New research shows that estrone, one of the three naturally occurring estrogen hormones in the body, has shown some promise in reducing inflammation and cell death in the brain.  Dr. Joshua Gatson, Assistant Professor of Surgery at the University of Texas Southwestern Medical Center in Dallas, revealed his findings on April 22, 2012 during Experimental Biology 2012 in San Diego, CA.

Giving estrone to rats links recovery after traumatic brain injury with increased recovery. It does this by reducing inflammation and subsequent damage. This presents new avenues for research.

It came to my attention last week that while I was blogging a series about Post Traumatic Stress Disorder during the month of February, there was something similar going on.  Dan Ball of Channel 3 News in Las Vegas (KSNV) was running a series on Post Traumatic Stress Disorder for soldiers returning from war.

You can see part 2 of his series on the Channel 3 website.  

The series concluded with a discussion of a Las Vegas District Court Judge's son, a career veteran, taking his own life due to the stress of the war and post trauma.  It is sad but worth taking the time to view since it demonstrates just how real this problem is.

There are several disorders associated with Traumatic Brain Injury (TBI). In representingpeople with Traumatic Brain Injury, I find some or more of the Disorders contribute to difficulty handling a case. For Instance, when communication is affected, it can make gathering specific facts hard. I occasionally see facts patterns change over time; like when a client begins to confabulate (to give fictitious accounts of past events, believing they are true, in order to cover a gap in the memory caused by a medical condition such as dementia or Post-Concussion Syndrome.) Or, when memory is impaired, there may be concerns about a client getting to work, doctor appointments, or other tasks.

Another difficulty is separating out symptoms of disorders from a person’s pre-existing propensity and personality. People or entities interested in someone NOT having a Neuropsychiatric Disorder, (ie. An insurance company, defense lawyer, defendant) will usually point to a person’s pre-existing personality as a basis to argue that any claimed Neuropsychiatric Disorders are not related to Traumatic Brain Injury.

Here is a list of potential Neuropsychiatric Disorders that can result after a Traumatic Brain Injury.

·        Delirium and Post-Traumatic Confusion

·        Mood Disorders

·        Psychotic Disorders

·        Post-Traumatic Stress Disorder

·        Personality Change

·        Aggressive Disorders

·        Mild Brain Injury

·        Post Traumatic Epilepsy

Delirium and Post-Traumatic Confusion

Delirium is a state somewhere between Coma and normal consciousness. It is an abnormal state of consciousness and is characterized by inattentiveness, language and thought abnormality, motor and affective changes, and sleep cycle disturbance.

Mood Disorders

Neuropsychiatric illness is prevalent in Traumatic Brain Injury.  TBI has been dubbed the “signature wound” in much of the literature describing blast injury to soldiers in operation Iraqi Freedom and Operation Enduring Freedom in the last decade.

Psychotic Disorders

               A predisposition to psychotic illness following brain injury in childhood has been documented. There is also substantial evidence of elevated psychosis incidence among those exposed to Traumatic Brain Injury.

Post-Traumatic Stress Disorder

               Traumatic Events often precipitate acute anxiety and stress reactions. Focus on Post-Traumatic Stress Disorder has received significant attention as military personnel return from overseas deployment.

Personality Change

               Most often disputed as pre-existing, Personality Change is shown to be related to Traumatic Brain Injury. Studies of patients with TBI find that the most significant problems at 1, 5, and 15 years post-injury are personality changes.

Aggressive Disorders

               Frequently mischaracterized are the symptoms of aggression in TBI cases. But aggression has long been linked to Traumatic Brain Injury. Irritability and aggressiveness are significant disabilities for people with TBI as well as a source of stress for those around them.

Mild Brain Injury

               There are three generally accepted definitions of Mild Traumatic Brain Injury. One is from the Centers of Disease Control, another from the World Health Organization and another from the American Congress of Rehabilitative Medicine. There is overlap in these definitions. A main point is that Mild Traumatic Brain Injury can be diagnosed without a loss of consciousness. An altered state of consciousness is sufficient.

Post Traumatic Epilepsy

               Trauma is one of the most identifiable causes for the development of Epilepsy. It occurs in roughly 20% of the cases of symptomatic Epilepsy.

Concluding Thoughts

               Since these potential Disorders create a subterfuge to effective communication, representing people with Traumatic Brain Injury presents a unique set of challenges. Patience and perseverance are necessary. It is fair to suggest that most lawyers do not have specific training in Traumatic Brain Injury cases. Similarly, most physicians are not properly trained to diagnose or detect symptoms or Disorders as being caused by Traumatic Brain Injury.

               If you or someone you know has suffered Traumatic Brain Injury as a result of an accident, fall, car crash, truck collision or other event caused by another, research the attorney’s in your State and be sure to understand what they practice. For instance, my web site is http://www.titololawoffice.com. I also publish several blogs. The Brain and Spine Injury Law Blog, Truck Accident Blog, Las Vegas Injury Attorney Blog, and Tim Titolo. You can visit any of these sites and get a good idea of the type of cases I handle regularly. You can also get to know me by seeing and hearing me.

With all the news about the soldier in Afghanistan who suffered from traumatic brain injury which lead to his committing horrific murders please remember that March is Brain Injury Awareness Month.

March is Brain Injury Awareness Month – Give Brain Injury a Voice

This March, in recognition of Brain Injury Awareness Month, CDC and our partners are working together to spread the word and raise awareness about traumatic brain injury (TBI) prevention, recognition, and response to help address this important public health problem. CDC estimates that 1.7 million Americans sustain a TBI, including concussions, each year.

Learn more about Traumatic Brain Injury.
 

We all know that brain cells do not regenerate once damaged.  Broken bones heal, and soft tissue injury rebuilds.  But the brain, holding the precious cargo of neurons, dendrites and axons, has traditionally been unreceptive to healing in terms of cell structure. 

The promise of stem cell research held up the hope that unspecialized cells could become neurons if introduced into the brain or spinal cord.  The problem has been political more than medical.  George Bush, in a State of the Union address condemned stem cell research based on religious grounds.

Now science is getting center stage on stem cells.  The Journal of Neurotrauma published a study.  Researchers at the University of Texas Medical Branch at Galveston conducted experiments with both laboratory rats and an apparatus that enabled them to simulate the impact of trauma on human neurons, and they identified key molecular mechanisms by which implanted human neural stem cells -- stem cells that are in the process of developing into neurons but have not yet taken their final form -- aid recovery from traumatic axonal injury.

A significant component of traumatic brain injury, traumatic axonal injury involves damage to axons and dendrites, the filaments that extend out from the bodies of the neurons. The damage continues after the initial trauma, since the axons and dendrites respond to injury by withdrawing back to the bodies of the neurons.

I will surely follow these discoveries as it has significant meaning for curing or lessening the adverse effects of traumatic brain injury.  

This is the final post in my series on Post Traumatic Stress Disorder.  Last week we looked at Treatment for Post-Traumatic Stress Disorder.  Today we will look at how the disorder and litigation relate.

In law, trauma which produces post-traumatic stress disorder is referred to as a tort. For many years only physical injury related to a trauma could form the basis of a lawsuit since it was observable and quantifiable. As the behavioral sciences gained ground, the concept of “traumatic neurosis” emerged and by the 1940s, testimony relevant to this psychiatric syndrome was accepted in many courts. By 1980, post-traumatic stress disorder found its way in the Diagnostic and Statistical Manual – the DSM – and the condition became a source of monetary damages to one so inflicted.

 The legal cause of action for emotional distress and psychiatric disorder including post-traumatic stress is readily accepted by courts for the person involved in the physical trauma. However the only time one not involved in the physical trauma can recover for emotional distress or post-traumatic stress disorder is if they were within the “zone of danger.” Please refer to my previous post.

 The Zone of Danger Rule - The Zone of Danger Rule, applied in almost every jurisdiction, allows a plaintiff to recover for emotional distress caused by a defendant’s negligent conduct if the plaintiff was in a location where the defendant’s conduct could have caused physical harm to the plaintiff.

 The theory supporting this doctrine is that the likely truth of a claim of emotional distress is increased if the person making the claim came close to suffering physical harm from the conduct that caused the person’s emotional distress.

 Predisposition to PTSD is frequently contested. Whether a person’s personality type gave way to PTSD where others with other personality types would have avoided the disorder is bandied about in trials. The question of predisposition has puzzled doctors over the years. Not all soldiers in the same battle, passengers in the same automobile accident, or workers exposed to the same industrial calamity develop PTSD. A dispute often arises in my practice over how a driver or passenger in the same car crash could develop PTSD while the other does not. Why certain individuals are vulnerable to PTSD must have something to do with heredity (genetics), environmental factors (family upbringing) together with the nature and impact of the trauma.

 Since my legal practice is significantly defined by the many traumatic brain injury cases I handle and have handled over many years, I come in contact with the PTSD diagnosis quite frequently. It is my experience that the condition is typically disputed and attempts are made to relate any psychiatric injury claims to predisposing factors.

 Today we are continuing our discussion of post-traumatic stress disorder by identifying treatments options.

Post-traumatic stress disorder consists of a spectrum of pathologic symptoms and behaviors involving the environment, the brain, and psychosocial influences. The environment is both cause and effect as the trauma from the environment initiates the disorder and leaves its imprint as an aftermath. The brain interacts with the trauma to produce symptoms of intense fear, dissociative flashback episodes, and physiological reactivity upon exposure to cues that resemble the traumatic event. Because of the constellation of symptoms typical of PTSD, the conceptualization of symptoms and pathologic behaviors related to the environment, the brain and psychosocial factors allows the clinician to select biologic, cognitive-behavior, psychosocial and environmental modalities to formulate a comprehensive treatment plan. (C.B. Scrignar)

The Mayo Clinic describes treatments.

Medications
Several types of medications can help symptoms of post-traumatic stress disorder improve.

•  Antipsychotics. In some cases, you may be prescribed a short course of antipsychotics to relieve severe anxiety and related problems, such as difficulty sleeping or emotional outbursts.
• Antidepressants. These medications can help symptoms of both depression and anxiety. They can also help improve sleep problems and improve your concentration. The selective serotonin reuptake inhibitor (SSRI) medications sertraline (Zoloft) and paroxetine (Paxil) are FDA-approved for the treatment of PTSD.
• Anti-anxiety medications. These drugs also can improve feelings of anxiety and stress.
• Prazosin. If your symptoms include insomnia or recurrent nightmares, a drug called prazosin (Minipress) may help. Prazosin, which has been used for years in the treatment of hypertension, also blocks the brain's response to an adrenaline-like brain chemical called norepinephrine. Although this drug is not specifically approved for the treatment of PTSD, prazosin may reduce or suppress nightmares in many people with PTSD.

Psychotherapy
Several types of therapy may be used to treat both children and adults with post-traumatic stress disorder. You may try more than one, or combine types, before finding the right fit for you. You may also try individual therapy, group therapy or both. Group therapy can offer a way to connect to others going through similar experiences.

Some types of therapy used in PTSD treatment include:

• Cognitive therapy. This type of talk therapy helps you recognize the ways of thinking (cognitive patterns) that are keeping you stuck — for example, negative or inaccurate ways of perceiving normal situations.

In PTSD treatment, cognitive therapy often is used along with a behavioral therapy called exposure therapy.

• Exposure therapy. This behavioral therapy technique helps you safely face the very thing that you find frightening, so that you can learn to cope with it effectively. A new approach to exposure therapy uses "virtual reality" programs that allow you to re-enter the setting in which you experienced trauma — for example, a "Virtual Iraq" program.
• Eye movement desensitization and reprocessing (EMDR). This type of therapy combines exposure therapy with a series of guided eye movements that help you process traumatic memories.

All these approaches can help you gain control of lasting fear after a traumatic event. The type of therapy that may be best depends on a number of factors that a PTSD sufferer and a health care professional can discuss.

As identified above, Medications and psychotherapy also can help you with other problems related to traumatic experience, such as depression, anxiety. Many PTSD sufferers engage in “self-medication” with alcohol or substance abuse. Therapy and treatment can help curb the burden of PTSD.

Next week we will look at special issues germane to litigation and post-traumatic stress disorder.

President Obama's Proposed FY2013 Budget and TBI Funding

 After analyzing President Barack Obama’s proposed FY2013 budget, BIAA is pleased to report that programs authorized by the TBI Act, including the HRSA Federal TBI Program and the CDC’s important TBI work have both been recommended to receive level funding found in FY11 final and FY12 CR appropriations bills, $10 million for HRSA and just under $7 million for CDC. In the current fiscal climate this is good news for TBI advocates. This would indicate TBI funding is not on the chopping block when the government is looking to cut a trillion and a half dollars in federal spending.

 The CDC collects data, links both military and civilian populations with TBI services, increases public awareness, and conducts public health research. The HRSA Federal TBI Program funds 21 states to improve systems coordination and access to care for people with brain injury.

 On another note, the budget recommends reducing funds for the National Institute on Disability and Rehabilitation Research (NIDRR) of the U.S. Department of Education. In FY 2012, NIDRR was funded at $109 million with FY 2013 funding to be decreased to $107 million.

 NIDRR administers grants to the TBI Model Systems, which is a collection of research centers located across the United States that conduct disability and rehabilitation research. The TBI Model Systems are the only source of non-proprietary longitudinal data on what happens to people with brain injury. The TBI Model Systems are a key source of evidence-based medicine, and serve as a “proving ground” for future researchers.

 The funding decrease was to the overall budget of NIDRR, not the TBI Model Systems. BIAA will address the issue with both the House and Senate Appropriations Committees to ensure that Congress is aware of the importance of full funding for NIDRR.

 BIAA will continue to work to ensure that legislators understand the importance of these programs and how they affect the 1.7 million people across the United States with brain injury. Grassroots advocates should be ready for appropriations alerts to drive home this vital message this spring.

 II.               What are the Types of Trauma that Causes of Post-Traumatic Stress Disorder?

Post-traumatic stress disorder (PTSD) is a mental health condition that's triggered by a terrifying event. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event.

According to http://www.medicinenet.com/posttraumatic_stress_disorder  

 Virtually any trauma, defined as an event that is life-threatening or that severely compromises the physical or emotional well-being of an individual or causes intense fear, may cause PTSD. Such events often include either experiencing or witnessing a severe accident or physical injury, receiving a life-threatening medical diagnosis, being the victim of kidnapping or torture, exposure to war combat or to a natural disaster, exposure to other disaster (for example, plane crash) or terrorist attack, being the victim of rape, mugging, robbery, or assault, enduring physical, sexual, emotional, or other forms of abuse, as well as involvement in civil conflict. Although the diagnosis of PTSD currently requires that the sufferer has a history of experiencing a traumatic event as defined here, people may develop PTSD in reaction to events that may not qualify as traumatic but can be devastating life events like divorce or unemployment.

It is an interesting observation that the traditional “Trauma Principle” discussed in my last post has been broadened to include trauma where the “zone of danger” is no longer requisite. In my experiences, I am most exposed, as a consumer rights attorney, to those individuals who suffer traumatic events that injure either themselves or someone with them. The following is a summary of such common events and others that can cause PTSD.

•       Vehicular Trauma

There is no denying that a vehicle weighing several thousand pounds can cause injury, trauma and even death. That is typical in cases of car “accidents.” But consider for a moment, big rig trucks carrying heavy loads of cargo or hazardous materials. Think of train wrecks and airplane crashes. As I state on my website, before there were trains, planes and automobiles, we simply did not travel or crash in the manner we see quite frequently today.

•       Industrial Trauma

Industrial settings – factories, oil refineries, construction sites, and other blue collar work places – have a high potential for accidents. Work related trauma could well be any trauma that is sustained while at work or on the job. Sometimes trauma can be very job specific like falling off scaffolding. Other times it could be like any other; a truck crash while hauling dirt. The point is trauma related to the job can result in PTSD.

•       Criminal Assaults

Statistics of criminal assault are staggering. When a person is attacked, beaten or hit, a trauma occurs. In cases of of negligent security, one can see how criminals and trespassers could gain access to apartments, hotels and other public sites and commit crimes that include injury to the victim.

•       Sexual Assaults

Sexual assault is defined as any sort of sexual activity between two or more people in which one of the people is involved against his or her will.

The sexual activity involved in an assault can include many different experiences. Women can be the victims of unwanted touching, grabbing, oral sex, anal sex, sexual penetration with an object, and/or sexual intercourse.

•       Child Sex Abuse
•       Terrorism

Veterans, like other people, respond to traumatic events in a number of ways. They may feel concern, anger, fear, and helplessness. These are all normal responses to an abnormal event. Research shows, though, that people who have been through traumas in the past may be even more likely than others to be affected by new events such as terror attacks and war.

•       Torture
•       The Holocaust
•       War Trauma

Now that the war in Iraq is over, the return of military personnel will reveal the residual injury of war, PTSD. The signature injury has already been well recognized by the military and government. Getting care will be the next challenge.

Experts think PTSD occurs:

§ In about 11-20% of Veterans of the Iraq and Afghanistan wars (Operations Iraqi and Enduring Freedom), or in 11-20 Veterans out of 100.

§ In as many as 10% of Gulf War (Desert Storm) Veterans, or in 10 Veterans out of 100.

§ In about 30% of Vietnam Veterans, or about 30 out of 100 Vietnam Veterans.

•       Natural or Man-Made Disasters

Every year, millions of people are affected by both human-caused and natural disasters. Disasters may be explosions, earthquakes, floods, hurricanes, tornados, or fires. In a disaster, you face the danger of death or physical injury. You may also lose your home, possessions, and community. Such stressors place you at risk for emotional and physical health problems.

Trauma producing post-traumatic stress disorder – PTSD – comes in many shapes and sizes and not in a one size fits all. As an attorney whose practice is defined by the significant cases of traumatic brain injury handled over the years, I am often disappointed at how difficult it is to convince insurance companies, defense lawyers and defense experts of the relation of trauma to a diagnosis of post-traumatic stress disorder – PTSD.

Next week we will continue our discussion of post-traumatic stress disorder. We will look at the treatments used to manage it and will look at the nuances PTSD brings to litigation.

During the month of February, I will do a short series of posts on Post-Traumatic Stress Disorder.  Starting today and for the next 3 Tuesdays in February we will look at what PTSD is, the types of causes of PTSD, treatment plans, and. finally, litigation issues.

I.               What is Post Traumatic Stress Disorder?

The National Institutes of Mental Health defines Post Traumatic Stress Disorder, also known as PTSD, as “an anxiety disorder that some people get after seeing or living through a dangerous event.” It is natural to feel afraid when faced with danger. The fear or “fight or flight” response triggers split second changes in the body to prepare to defend against the danger or to avoid it. The reaction is designed to protect a person from harm. However in people with post-traumatic stress disorder, PTSD, the reaction is changed or damaged. These folks feel stressed or frightened even when they are no longer in danger.

Some of the classic characteristics of post-traumatic stress disorder include:

•  Nervousness
•  Preoccupation with the trauma
•  Pain or physical discomfort
• Sleeplessness and nightmares
• Flashbacks and intrusive thoughts
• Deterioration of performance
• Phobia
• Personality change
• Unprovoked outbursts

A concept, known as the “Traumatic Principle,” helps to sort out those victims of trauma more likely to develop PTSD. Important elements of serious trauma include:

•        Vulnerability

Predisposition recognizes the role of genetics, family upbringing, and other risk factors in the diagnosis of PTSD.

•        Environmental Stimulus

This refers to any traumatic event coming from outside of the individual.

•       Realistic Threat

This means that by observable and obvious standards, the environmental event has the capacity to produce physical injury or death.

•       Perception by Five Senses

Here is the acknowledgment that neurobiological components exist from the traumatic event.

•       Cognitive Awareness

Perception involves cognitive awareness and the nervous system.

•       Activation of the Sympathetic Nervous System

This is the most obvious neurobiological indication of intense fear, helplessness, or horror.

•       Zone of Danger

This concept, somewhat controversial among experts, holds that before PTSD can develop, the victim must be present at the traumatic scene and experience, witness, or be confronted with a dangerous situation that can be actual or threatened death or serious injury.

A compilation of these factors results in the Traumatic Principle which C.B. Scignar, M.D. describes as:

Any environmental stimulus which poses a realistic threat  to life or limb, if perceived by one, or more likely a combination of the five sensory pathways to the brain, if cognitively interpreted as dangerous (a serious threat to life or physical integrity to self or others), and followed by intense stimulation of the sympathetic nervous system, whether it produces a physical injury or not, can be regarded as a traumatic event which can precipitate PTSD in a vulnerable individual who is in the zone of danger.

Anyone, according to the National Institutes of Mental Health, can get PTSD at any age. This includes war veterans and survivors of physical and sexual assault, abuse, accidents, disasters, and many other serious events. In contrast to Dr. Scignar, the National Institutes of Mental Health endorses that not everyone with PTSD has been through a dangerous event. Some people get PTSD after a friend or family member experiences danger or is harmed. For instance, the sudden, unexpected death of a loved one can also cause PTSD.

In the posts to follow this month we will examine the types of trauma, treatment and some of the issues in litigation that are affected by post-traumatic stress disorder. 

On Tuesday, February 7, 2012, the Senate Health, Education, Labor, and Pensions (HELP) Committee held a hearing on accessible technology. Chairman Harkin (D-IA) spoke about how America is at a critical juncture in technological development related to education. Technology can either be used in the classroom to keep all students, including students who have sustained a TBI, on equal ground or to segregate those with disabilities by not developing accessible technology. Click here to link to the HELP Committee’s website to read testimony from the hearing.

Brain Injury Awareness Day 2012

This year, brain injury awareness day on Capitol Hill will be held on Wednesday, March 21, 2012. As in years past, there will be an awareness fair, briefing and reception. The full schedule for the day is as follows:

10:00 AM - 1:00 PM: Brain Injury Awareness Fair
First Floor Foyer of the Rayburn House Office Building

1:00 PM – 2:30 PM “Anytime, Anyone, Any Age: the Impact on Brain Injury”
Congressional Briefing; Capitol Visitor Center

5:30 PM - 7:30 PM Reception Celebrating Brain Injury Awareness Month
Location to be Announced

BIAA is committed to helping the Congressional Brain Injury Task Force plan a successful event. Stay tuned for more details including a list of speakers for the briefing.

TBI Act Reauthorization 2012

This week, BIAA’s director of government affairs, NASHIA’s lobbyist and staff representing the National Disability Rights Network met with Senator Harkin and Senator Hatch’s staff to discuss TBI Act reauthorization in 2012. BIAA will continue to work closely with other stakeholders as the reauthorization of the TBI Act moves forward.

 Baseline (Step 0): As the baseline step of the Return to Play Progression, the athlete needs to have completed physical and cognitive rest and not be experiencing concussion symptoms for a minimum of 24 hours. Keep in mind, the younger the athlete, the more conservative the treatment.

Step 1: Light Aerobic Exercise
The Goal: only to increase an athlete’s heart rate.
The Time: 5 to 10 minutes.
The Activities: exercise bike, walking, or light jogging.
Absolutely no weight lifting, jumping or hard running.

Step 2: Moderate Exercise
The Goal: limited body and head movement.
The Time: Reduced from typical routine
The Activities: moderate jogging, brief running, moderate-intensity stationary biking, and moderate-intensity weightlifting

Step 3: Non-contact Exercise
The Goal: more intense but non-contact
The Time: Close to Typical Routine
The Activities: running, high-intensity stationary biking, the player’s regular weightlifting routine, and non-contact sport-specific drills. This stage may add some cognitive component to practice in addition to the aerobic and movement components introduced in Steps 1 and 2.

Step 4: Practice
The Goal: Reintegrate in full contact practice.

Step 5: Play
The Goal: Return to competition

The Center for Disease Control espouses that an athlete should be free of symptoms prior to being put back into play.  If symptoms are present, the athlete should not be put back into play for at least 24 hours.  A health care provider should carefully monitor the athlete after injury.

Online training for Health Care Professionals can be accessed here.  Health Care Professionals can access state, league, or sports governing body’s laws or policies on concussion.

Protecting our kids and teens from concussions should be a priority. Check out An International Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.

This sheds new information on the Shaken Baby Syndrome in infants and all the way through childhood.  The changes don't reflect damage to the brain. Rather, the patterns represent the brain's way of adapting to a challenging or dangerous environment. Still, those shifts may come at the cost of increased vulnerability to later stress.

Violence against women in a family also has serious consequences for the children's growth, health, and survival. There are several possible explanations for why violence against a mother can affect her children's health. During pregnancy the fetus grows less, and after birth the mother's mental health is crucial both for her emotional contact with the children and for her ability to care for the children. What's more, women who have been subjected to violence often have weaker social networks and often lack economic resources to seek medical care for their children, for example. This means that the children's health is dependent on the economic resources and the protection that the environment can offer.

Boogaard had chronic traumatic encephalopathy, commonly known as C.T.E., a close relative of Alzheimer’s disease. It is believed to be caused by repeated blows to the head. It can be diagnosed only posthumously, but scientists say it shows itself in symptoms like memory loss, impulsiveness, mood swings, even addiction.

More than 20 dead former N.F.L. players and many boxers have had C.T.E. diagnosed.  Typically they are left in a permanently scarred state in later life.

The issue of repeated trauma is explained in a video.  To read more about this particular case you can read the New York Times Article.

The Center for the Study of Chronic Traumatic Encephalopathy states the following:

Chronic Traumatic Encephalopathy (CTE) is a progressive degenerative disease of the brain found in athletes (and others) with a history of repetitive brain trauma, including symptomatic concussions as well as asymptomatic subconcussive hits to the head. CTE has been known to affect boxers since the 1920s. However, recent reports have been published of neuropathologically confirmed CTE in retired professional football players and other athletes who have a history of repetitive brain trauma. This trauma triggers progressive degeneration of the brain tissue, including the build-up of an abnormal protein called tau. These changes in the brain can begin months, years, or even decades after the last brain trauma or end of active athletic involvement. The brain degeneration is associated with memory loss, confusion, impaired judgment, impulse control problems, aggression, depression, and, eventually, progressive dementia.

 A new paper published in the Journal of Neuropathology and Experimental Neurology suggests head trauma may also lead to a neurodegenerative disorder mimicking ALS.  This paper adds to literature suggesting an elevated risk of ALS in veterans and professional soccer players who have suffered head injuries, and is certain to contribute to the controversy regarding the link between head trauma and ALS. A recent article in the New York Times points out that Lou Gehrig himself may have had this entity rather than ALS.

Researchers at Albert Einstein College of Medicine of Yeshiva University and Montefiore Medical Center, the University Hospital and academic medical center for Einstein, used diffusion tensor imaging, an advanced type of MRI-based imaging technique, as well as cognitive tests, to assess brain function in amateur football players. Their findings indicate the possibility of brain injury from frequently heading the ball.

The Brain Injury Alliance of Oregon is sponsoring  a conference on March 1 to 3, 2012 at the Sheraton Portland Airport Hotel.

I have been involved with this conference and recommend it to those who can attend.

On the particular Friday morning, Sally woke early and stepped out of her small 2 room unit to smoke a cigarette. While standing outside of her unit she was brutally attacked by a trespasser. She does not remember the specifics of the attack but recalls being hit in the face. Her teeth were knocked out and she remembers seeing them with blood pouring out of her mouth while on her knees on the ground.

At the instant she was attacked, Sally’s dog, who was locked in the bedroom portion of the unit with Bill who was sleeping, began barking and trying to scratch her way to where she heard Sally’s attack. This caused the would-be burglars to flee the scene. They were never found or identified.

Budget Suites did not have adequate security. No security cameras, fences, gates, or patrols and only one security officer on the 17 acre campus.

Sally sustained traumatic brain injury and spinal injury in the attack and is permanently unable to walk without the assistance of a walker. Sally and Bill’s lives have been dramatically changed since January 23, 2009.

I became involved in the couple’s case later that year. Budget Suites denied responsibility for the injury and forced the couple to file a lawsuit. The medical bills for Sally exceeded $300,000 and Budget only offered $15,000 to compensate her. The trial began over two and a half years later and lasted five weeks. The couple was awarded over $4,000,000.

Craig Hospital 2012 Brain Injury Summit

A Meeting of the Minds
January 9-11, 2012
Beaver Creek, Colorado

Craig Hospital invites you to join us in one of North America’s most popular winter venues for a state-of-the-art continuing education experience designed for professionals committed to enhancing the lives of persons with brain injury and their families. Please visit the official conference website at:

http://www.braininjurysummit2012.org.

An overview of the course content is to:

• Examine current research on what may be happening to the brain after a concussion
• Understand why young people are at increased risk
• Explore acute concussion assessment and individualized management of young athletes to help prepare for diagnosing and managing concussions
• Learn about the 5-Step Return to Play progression and helping athletes safely return to school and play
• Focus on prevention and preparedness to help keep athletes safe season-to-season
• Receive continuing education credits through the American College of Sports Medicine

To view the course or for more information, visit: www.cdc.gov/Concussion.

Approximately 7.7 million Americans suffer from PTSD, according to recent population-based survey research. The most common causes of PTSD in the civilian sector are motor vehicle crashes and assaults (including domestic violence and rape), with women approximately
twice as likely as men to suffer from PTSD.

Surveys of military personnel returning from deployments to Iraq and Afghanistan find prevalence rates of PTSD ranging from 8% to 16%; it is likely that these rates are underestimates, given the many barriers to reporting mental health problems in the military . Approximately 15% of
these veterans seeking care at Veterans Administration hospitals in the United States have been given a diagnosis of PTSD.

One train of thought says that in order to have post traumatic stress disorder you must remember the traumatic event.  Indeed it is the very memory of the event that causes the post traumatic stress.  Yet others opine that mild traumatic brain injury must involve some loss of consciousness and therefore memory of the event is missing.  Hence you can not have mild traumatic brain injury and post traumatic stress disorder.  However the fact of realizing what happened when revived leaves the post traumatic stress question wide open for discussion.

An estimated 1.5 million brain injuries occur every year in the United States, and over 5 million Americans (2% of the population) live with disabilities resulting from TBI. In the civilian sector, the leading causes of TBI are falls, motor vehicle crashes, struck-by-or-against events, and assaults . Interestingly, motor vehicle crashes and assaults are also two of the most common causes of PTSD in the U.S. civilian population, highlighting the overlap in exposures to TBI- and PTSD-causative events.

In the U.S. military, TBI is the most common type of physical injury sustained by combatants in Afghanistan and Iraq, and explosion or blast injury is the most common cause. In a 2006 survey of more than 2,500 recently returned army infantry soldiers, 5% reported injuries with loss of consciousness during a yearlong deployment to Iraq, and 10% reported injuries with altered mental status. A recent RAND report suggested even higher rates of probable TBI in a 2007 telephone survey of almost 2,000 previously deployed service personnel. A similarly high rate (23%) of clinician-confirmed TBI history in a U.S. Army brigade combat team with at least one deployment corroborates these findings.

 It is important clinically to recognize that both disorders are associated with higher rates of other psychological health problems, including depression, substance abuse, and suicidal behavior in both civilian and military populations . Furthermore, the presence of these comorbid conditions may have an impact on conventional treatments, lending additional impetus to the need to understand these interactions more completely.

This relationship is best understood in the context of both the neuropathophysiology and the typical profile of regional brain injury associated with biomechanical trauma. The disturbance of brain function from MTBI is related more to dysfunction of brain metabolism rather than to structural injury or damage. The current understanding of the underlying pathology of MTBI involves a paradigm shift away from a focus on anatomic damage to an emphasis on neuronal dysfunction involving a complex cascade of ionic, metabolic and physiologic events. Clinical signs and symptoms of MTBI such as poor memory, speed of processing, fatigue, and dizziness result from this underlying neurometabolic cascade.

The relationship is further understood as the psychosocial sequelae that often follow the injury and their attendant effects on social, vocational, and family functioning. Thus, in many ways TBI
is a prototypical neuropsychiatric disorder.

There remains much that is incompletely understood about neuropsychiatric and functional outcome after TBI. Individuals may have disparate long-term outcomes after seemingly similar injuries. Probable contributors to this variance include preinjury host factors, injury-specific
biomechanics, and genetic factors.  Further investigation of these matters is needed to improve our ability to understand, identify, and more effectively treat those individuals at risk for poor outcomes following mild TBI.

Currently, a multidimensional approach is critical to the assessment and treatment of the neuropsychiatric sequelae of mild TBI. The most important initial step is accurate diagnosis, which can be challenging in cases of mild TBI. A combination of psychotherapeutic and
pharmacologic interventions can alleviate many symptoms, and improved quality of life for persons with TBI and their families can be achieved.

Psychiatrists, armed with a neuropsychiatric approach to mild TBI, are critical members of the health care team attending to persons with mild TBI and have an important role in the
management of this significant public health problem.

I typically involve a psychiatrist in the treatment team, along with a neurologist, neuropsychologist, neuroradiologist, and others in my cases.