Traumatic Brain Injury (TBI)

Technology Helps Explain Medication Failure

In almost every area of medicine, doctors can order tests to provide objective physical data to guide their medication selection. However, the practice of psychiatry is most often based on observation, self-report and psychological testing. It appears that we are better at measuring impairment than we are at identifying the source and prescribing an effective medication. Is there a way we can do better?

The director of the National Institute of Mental Health, Tomas Insel, suggests there are many medicines, but they are not working adequately. This is because the symptoms of mental illness are too illusive and are shared by many diagnoses. Insel (2012) says, “It’s much harder to fix something if you don’t know what is going wrong.” Medications are being prescribed to treat a set of symptoms suggestive of a specific disorder without any objective evidence of the cause. Additionally, the practice of polypharmacy has become way too common in children and adolescents.

Pharmaceutical industry advertising promotes adding a medication when the first medication fails to produce the desired results (i.e., adding Abilify to your antidepressant). The message is that when one medication fails, keep adding more in an effort to address the additional symptoms. Each additional medication increases the risk of side effects. It is not uncommon for children to come to us with several medications prescribed. Last month, for example, we saw a 9-year-old female with prescriptions for Olanzapine three times a day, Lithium Carbonate daily and Amphetamine Salts three times a day. Also, a 10-year-old male came to us on Focolin three times a day, Seroquel twice a day, Lexipro daily and Zyprexa daily. If there was a way to determine why a medication failed, would it not be prudent to investigate why? If current technology could help?

House Again Passes Thompson’s Bipartisan Amendment to Improve TBI, PTSD Treatment For Troops & Veterans

Washington, DC, Jul 18 – Congressman Mike Thompson (CA-1), co-chair of the bipartisan Military Veterans Caucus, today again secured the passage of his bipartisan amendment with Congressman Pete Sessions (TX-32) to expedite new and innovative treatments to our nations’ veterans and active duty soldiers suffering from Traumatic Brain Injuries (TBI) and Post-Traumatic Stress Disorder (PTSD). This is the second time the House has passed the amendment. In May, the TBI treatment expansion initiative was adopted as a House amendment to the National Defense Authorization Act (NDAA) for Fiscal Year 2013 (H.R. 4310), however the Senate has yet to take up this bill. Today it was passed as an amendment to H.R. 5856, the Department of Defense (DOD) Appropriations Act for Fiscal Year 2013. The amendment passed by voice vote. The House will vote on H.R. 5856 later this week.

“Our troops and veterans have earned the very best treatment and care that we can provide,” said Thompson. “But sometimes the best treatments aren’t available at military and veteran medical facilities. My amendment will make sure that our heroes who return from combat with TBI or PTSD have access to the highest quality care our nation has to offer. I will keep introducing this legislation until it is law. It’s what our heroes have earned.”

“I am pleased that our colleagues have joined us in recognizing the importance of providing treatment options not currently available within military and veteran medical facilities to those who return from combat with TBI or PTSD,” said Sessions. “As we approach the Memorial Day holiday, I believe we can best honor our nation’s active duty soldiers and veterans by ensuring that their health is a top priority and that they have access to the most effective treatments available.”

Head Impact Exposure in Youth Football

Ray W. Daniel¹, Steven Rowson¹ and Stefan M. Duma¹

(1)	Center for Injury Biomechanics, Virginia Tech-Wake Forest University, 440 ICTAS Building, Stanger St., Blacksburg, VA, 24061, USA

Steven Rowson Email: srowson@vt.edu

Received: 1 February 2012 Accepted: 3 February 2012 Published online: 15 February 2012

Associate Editor K. A. Athanasiou oversaw the review of this article.

Abstract

The head impact exposure for athletes involved in football at the college and high school levels has been well documented; however, the head impact exposure of the youth population involved with football has yet to be investigated, despite its dramatically larger population. The objective of this study was to investigate the head impact exposure in youth football. Impacts were monitored using a custom 12 accelerometer array equipped inside the helmets of seven players aged 7–8 years old during each game and practice for an entire season. A total of 748 impacts were collected from the 7 participating players during the season, with an average of 107 impacts per player. Linear accelerations ranged from 10 to 100 g, and the rotational accelerations ranged from 52 to 7694 rad/s2. The majority of the high level impacts occurred during practices, with 29 of the 38 impacts above 40 g occurring in practices. Although less frequent, youth football can produce high head accelerations in the range of concussion causing impacts measured in adults. In order to minimize these most severe head impacts, youth football practices should be modified to eliminate high impact drills that do not replicate the game situations.

Introduction

Sports related concussions have received increased public awareness, with many states considering or implementing laws directing the response to suspected brain injury. This is a result new research suggesting possible links to long-term consequences from repetitive concussions.13,21,22 Emergency department visits for concussions increased 62% between 2001 and 2009, and researchers estimate that between 1.6 and 3.8 million sports related concussion occur each year in the United States.5,19 Of all sports, football accounts for the highest incidence of concussion, and therefore receives the most attention.34 One of the leading thoughts to minimize the incidence of concussion in football is to limit players’ exposure to head impacts.9 Strategies to reduce a player’s exposure to head impact include teaching proper tackling techniques and modifying the rules of the game.

Electrophysiological assessments of cognition and sensory processing in TBI: Applications for diagnosis, prognosis and rehabilitation

This article from the International Journal of Psychophysiology shows the full acceptance of the use of EP and ERP testing to evaluate TBI. The paper is co-authored from the Defence Veterans Brain Injury Center (DVBIC), and this paper shows none of the quibbling or caveats about a lack of specificity or sensitivity in TBI. It is a paper that looks at full adoption for use, not a call for plenty of more studies and funding!

This ERP technology is ready for prime time in TBI. The peer review and publication process is how science moves forward, and the use of ERP for TBI evaluations is now accepted by the peer review process, but not the EEG/qEEG yet fully, and definitely not EEG based discriminants for TBI, which are now counseled against in the peer reviewed literature.

Jay

ABSTRACT

Traumatic brain injuries are often associated with damage to sensory and cognitive processing pathways. Because evoked potentials (EPs) and event-related potentials (ERPs) are generated by neuronal activity, they are useful for assessing the integrity of neural processing capabilities in patients with traumatic brain injury (TBI). This review of somatosensory, auditory and visual ERPs in assessments of TBI patients is provided with the hope that it will be of interest to clinicians and researchers who conduct or interpret electrophysiological evaluations of this population. Because this article reviews ERP studies conducted in three different sensory modalities, involving patients with a wide range of TBI severity ratings and circumstances, it is dif!cult to provide a coherent summary of !ndings. However, some general trends emerge that give rise to the following observations and recommendations:

1) bilateral absence of somatosensory evoked potentials (SEPs) is often associated with poor clinical prognosis and outcome;

2) the presence of normal ERPs does not guarantee favorable outcome;

3) ERPs evoked by a variety of sensory stimuli should be used to evaluate TBI patients, especially those with severe injuries;

4) time since onset of injury should be taken into account when conducting ERP evaluations of TBI patients or interpreting results;

5) because sensory de!cits (e.g., vision impairment or hearing loss) affect ERP results, tests of peripheral sensory integrity should be conducted in conjunction with ERP recordings; and

6) patients’ state of consciousness, physical and cognitive abilities to respond and follow directions should be considered when conducting or interpreting ERP evaluations.

Clinical Policy Bulletin: Quantitative EEG (Brain Mapping) from Aetna

Recently Released Clinical Policy Bulletin: Quantitative EEG (Brain Mapping) from Aetna

It is no surprise when insurance companies find ways to restrict what they will cover as a service for their clients, whether flood insurance liability insurance, or any other branch of this financial industry. This is especially true for medical insurance companies, which are always finding reasons to restrict payments.

This decision restricts the payment for a qEEG to be an extension of the analysis of an EEG analysis, which makes the qEEG a medical procedure requiring licensure adequate to provide credentials to do a medical EEG interpretation. If further restricts the payments to applications that match the American Academy of Neurology position paper, which approves the technique in vascular cases, encephalopathies such as dementia cases, or for epilepsy, as well as longer term EEG monitoring, where quantitative analysis allows the selection of segments for review visually, assisting the electroencephalographer in eliminating long time segments from detailed analysis.

Specifically restricted from payment are these applications:

Houston’s Tarnow Center offers solution for service members with PTSD

A friend of qEEGsupport.com ( Dr. Ron Swatzyna) was recently featured on a local news station in the Houston area.

HOUSTON – A Houston doctor is working on something that could help the many service members who return from the battle field suffering from post-traumatic-stress disorder.

By its own admission, The Veterans Administration has had little success treating people who are suffering from both traumatic brain injury and post traumatic stress disorder.

“They end up not having any cognitive strategies to manage the therapy, and they’ll either get out of therapy, or end their lives and that’s what’s happening,” said Dr. Ron Swatzyna, a psychotherapist, neuro-therapist, and biofeedback therapist for Houston’s Tarnow Center. “I’ve been working on this issue for about four years now.”

He said resetting the brain, lining it back up through stimulation, is the key. And by mapping the brain, he believes he can tell when the patient is ready for therapy.

“Not at the beginning. If you push them too quick that’s a problem. If they are pushed into therapy too quick,” he said.

Swatzyna said the defense department and the VA both realize more research is needed, and if he can get funding, and cooperation from a group in the Texas Medical Center, he would like to open up a research center in Houston.

Vietnam veteran Billy Miller, who one of Swatzyna’s patients, is now helping him pull it off.

“Everyone I had been to before, all 25 doctors had never had military experience, they didn’t know what I was going through,” Miller said.

Swatzyna was a captain in the Air Force, and now many believe he is the best in the country at understanding veterans.

Army soldier Joel Brasier, who suffers from TBI and PTSD, believes Swatzyna is on the right track and is hoping research will lead to better, faster treatment.

“It’s an ongoing process, but eventually they are going to make a breakthrough and get us the help we need,” Brasier said.

Full story from khou.com

Current Research Regarding Blast Injuries in Veterans

This current research from the New England Journal of Medicine – Detection of Blast-Related Traumatic Brain Injury in U.S. Military Personnel – shows that Blast Injury is not at all like mild traumatic brain injury, since the mTBI does not involve white matter injuries. The research does show white matter changes during the medical evacuation, done in Germany using Diffusion Tensor Imaging, and also that the white matter changes continue to evolve. They also show that not all symptomatic blast injuries are seen with this technique.

No traditional structural neuroimaging was able to see this damage (like CT or routine MRI). The NY Times recently reported on soldiers injuries evading the M.R.I and CT Scans

The brain areas involved included the orbital surfaces of the frontal lobe and the temporal areas.

These results point to the need for a clinical diagnosis, not a reliance on any given technology to answer the clinical question.

The endocrine changes from supposed pituitary injury, and the presence of micro-emboli due to pressure wave impact on the thorax that are reported in blast injury is not at all dismissible with these findings.

Sports Related Brain Injury aka Chronic Traumatic Encephalopathy(CTE)

It is now almost common to hear about athletes who suffered a number of concussions over their careers having some difficulties later in life. The damage can be very serious.

Chronic Traumatic Encephalopathy(CTE) is associated with repeated head traumas — concussions or sub-concussive hits — that are not allowed to properly heal. It is a progressive degenerative disease found in individuals who have been subjected to multiple concussions and other forms of head injury. A variant of the condition, dementia pugilistica, is primarily associated with boxing. CTE has been most commonly found in professional athletes participating in gridiron football, ice hockey, professional wrestling and other contact sports, who have experienced head trauma, resulting in characteristic degeneration of brain tissue and the accumulation of tau protein. Individuals with Chronic Traumatic Encephalopathy may show symptoms of dementia such as memory loss, aggression, confusion and depression which may appear within months of the trauma or many decades later.

A number of athletes have been affected by the condition with serious consequences. Recently a former NFL lineman committed suicide after serious mental decline. His wife said it started with the nightmares and progressively got worse.

Bob Probert’s brain was examined after his early passing at the age and was found to have CTE (read more here).

The American Academy of Neurology (AAN) Position Statement On Sports Concussion

The American Academy of Neurology (AAN)—an association of more than 22,500 neurologists and neuroscience professionals dedicated to providing the best possible care for patients with neurological disorders—is an advocate for policy measures that promote high quality, safe care of individuals participating in contact sports.

Concussion is a common consequence of trauma to the head in contact sports, estimated by the Centers for Disease Control and Prevention to occur three million times in the United States each year. Among people aged 15 to 24 years, sports are now second only to motor vehicle accidents as the leading cause of traumatic brain injury. While the majority of concussions are self-limited injuries, catastrophic results can occur and the long-term effects of multiple concussions are unknown.

Members of the AAN specialize in treating disorders of the brain and nervous system, and some members have particular interest and experience caring for athletes and are best qualified to develop and disseminate guidelines for managing athletes with sports-related concussion. Based on the clinical experience of these experts, the AAN supports the implementation of policy that supports the following recommendations:

Recommendations

Any athlete who is suspected to have suffered a concussion should be removed from participation until he or she is evaluated by a physician with training in the evaluation and management of sports concussions
No athlete should be allowed to participate in sports if he or she is still experiencing symptoms from a concussion.
Following a concussion, a neurologist or physician with proper training should be consulted prior to clearing the athlete for return to participation.
A certified athletic trainer should be present at all sporting events, including practices, where athletes are at risk for concussion.
Education efforts should be maximized to improve the understanding of concussion by all athletes, parents, and coaches.

Position Statement History
Approved by the AAN Sports Neurology Section, Practice Committee, and Board of Directors
October 2010 (AAN Policy 2010-36).

VA Eases PTSD Claims Process

The Veterans Affairs Department has published a final regulation intended to ease the claims process and improve access to health care for veterans with post-traumatic stress disorder. Under the new rule, VA no longer will require substantiation of a stressor tied to fear of hostile military or terrorist activity if a VA psychiatrist or psychologist can confirm that the experience recalled by a veteran supports a PTSD diagnosis and the veteran’s symptoms are related to the stressor. The Veterans Affairs Department has posted a fact sheet including questions and answers about the new rule governing PTSD claims on the VA website or call VA’s toll free benefits number at 800-827-1000