside the bony skull. DAI usually causes coma and injury to many different parts of the brain. The changes in the brain are often microscopic and may not be evident on computed tomography (CT scan) or magnetic resonance imaging (MRI) scans.” https://www.hopkinsmedicine.org/health/conditions-and-diseases/traumatic-brain-injury

Once damage occurs within the brain there can be secondary sequelae. This is referred to as secondary brain injury.

 “Secondary brain injury refers to the changes that evolve over a period of hours to days after the primary brain injury. It includes an entire series of steps or stages of cellular, chemical, tissue, or blood vessel changes in the brain that contribute to further destruction of brain tissue.” https://www.hopkinsmedicine.org/health/conditions-and-diseases/traumatic-brain-injury

In the story of the Missouri Amtrak derailment, there is a statement which stands out to me regarding the aftermath of those who walked away from the accident. In such a traumatic event, how does one differentiate the emotional impact of surviving such an ordeal and physical sequelae which result from a brain injury? From the interview in the NPR article-

After a day in the emergency department, Hoffman said he finally made it home.

“The whole night when I was trying to fall asleep I kept getting flashbacks, and like visuals and things running through my head and it made it very hard to sleep,” he said.

“I will say I’ll never be on a train again for many years, many, many years.”

“I feel blessed to be alive, but bumped up, bruised up, and kind of tattered and sore.” https://www.npr.org/2022/06/28/1108391218/amtrak-train-derailed-missouri

Symptoms of a closed head injury may occur quickly, within 24 hours, or they may emerge days or weeks after an injury.

 “Sometimes the symptoms are subtle. A person may notice a problem but not relate it to the injury. Some people will appear to have no symptoms after a TBI, but their condition worsens later.” https://www.medicalnewstoday.com/articles/179837#symptoms

According to MedicalNewsToday some of the more subtle symptoms to be aware of are:

  • confusion
  • changes in mood
  • memory problems
  • inability to remember what happened before or after the incident
  • fatigue (tiredness) and lethargy
  • getting lost easily
  • persistent headaches
  • persistent pain in the neck
  • slowness in thinking, speaking, reading or acting
  • moodiness, for example, suddenly feeling sad or angry for no apparent reason
  • sleep pattern changes, such as sleeping more or less than usual, or having trouble sleeping
  • light headedness, dizziness
  • becoming more easily distracted
  • increased sensitivity to light or sounds
  • loss of sense of smell or taste
  • nausea
  • tinnitus, or ringing in the ears

These secondary symptoms also require urgent attention and should not be discounted as due to the adrenaline-induced, emotional state following a traumatic event.

The mechanics of a train experiencing a collision and the subsequent derailment and carriage rollover is sufficient to cause closed head injury. And as we see, even negative imaging studies in the emergency room setting may not be sufficient to rule out a brain injury. Brain injuries can have life-long implications and consequences.

The last consideration is in regard to Amtrak’s responsibility to its passengers. A train is considered a common carrier and under the law, owes all passengers a duty of care. This means that in any incident that passengers are injured or killed that all actions taken by the crew prior to and during impact were in total accordance to guaranteeing safety of the passengers. This is at the root of the investigation into the accident and why the train’s speed, the length of time it took the engineer to sound a warning to the vehicle on the tracks and the actions of the crew as a result come into question.

Bus Crash in Chattanooga Kills Six Children

A school bus crash in Chattanooga, Tennessee slammed into a tree and split apart Monday, killing at least six children, according to the CNN report. The bus was carrying 35 students in kindergarten through fifth grade. The Woodmore Elementary bus driver was arrested and charged with five counts of vehicular homicide, reckless endangerment, and reckless driving. The crash injured at least 23.

Authorities are saying that speed is being investigated as a factor in the crash. A witness says she heard a boom, just before 3:30 p.m., and the crash was so strong that it knocked her power out. Parents and first responders rushed to the scene. The firefighters reportedly “worked for hours” to remove the 35 children trapped inside the bus. Five children died on the bus, and one more died at the hospital.

The community is gathering for a blood bank to donate blood to the victims. The police say they are working hard to make sure the kids are successfully reunited with their families.

Traumatic brain injury is a big risk factor in a bus crash such as this. Whenever the skull strikes another object, there is a risk for a TBI, even when the wound is not penetrating. The sheer force of the accident could have had the soft matter of the brain collide with the hard surface of the skull, causing brain damage.

When the skull stops moving as it hits an object, the brain continues to move with same force until it is stopped by the skull. This kind of accident can cause bruising of the brain, referred to as a contusion or bleeding of the brain referred to as a hemorrhage.

When the head strikes an object, the brain may bounce back to the other side of the skull, causing another injury on the opposite side of the brain. This kind of injury is called a coup contrecoup injury.

There is an obvious defect on every single bus and in every single bus crash that is on the news. Most buses today do not have seat belts. Even when a bus does have a seat belt, passengers rarely use them. The American School Bus Council says that school buses don’t have seat belts because the children are protected like eggs in a carton, compartmentalized with strong, closely spaced seats that have energy-absorbing backs. On the other hand, the American Academy of Pediatrics advocates for having seat belts on large school buses.

New Technology Can Help Improve Brain Surgery

It’s brain surgery, and there’s no question that the stakes are high. There is really no room for error in this kind of surgical procedure. One wrong move, and you could damage one of the two most important organs in the body, the brain. It takes a steady hand, laser-sharp focus, and now it also requires radar-like listening skills.

New technology, which has yet to be tested in a clinical setting, uses a laser probe to transmit an audio signal that indicates whether the cells are healthy or cancerous. In recent operations, surgeons relied on a laser probe that would project to a visual screen that would tell them whether or not they were cutting into healthy or cancerous tissue.

This new sound-based technology is beneficial because it allows the surgeon to focus on the scalpel. The surgeon never has to take his eyes off of where he is cutting. The goal would be to hopefully create more efficient and more effective brain surgeries.

The technology involves firing lasers at the cells and analyzing how the light bounces back. The results produce a graph that is similar to a fingerprint of brain cells. When looking at the graph, it is possible to tell whether the scalpel hovers over a cancerous or a healthy cell.

This increases accuracy of surgery. Not removing cancerous cells could leave the patient with cancer still. Removing healthy cells could leave the patient with brain damage. There is a delicate balance for the neurosurgeon.

The visual probe technology has been successfully trialed in the United Kingdom and Canada. Matthew Baker of the University of Strathclyde in the UK hopes to improve on the technology further with audio signaling. The update has come out of a collaboration between UK universities and hospitals.

It takes the most important features of the probe’s signal and synthesizes them into sounds rather than visual cues. This new technology can help the neurosurgeon to maintain the laser-sharp focus necessary for brain surgery. It would hopefully make neurosurgery for brain tumors quicker and more effective, too.

$3 million seeded to center for studying brain trauma

In an op-ed in the Baltimore Sun, the presidents of University of Maryland, College Park and the University of Maryland, Baltimore announced their vision for opening a sports medicine center to study brain trauma.

Brain Trauma

The Center for Sports Medicine, Health and Human Performance is located in Cole Field House in College Park, MD, where innovative research on the brain will be done. They will be using big data capabilities to study the brain’s membranes and metabolic pathways. (Flickr / Creative Commons / AJC1)

The hub will “integrate research, innovation and athletics and bring together leading researchers in neuroscience, genomics, biomechanics and other fields engaged in the advanced study of the brain and nervous system,” according to their letter.

The leaders of the center will be University of Maryland biology professor Elizabeth Quinlan and Dr. Alan Faden, David S. Brown Professor in Trauma at the University of Maryland School of Medicine in Baltimore.

This may be a great resource for people with questions about brain injury, as they will be doing cutting edge research into some of the most common big ideas of brain injury, such as why some people recover better than others.

Researchers will be studying “big data” mapping of the brain’s network of membranes and metabolic pathways. They will be looking into brain flexibility, and the brain’s ability to return back to normal after a brain injury.

When we wrote about “space brain,” the brain condition that arises from traveling to space, the brain does not return to normal. But when we wrote about football, the brain changes can return to normal after six months in some subjects. On our page subtlebraininjury.com, you will learn that even mild brain injury can cause permanent damage.

The center will study how brain’s flexibility can be reactivated after brain trauma, which would aid in and speed up recovery. The center was seeded with $3 million. Each year, about $76 billion are spent due to traumatic brain injury in the United States, according to the op-ed. It seems worth it considering that, and that 30 percent of injury deaths each year in the United States are due to traumatic brain injury as well.

Space Brain Is A Real Thing

While most of the stories on this website revolve around research on brain injury on Earth, I thought this story about brains in outer space, which has been in the news a lot lately, was interesting. Yes, this new research about what is being called space brain has been in major news outlets, such as Yahoo, Popular Science, and the LA Times. Even though no men have been on Mars yet, researchers are planning ahead, as the first manned mission to Mars is scheduled for the 2030s. This research is deepening our understanding of what a mission to Mars might mean.

Space brain

Space brain is the term being used to describe the physical brain damage that might result from a trip to space. Researchers studied the effects of cosmic radiation on rodent brains. (Flickr / Creative commons / Adobe Stock)

The study that has been making headlines involved exposing rodents to cosmic radiation and the resulting brain damage. The brains of these rodents experienced physical damage that included modification of neurons and break down of synapses that could transfer neurotransmitters between neurons. The physical damage is linked to cognitive and behavioral problems, such as memory problems, anxiety, and impaired judgement, which can be problematic for astronauts operating autonomously in space.

In addition to the initial physical damage, the researchers found that the brains were not returning back to normal after six months. The brains were staying the same: damaged. No evidence of the brain trying to resolve these issues was seen. Therefore, the damage could be permanent.

Even though the research was in rodents, the scientists believe that it applies to humans, too. Knowing this will likely not prevent the mission to Mars. More than likely, scientists will try to find ways to curtail this physical brain damage. This may be done through creating a protective shield or figuring out a combination of drugs that would protect against this kind of damage.

One of the scientists, Charles Limoli, told Popular Science that “this is not a deal breaker. I do not think that during the course of a trip to Mars and back the astronauts will come back with anything remotely similar to full-blown Alzheimer’s.

“But more mild changes, more subtle changes—they would still be concerning, given the level of autonomy astronauts operate under and the amount of work they have to do.”

Subtle brain damage may not be a stranger to some of our readers, see our website http://subtlebraininjury.com/.

In the future, researchers will have to develop ways to protect our astronauts from brain damage. Protecting against the memory loss, anxiety, and judgement impairment will be essential. These kinds of problems could be roadblocks to the problem solving necessary in space, which is why it’s good we know now, and can find ways to prevent it.

Laser Treatment May Help Heal Injured Brains

A former police officer from Colorado Springs is swearing by an experimental treatment for several concussions, according to CBS Denver. The therapy is a laser treatment that emits near infrared light into the person’s brain. The laser itself is FDA approved, but the treatment is experimental.

The cost is $100 per treatment for first responders and veterans, and $200 per treatment for all others. Doctors are recommending 20 treatments. Jennifer Fortezzo called the brain-stimulating device “miraculous.”

She is just 43 years old, but retired from her job as a police officer after ten years because of a hip injury. Ten years ago in 2006, she lost a baby girl. She began suffering from severe depression and suicidality.

As a result, the doctors ordered a brain scan. It showed damage that she believes was caused by several sports- and work-related concussions. The foundation that gives her the laser therapy treatment is called the Neuro-Laser Foundation, founded by Dr. Theodore Henderson and Dr. Larry Morries.

One study in April 2015 in the journal Neuropsychiatric Disease and Treatment found that patients with TBI responded very well to near infrared laser treatment. The foundation claims that patients in the study and others since have demonstrated marked improvement in symptoms. The symptoms they exhibit typically include anxiety, depression, headaches, sleep disturbances, cognitive breakdowns, mood dysregulation and irritability.

Fortezzo and her husband both go on the record saying that the difference the therapy has made in their lives is incredible. The way the laser works is that it energizes brain cells, stimulating blood supply and oxygen. Dr. Henderson says that the laser works by stimulating the brain’s own healing power.

The hope is that this technology will not only help with traumatic brain injury, like Fortezzo’s, but also might help with neurodegenerative disorders like Alzheimer’s. The doctors who founded the Neuro-Laser Foundation are hoping to raise $680,000. The money would help fund research that would benefit other first responders and veterans.

The key to all of these experimental interventions for brain injury is they offer hope for a better outcome in the future. Most of these therapies are not going to fundamentally change the outcome for the vast majority of those with TBI. But progress is important and the more things that are tried, the better the long range prospects for treatment are. But just because a study or news story talks about a coming miracle, doesn’t mean that such treatment is appropriate for the care of brain damage now or in the near term.

Gordon Johnson

Technicalities in Diagnosing Mild Traumatic Brain Injury

We wrote a blog about some of the things you need to know about a mild traumatic brain injury, including what it is exactly. Today, we talk about some of the technicalities clinicians need to bear in mind when diagnosing mild traumatic brain injury. Before you read on, be sure to check out the definition of mild traumatic brain injury by the American Congress of Rehabilitation Medicines (ACRM): https://www.acrm.org/wp-content/uploads/pdf/TBIDef_English_10-10.pdf

Assessing Loss of Consciousness

Loss of consciousness (LOC) can be difficult to assess. So, doctors should rely on collateral sources to assess LOC. If LOC is self-reported, then the patient might assume that his periods of recall were the only times he was conscious. The patient could have been awake, but just not remember it. First responders may notice the patient up and talking, while the patient can’t remember and assumes LOC.

Therefore, instead of asking the patient if they were knocked out or if they had lost consciousness, it’d be better to ask who saw you unconscious or did anyone tell you that you were unconscious.

Assessing Amnesia

In diagnosing amnesia, the doctors need to distinguish between what the patient remembers and what he has been told or surmised. This can be challenging. Doctors may ask what the first event is that they remember after their injury. Then, doctors may ask what’s the last event they remember before the accident.

Some doctors may want to find out all of the details about what happened before, during, and after the injury. They might say tell me about the injury, and ask for as many details as possible. In this case, doctors need to distinguish between what the patient actually remembers and what he has surmised in order to assess the period of memory loss.

Assessing Confusion and Disorientation

This can be the most difficult criterion to establish. After an accident, people can feel scared and overwhelmed. The clinician needs to differentiate between psychologically induced confusion and biomechanically induced confusion. This might be done by asking the patient if he or she was scared, overwhelmed, or had a panic attack.

The confusion must not follow the realization of what took place, but it must follow the acceleration or deceleration trauma to the brain. This is why establishing a timeline can be helpful in diagnosis.

Neurologic Deficits Associated with mTBI

The most common focal neurological symptoms of brain injury include post-traumatic seizures, intracranial lesions, loss of sense of smell, vision problems, language disorder, and gait/balance problems caused by central nervous system injury.

The DSM provides the following physical symptoms of concussion: fatigue, disordered sleep, headaches and/or vertigo/dizziness. The International Classification of Diseases expands the number of symptoms to include ringing in the ears, increased sensitivity to sounds, photosensitivity, and reduced tolerance to alcohol and medications.

Clear presence of some of these symptoms accompanied by a plausible mechanism of injury along with LOC or amnesia should increase the clinician’s confidence in diagnosing a mild TBI. These symptoms should not be the only basis for a diagnosis of mild TBI, especially long after the injury. This is because many other factors could cause these symptoms, such as diverse medical problems, chronic pain, depression, and anxiety.

Addiction: What You Need to Know

By: Michelle Peterson

Learning that someone you care about is struggling with addiction is frightening, particularly if they have not yet begun receiving help. Helping a loved one through their addiction is not something you should take on without understanding what you’re getting into. You should never attempt to handle a situation like this by yourself.

addiction-brain-injury-help

Addiction recovery is a path that requires many people and a good support network. However, you may be the one to find and gather that support network, meaning you should have a basic understanding of what addiction is, what it looks like, and how to handle related emergencies. Here are a few things you should know about addiction.

Addiction is Easy to Fall into and Hard to Overcome

For someone who has never experienced addiction, it may seem that people who have become addicted to a substance have intentionally harmed themselves and simply don’t have the mental strength to quit. Yet many people actually find themselves addicted to a substance as a result of self-medication or escapism. People who are suffering from an illness, whether mental or physical, may resort to abusing substances in an attempt to control their symptoms.

People who experience things like social rejection, bullying, poverty, or any number of bad circumstances tend to abuse substances in order to escape the negative aspects of their lives. These people aren’t making an intentional decision to become an addict; it is an attempt at self-preservation.

Once addicted, the person is now considered to have a mental illness. Like any mental illness, just thinking the symptoms away is not a practical solution. People with addictions require therapy and support in order to overcome both the addiction and the reasons they began abusing substances in the first place. It is not a matter of merely quitting.

You Should Have an Emergency Plan

If the substance in question can be deadly in large quantities, you should create an emergency plan with your loved one. If you do not include your loved one in the recovery process, they will not feel supported but rather controlled and infantilized. Sit down with your loved one and prepare plans for events including relapse, overdose, or even potential for relapse.

Set up a system for which people to call, when an ambulance is necessary, and information to give hospital staff. Make everyone involved aware of the plan so that other friends and family can also be prepared.

Treatment is Necessary

If your loved one is not receiving treatment, you should be pushing them to get the help they need. Overcoming a mental disorder like addiction is not something someone can do on their own. Even if your loved one seems to be quitting the substance, the conditions that caused them to use are probably still in place, making it likely that they will relapse.

Getting professional treatment for an addiction is not an option, it is a necessity. Work together to find a treatment that will work for your loved one and continue supporting them as they undergo the recovery process. You might also want to look into supplemental alternative therapies. Options, such as aquatic therapy, have been shown to be very beneficial to those in addiction recovery.

Though the knowledge that your loved one is struggling with addiction is difficult to hear, you should keep in mind that recovery is not only possible, but it is probable with proper treatment. Supporting your loved one though addiction does not mean you have to play the part of counselor, it simply means being there for someone who needs you.

What You Need To Know About a “Mild” Traumatic Brain Injury

Concussions are a serious injury, even if they are considered “mild” on the spectrum of brain injury severity. Of the 1.5 million TBIs that occur annually, it is estimated that about 80 percent are mild. This data comes from hospital emergency rooms. Since most people with mild traumatic brain injury (mTBI) consult a primary care physician or seek no care at all in the days after the injury, the incidence of the condition is underdiagnosed.

How are you possibly making your kids’ concussion worse?

A survey by UCLA Health showed that parents are not always listening to medical advice when it comes to dealing with concussions. If a child shows symptoms of a concussion after one week, 77 percent of parents said they are likely to wake their child up throughout the night. Professional advice recommends getting a full night of sleep for a full recovery. Headache, mood, and memory will all be worse without a good night’s sleep.

84 percent of parents said they would make their kids refrain from any physical activity. In reality, a bit of physical activity, if it’s safe, after the first few days is good for recovery.

64 percent said they would take away electronic devices, but remaining social is an important part of recovery from brain injury. It’s good for them to interact with their peers.

Getting the right advice early on reduces your risk may reduce the risk of postconcussion syndrome.

Retrograde and Anterograde Amnesia

Amnesia can be caused by a concussion when a bump to your head or body causes your brain to move around in your skull, causing damage to delicate tissue. The sloshed around neurons in the brain are really fragile, which can lead to post-traumatic amnesia. For more information, see the page “Post-traumatic Amnesia.”

There are two kinds of amnesia that a person can experience, both possible in concussions. Retrograde amnesia is where you forget things in your past. Anterograde amnesia is where you can’t make new memories. The length of amnesia can help doctors understand the severity of brain injury.

What are the outcomes of mTBI?

“The term ‘‘mild’’ continues to be a misnomer for this patient population and underscores the critical need for evolving classification strategies for TBI for targeted therapy…For these patients, mTBI is anything but mild,” says the study “Symptomatology and Functional Outcome in Mild Traumatic Brain Injury” published in the Journal of Neurotrauma.

In this study, at both six and 12 months after mTBI, 82 percent of patients reported at least one postconcussion syndrome symptom. At six and 12 months, 44.5 and 40.3 percent of patients had significantly reduced satisfaction with life scores, respectively. After three months, one-third were functionally impaired. About 20 percent were still below functional status after one year. Functional status was measured by being greater than or equal to seven on the Glasgow Outcome Scale-Extended score, which means either lower good recovery (seven) or upper good recovery (eight).

Another study measured the outcomes of mTBI patients on average six years after the injury. In the study, 33 mTBI patients were matched with 33 healthy controls. The injured individuals had significant impairments in all cognitive domains compared to healthy individuals. The cognitive domains included learning, recall, working memory, attention and executive function.

“Primarily, well-recovered individuals who had sustained a minor trauma more than half a decade ago continue to have long-term cognitive and emotional sequelae relevant for everyday social and professional life,” the study says. See “MTBI Requires Serial Follow-ups” for more information.

What is an mTBI?

A mild traumatic brain injury presents a diagnostic challenge in part because there is no universally agreed upon definition of an mTBI. The American Congress of Rehabilitation Medicine (ACRM) advocated for four specific criteria, and more recently the World Health Organization (WHO) maintained the same four criteria with two modifications.

The ACRM definition is reprinted below.

A patient with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function, as manifested by at least one of the following:
1. any period of loss of consciousness;
2. any loss of memory for events immediately before or after the
accident;
3. any alteration in mental state at the time of the accident (eg, feeling
dazed, disoriented, or confused); and
4. focal neurological deficit(s) that may or may not be transient;
but where the severity of the injury does not exceed the following:
loss of consciousness of approximately 30 minutes or less;
after 30 minutes, an initial Glasgow Coma Scale (GCS) of 13–15; and
posttraumatic amnesia (PTA) not greater than 24 hours.

The WHO definition agrees but on two points. It drops the word “dazed” from its definition, just including disoriented or confused. The point is to evaluate the confusion or disorientation from the biomechanical force to the head not the emotional shock of a traumatic event. “Dazed” may have been more of an emotional word, which could have been why it was dropped. For more information on identifying confusion, see this page: https://braininjuryhelp.com/confusion-and-amnesia-thing/.

The second difference is that it says “transient neurological abnormalities;” but, the ACRM says the deficits “may or may not be transient.” Since diagnosis should happen right after the injury, doctors may not know whether or not the symptoms are transient or persistent; therefore, the ACRM definition may be more accurate in this case. For more information on mTBI pathology, please visit: https://braininjuryhelp.com/mild-brain-injury-neuropathology/.

PTSD and TBI in War Veterans

This week, NPR had a story about a man who had a confirmed case of concussion and then post traumatic stress disorder (PTSD) after coming home from war.

ptsd

One study showed that men in the military who suffered a traumatic brain injury were twice as likely to suffer from PTSD. (Flickr / Creative Commons / Peter Murphy)

The wars in Afghanistan and Iraq has produced many cases like this man, where it starts as a concussion and ultimately turns out to be PTSD. The man profiled in the story experienced fear of IEDs, or improvised explosive devices. He would avoid trash piles because that is normally where they would hide IEDs.

The man profiled started school when he returned home. He noticed he started to have trouble with math problems he had no trouble with before.

“At one point we got this battalion that went to Helmand province in Afghanistan, and literally 50 percent of them were complaining of blast exposures and symptoms. I got concerned.” – Dewleen Baker, a psychiatrist at UCSD and the VA San Diego Healthcare System

Baker and her team studied more than 1600 servicemen, who were assessed before they were deployed and three months after returning. The study found that servicemen who suffered a traumatic brain injury were twice as likely to suffer from PTSD. See the “Nightmare of a Combat Injury” for more information on TBI in war.

Another relevant experiment occurred at the University of California, Los Angeles, where scientists compared healthy rats to rats with traumatic brain injury. All of the rats were treated with a kind of behavioral conditioning known to induce fear. The rats with traumatic brain injury experienced more fear than they would have normally. When they looked at cells in the amygdala, they found changes that would amplify an animal’s response to a fearful stimulus in the brains with TBI. The amygdala is the part of the brain that decides whether to be afraid or not. That is how they think that TBI increases the risk of PTSD.

Baker and her colleague used MEG to study the brains of regular civilians and servicemen. They found in people with concussions there was overactivity in the amygdala and not enough activity in the part of the brain that controls emotions. They referred to it as like having a car with no brake.

What’s interesting about this story is that Baker has plans to expand her research, and she hired the very man who was profiled earlier in the story. When he got out of school, he wanted to research the problems he experienced himself. Baker’s research was at the top of the list, and she hired him to help her.

The experiments show that PTSD is actually a physical condition, not just a mental one. It actually is represented in the brain in real ways. It’s not all in one’s head. It’s actually an imbalance in the brain’s circuitry.

 

Deep Brain Stimulation Helps Severe TBI

Deep brain stimulation (DBS), which sends electrical impulses to certain areas of the brain, may help people with chronic, disabling traumatic brain injury and problems of behavioral and emotional regulation.

The study was published in the journal Neurosurgery, and the abstract may be viewed here.

The study states that severe traumatic brain injury “damages the frontal lobes and connecting networks, which impairs executive functions, including the ability to self-regulate.” There are few treatment options available in the chronic phase after injury.

Ali Rezai, M.D., director of the Neurological Institute at The Ohio State University in Columbus, and colleagues studied the safety and potential effectiveness of DBS in four patients, who suffered severe traumatic brain injury in automobile crashes six to 21 years earlier.

The study participants did not have trouble staying awake or alert, but they needed help in other domains. Three needed help getting dressed, going to the bathroom, and grooming. All couldn’t be alone overnight and required daily supervision.

The DBS system contains an electrode, also known as a lead, the extension, and the pulse generator, essentially like the batteries. The lead was connected to the damaged areas of the brain. The extension is implanted under the skin and travels through the head down the neck to the pulse generator, which is implanted in the collarbone area.

After two years of treatment with the DBS system, all four of the patients showed improvements in alertness and engagement. Three of the four patients showed substantial improvements in behavioral and emotional domains, and substantial gains in functional independence. Two needed less help with activities of daily living. Three of the four increased their activities outside of the home.

DBS is a well-established therapy for people with Parkinson’s disease. This is a small study, so larger controlled trials need to be done to confirm these findings for traumatic brain injury patients and to refine the treatment.

The safety of the treatment was confirmed, and the results suggest potential effectiveness of treatment for severe TBI patients, not just those in car accidents but also those injured in sports or combat. “The primary impact was on behavioral and emotional adjustment, which in turn improved functional independence,” the study authors write.

Future studies should be larger and test the treatment against a placebo group to confirm the findings.

Scientists Discover a Neuroprotective Mechanism in the Brain

Last week we wrote about a study published recently in the journal Scientific Reports that demonstrated how brain damage spreads and how it could be limited with a neuroprotective mechanism.

neuroprotective mechanism

Following this blog, we decided to talk to the lead author of this study, Andrew Samson, who works in the division of neuroscience at the University of Dundee in Scotland.

First, he explained how brain damage spreads across the brain.

“Following an insult to the brain, either as a result of a stroke or a traumatic brain injury, cells at the insult site die rapidly, spilling out large quantities of toxic chemicals into the surrounding area,” Samson said. “These toxic chemicals spread out, killing more cells, which in turn causes a further release of toxic chemical, and therefore a ‘snowballing’ of toxicity could occur.”

He said that any insult to the brain that kills brain cells should spread and consume the entire brain. But this doesn’t happen. This was how they knew there must be some neuroprotective mechanism at work in the brain.

“We have recently developed a model for this spreading toxicity and this has allowed us to discover the existence of the in-built neuroprotective signal that spreads rapidly as a warning signal when local damage occurs,” Samson said. “In our study, we demonstrated that an artificial non-toxic stimulus could also trigger this response and so prevent spreading damage.”

He said that this provides the scope for a therapeutic block to prevent brain damage.

“If properly harnessed, this innate protective mechanism may provide a fast acting strategy to terminate spreading damage caused by a stroke or traumatic brain injury, just when a rapid response is essential,” he said.

He explained that no current treatment exists for spreading toxicity following stroke or traumatic brain injury, and current therapy is limited to promoting recovery and physical rehabilitation.

“Our research has identified a new opportunity to prevent damage spreading into surrounding networks of the brain, thus limiting brain damage and speeding recovery,” he said. “Our research however is in the very early days, and a significant amount of work now needs to be done in order to fully characterise this protective mechanism and how best to harness this natural protective power in acute, emergency situations.”

As for Samson’s hope for the future, he hopes his team can develop a device that will stimulate the protective power of the brain after an acute injury. His team also plans to investigate whether or not this kind of therapeutic device can help protect against spreading toxicity in chronic diseases, such as Alzheimer’s.

“There is still a long way to go, but we have at least opened the door,” he said.

Neuroprotective Mechanisms Discovered To Potentially Help with Brain Damage

A study published in the journal Scientific Reports demonstrated how brain injury spreads and how it could potentially be limited with a neuroprotective mechanism. The discovery was made in a collaboration between neuroscientists and engineers at the Universities of Dundee and Strathclyde. The study was published online Sept. 21, 2016.

neuroprotective

The researchers, led by Andrew J. Samson, a neuroscientist at the University of Dundee, found a mechanism that uses the neuronal networks to provide protection against secondary damage of traumatic brain injury or strokes.

Neurodegenerative diseases, traumatic brain injuries or strokes tend to have acute secondary damage, where neurotoxicity is spread into uninjured brain areas. One of the researchers, Christopher N. Connolly, said that if the network could be triggered in a clinical setting as soon as possible then secondary damage could be minimized and recovery time shortened.

Network neuroprotection can be stimulated after a brain injury, opening a new window to therapeutic intervention. Current treatments are limited to aiding the recovery process, because only slow-acting network neuroprotection is known, which has little clinical, realistic significance.

The researchers have identified that neuronal networks react to an injury by sending warning signals very rapidly (in minutes) to protect against brain damage. This may be a mechanism that can be used in clinical settings to prevent brain damage. They can recruit the help of surrounding neurons for the neuroprotective help.

They also found that benzodiazepines, anxiety medications, can mimic neuroprotective mechanisms. This is a possible pharmacological treatment for stroke, but must be tested further, Connolly said.

The neuroscientists, Samson and Connolly, teamed up with engineers, including Michele Zagnoni, who said they were able to study the spreading of damage in the brain using microfluidic technology in the lab.

Through this technology, they were able to see how damage is spread in the brain by simulating a brain injury and to identify a “fast-acting neuroprotective signaling mechanism.”

This therapy uses surrounding networks of neurons grown in the lab to protect against secondary damage. This could be stimulated in order to stop the spread of brain damage. This requires more work, but is an interesting, exciting possibility.

Biomarkers for Neuronal Damage Discovered

A study published in JAMA Neurology demonstrated that ice hockey players with postconcussion syndrome (PCS) had higher levels of neurofilament light proteins and lower levels of amyloid β.

brain-mri-for-biomarkers-article

The objective of the study was “to determine whether persistent symptoms after mTBI are associated with brain injury as evaluated by cerebrospinal fluid biochemical markers for axonal damage and other aspects of central nervous system injury,” the study authors wrote.

To do this, they studied professional Swedish hockey players who had repeated mild traumatic brain injury, postconcussion symptoms for more than three months, and met criteria for PCS. The participants were matched with neurologically healthy controls.

Of the 16 players with PCS, nine had PCS symptoms for more than one year. The remaining seven returned to play within one year. Researchers, led by Pashtun Shahim, MD, PhD of the University of Gothenburg in Sweden, found significantly higher levels of neurofilament light proteins in the cerebrospinal fluid of players with PCS for more than one year as compared to players whose PCS resolved in one year and controls.

In addition, neurofilament light protein concentrations correlated with Rivermead Post Concussion Symptoms Questionnaire scores and lifetime concussion events. Finally, players with PCS had significantly lower amyloid β levels in the cerebrospinal fluid as compared to controls.

The results, elevated levels of neurofilament light protein and lower levels of amyloid β, indicate that there may be axonal white matter injury and amyloid deposition.

Amyloid β is the name for peptides, or short chains of amino acid monomers linked by peptide bonds, of 36 to 43 amino acids. Deposition of amyloid β is seen in the brains of patients with Alzheimer’s disease, which shares microscopic changes with the disease CTE, which is found in people with a history of repeated head trauma, such as athletes and military veterans.

Neurofilaments are composed of polypeptide chains and found in neurons. There are three subunits, with the neurofilament light protein having the smallest mass. In independent studies in 2015, increased levels of neurofilament light proteins were found to be associated with neurodegenerative disorders, particularly Alzheimer’s disease, and indicates injury to large-caliber myelinated axons in the white matter.

The study authors are hoping that “measurement of these biomarkers may be an objective tool to assess the degree of central nervous system injury in individuals with PCS,” they write.

The other motivation behind the study is “to distinguish individuals who are at risk of developing chronic traumatic encephalopathy.”

The only limitation of this study was its relatively modest sample size, with only 16 participants with PCS and 15 neurologically healthy controls.

Bus Carrying Football Team Crashes on Highway in North Carolina

A football team bus crashed on the highway, killing four people, while it was carrying Clinton College’s team. In addition, 42 other passengers, whose injuries ranged from minor to critical, were taken to area hospitals. The bus’ front left tire blew, which made the bus travel out of control into the median.

The bus hit the guardrail and sideswiped a concrete bridge column, according to CNN’s report. The team was traveling from Rock Hill, South Carolina to compete against the University of God’s Chosen, which is located in Fayetteville, North Carolina.

What makes bus accidents so dangerous is that almost all of the safety devices that have made cars increasingly safer, don’t exist on buses. There are no airbags and few buses have seat belts. One argument against more safety measures is that buses weigh so much that they rarely stop as fast as a car. Here the bus hits concrete, stopping it immediately.

Another analogy is that the brain moves around in the skull like jello. When the brain strikes the skull, it can bounce back to the other side of the skull, causing damage on both sides of the brain. This would be called coup contrecoup injury.

When the brain collides with the hard skull, or the skull collides with another hard object like the windshield, damage can occur to the brain. The skull can be fractures, and there may or may not be an open wound as a result. Blunt trauma occurs when the skull hits a hard object without penetration.

According to the CDC, motor vehicle crashes are the third leading cause of traumatic brain injury (14 percent), and the leading causes of TBI-related death (26 percent) among all age groups. Teens and young adults have the highest rates of motor-vehicle-related TBIs. To prevent motor-vehicle-related TBI, the CDC recommends wearing a seatbelt. However, on many buses there may not be any seatbelts, or people may not want to wear them.

Motor vehicle crashes are the leading cause of death in the United States. In one year time frame, the medical costs and productivity losses associated with injuries from motor vehicles crashes exceeded $80 billion.

The more critical injuries may take months and years to heal, but there is hope after brain injury. Although it may be difficult, people can return to their pre-injury baseline levels with proper care. This tragedy in North Carolina is no different. Our thoughts are with the victims of the crash in their recoveries.

Define smart: It goes beyond knowledge and information

Ann Zuccardy used to think that being smart depended on how much knowledge and information a person had stored in their mental framework. It was only after she suffered a mild traumatic brain injury that she figured out that being smart was not just about knowledge.

being smart

Smart goes beyond knowledge, Zuccardy says. (Flickr / Creative Commons / TZA)

Charged with this life challenge of brain injury, she responded by finding creative solutions to her problems. In her TED Talk, she outlined three pillars of being smart. TED is a nonprofit dedicated to spreading ideas in the form of brief, meaningful talks. It started in 1984 as a conference where technology, entertainment, and design came together (hence, the acronym TED), and today covers a wide range of topics in more than 100 languages.

The three pillars of being smart, as defined by Zuccardy, have nothing to do with acquiring knowledge. This is an interesting and encouraging perspective for anyone who has had to overcome life challenges or disability. It offers hope to people who might struggle with feeling smart in a hectic, fast-paced world.

What really makes people smart, Zuccardy says, is first and foremost creative adaptive mechanisms. When she suffered from a head injury, she had trouble with daily tasks, such as going down stairs, crossing the street, and remembering what day of the week it was. She developed creative solutions to all of these problems. She had to creatively adapt to a life where these problems with daily tasks were a reality. People who find creative ways to adapt to life have a kind of smart that was only brought to the forefront in Zuccardy after her head injury.

The second tenet of being smart, Zuccardy says, is resilience. This word means having the strength to get up after you fall down. When life gives you challenges, you keep persevering and pushing forward. It means you never give up. This is an encouraging point because it focuses on the positive in what can be a negative situation. Despite troubling circumstances, you have the willpower to continue. This quality is often indicative of a successful life.

The third tenet of being smart, she says, is twofold: being creative and curious. Even people who are developmentally challenged can be smart as long as they have a hunger to learn. Being smart is not so much about how much you learn, but how much you want to learn. This offers hope to disabled people everywhere.

If you are doubting yourself, how smart you are, this video is the perfect spark of encouragement. If you are struggling to overcome an obstacle in life, this video will give you a positive outlook on what can be a challenging reality.

“I used to think that smart was about how much knowledge I had. Now, I define smart as my craving to learn,” she says. “Creative adaptive mechanisms, resilience, creativity, curiosity. This is the new smart.”

A New Way of Mapping the Brain

By Jennifer Ball

A new study in the journal Neuron describes a whole new way of mapping the brain at the resolution of individual neurons.

concussions

This new method was demonstrated successfully in the mouse brain. Anthony Zador, MD, PhD, professor at Cold Spring Harbor Laboratory, said that their method is different than the usual methods that map out brain wiring. However, it does not have the potential for human use, Zador said in our interview with him.

He said that usually scientists inject a tracer in one brain area, which then spreads to other brain areas. The common way to do it is with green fluorescent protein (GFP).

One injects the GFP into one part of the brain and then waits a few days. That green color indicates that those neurons send signals to that place.

Zador said that the problem with that method is that the everything is labeled green, so you cannot tell one neuron goes to one place, and a different neuron goes to a different place.

The team of researchers is doing something fundamentally different by using high-throughput DNA sequencing, a new technology that is revolutionizing other branches of biology, but hasn’t been used in this way before. This is the same technology that was used to map the human genome. This allows people to map their genomes for under $1000.

The researchers are using the same technology, using DNA “barcodes” instead of colors. This allows researchers to do in a single experiment what would before require months or years of work. It is also much less costly, not only because of the labor saved.

The cost of sequencing is decreasing rapidly. Originally, fifteen years ago, it cost over one billion dollars to sequence the human genome, while today it costs under $1000.

The method is called Multiplexed Analysis of Projections by Sequencing (MAPseq). Each injection contains a deactivated virus that has been engineered to contain massive pools of individually unique RNA molecules, each of whose sequence, consisting of combinations of 30 letters, is taken up by a single neuron.

To demonstrate MAPseq’s capabilities, the team of researchers injected the deactivated virus into a part of the mouse brain called locus coeruleus, which is in the brain stem. After about two days, the cortex was divided into 22 pieces, dissected and sequenced for RNA barcodes. The sequence readouts were matched with barcodes of cells in the source region, establishing paths of neurons.

We talked to Dr. Zador, and he said he doesn’t think this has much potential for use in humans because it requires “injecting a barcoded virus into the brain” and “extracting the virus in the brain tissue.”

“There is no technology on the horizon that would allow this to be done non-destructively,” Dr. Zador told us.

Although it can’t be used in humans, he said that this could still have relevance to humans.

“That said, I believe that the basic microcircuitry of mammalian brain, especially cortex, is largely conserved across mammalian evolution, and right now there is so much we do not know about how single neurons are wired up to make cortical circuits, in any species, that what we don’t know completely swamps any differences between humans and related mammals.”

Researchers Find Parts of the Brain Responsible for Physics

Researchers have discovered the parts of the brain responsible for comprehending and computing real time physics calculations, which help us better understand the world around us. The research is coming out of a combined effort of Johns Hopkins Krieger School of Arts and Sciences and the Massachusetts Institute of Technology (MIT).

parts of brain responsible for physics calculations

“We run physics simulations all the time to prepare us for when we need to act in the world,” said lead author Jason Fischer, an assistant professor of psychological and brain sciences in the Krieger School of Arts and Sciences, in a news release. “It is among the most important aspects of cognition for survival. But there has been almost no work done to identify and study the brain regions involved in this capability.”

The study was published in the journal Proceedings of the National Academy of Sciences.

The researchers out of Johns Hopkins and MIT conducted a series of fMRI experiments to try to engage the part of the brain responsible for making physics calculations. They recruited 12 subjects to look at a video of a Jenga tower and predict where the blocks would fall as well as if there were more yellow or blue blocks, while their brains were being monitored. Guessing the positions of the blocks was a physics question, while the color question was merely visual.

The second experiment had people look at a screen with two bouncing dots and had them predict the direction the dots would head, based on physics or social reasoning.

The researchers found that in both experiments, when the subjects tried to predict physical outcomes, the most responsive brain areas were the premotor cortex and the supplementary motor area. This is the brain’s action planning region. The article’s abstract describes this as the “physics engine” in the brain.

However, the functions of these regions of the brain are not exclusive to physical inferences or even to scene understanding. The function of these regions of the brain overlap with what is described as the “multiple demand” system, especially those engaged with action planning and tool use.

“Our findings suggest that physical intuition and action planning are intimately linked in the brain,” Fischer said in the news release. “We believe this might be because infants learn physics models of the world as they hone their motor skills, handling objects to learn how they behave. Also, to reach out and grab something in the right place with the right amount of force, we need real-time physical understanding.”

For the last part of the experiment, the researchers asked the subjects to watch video clips, while their brains were being monitored. Some of the video clips included lots of physics content, others very little. They found that the more physics content in the video, the more the key regions in the brain were activated.

“The brain activity reflected the amount of physical content in a movie, even if people weren’t consciously paying attention to it,” Fischer said in the news release. “This suggests that we are making physical inferences all the time, even when we’re not even thinking about it.”

The results offer insights into disorders such as apraxia, a movement disorder caused by damage to the brain, in which someone has difficulty with motor planning to perform tasks or movements when asked. It’s possible people with damage to the motor areas also have trouble making physical judgments.

Knowing which parts of the brain are responsible for physics calculations could also help with robot design. A robot built with a physics model could navigate the world more fluidly.