Once common treatment of concussion

Head injuries at the time were treated as mere nuisances. Players reacted to violent head blows by trying to blink away their blurred vision, shake the ringing from their skulls, and trundle back to their huddles, unless they were flagged by sideline doctors. Even then, they generally returned quickly to action.  Boston Globe October 2017
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Neurological trauma and enduring change in survivors

Westborough, MA December 18, 2017 The British Medical Journal Lancet recently published a series of articles describing the long-term effects of brain trauma. The series is worth a serious read for those who are in the position to take care of trauma patients.

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There has been little change in our approach to handling the individual grind of caring for the TBI patient I must sadly admit.  Young and old it takes both patience and dedication to achieve the best outcomes with those we bring into our treatment continuum. “Survivors experience a substantial burden of physical, psychiatric, emotional, and cognitive disabilities, which disrupt the lives of individuals and their families, and pose huge costs to society” according the Lancet, 2017.  Many readers have read my post Updates in these pages where I have detailed well-known athletes like Formula 1 car driver Michael Schumacher and Mike Towell, the Irish boxer both of whom were seriously injured from TBI.  Towell died from injuries linked to second impact syndrome following a match in 2016.
Schumacher remains in a minimally conscious state in Switzerland.  He is conscious but does not speak or move about.  He requires 24 hour medical care and is living is a special suite adapted in his home that allows him to continue to receive the best care possible while being in his familiar setting surrounded by family and friends.  The cost of his care exceeds $ 100,000 per month.
Some reports suggest Mr. Trowell had sustained a brain injury in the early rounds of the fight.  “Essentially, “second impact syndrome” or SIS results from the brain’s inability to autoregulate cerebral perfusion pressure and swelling as a result of repeated cerebral trauma.” Sefton, 2016 on second impact syndrome and Mike Trowell
Autonomic regulation is the role of the brain stem that maintains the diurnal pattern of arousal for wakeful activity and sleep hygiene.  The brain stem regulates heart rate and respiratory drive as well.  These functions are vital to survival and comprise the autonomic nervous system.  The ANS functions as the brain and body’s alarm system signaling the need for fight-flight activation according to a Autonomic Storming post by Michael Sefton, Ph.D.
Lancet identifies the complexity of TBI and its multifactorial underpinning.  A growing number of patients are elderly that contribute to “heterogeneity of outcomes and consider ways forward for targeted management of severe TBI in the intensive care unit” as mentioned in the 2017 Lancet summary.  Improved management of TBI in the trauma centers and ICUs bring forth better rehabilitation candidates and better outcomes including return to home and eventually return to preinjury employment for many.  Surgical intervention crafted to decrease secondary injury to brain have been enhanced by improved diagnostic accumen, imaging and novel techniques such as radical craniectomy and cranioplasty for management of intracranial pressure and its associated edema.
The series also explains PSH or “autonomic storming” something that I have described in several posts and can be quite serious both in the trauma canter and later in the rehabilitation hospital   “Geert Meyfroidt and colleagues provide an overview of paroxysmal sympathetic hyperactivity, a consequence of acute brain injury, and discuss the promise of improved characterization and implications for management”. Damage to the system that regulates sympathetic and parasympathetic functioins due to traumatic brain injury can be unsettling for familiy members and clinicians alike. The recovering subject can have wild swings of autonomic arousal such as elevated heart rate – patients sometimes chug along at 140-160 while autonomic storming.  Paroxysmal changes in blood pressure may pose significant risk, respiratory rate may become tachypnic, patients frequent are febrile and may become excessively sweaty  as a consequence of autonomic dysfunction.  Patients in our rehabilitation frequently undergo repeated blood cultures and lab studies looking for a source of infection.  Many are returned to the trauma centers for additional brain imaging studies and cardiac monitoring that takes hours and is often unneccessary.  These procedures delay recovery and add confusion to the patient and his family.
The regulation of the secondary injuries such as paroxysmal sympathetic hyperactivity is essential for patient well-being and outcome measures including returning home and re-entering the work force. The Lancet series is a well written update on current brain injury treatment and management of this serious public health threat.

 Lancet Neuology (2017) Jun;16(6):452-464. doi: 10.1016/S1474-4422(17)30118-7. Traumatic Brain Injury. Taken 12-18-2017.

Clock of the Week – September 25, 2017 Micrographia

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Clock of the week drawn by 79-Y/O male with bilateral embolic CVA (note size approximately 8 mm)
WESTBOROUGH, MA September 25, 2017 This clock is unique simply on the basis of it’s size.  The scale below the 3 clocks is used for measuring wounds.  It was given to me by the certified wound care specialist here at Whittier.  The top clock was the “finished” product.  One can see all the numbers were written and there was a series of hands drawn that appear as scribble moving from left to right.  The numbers fall outside of the circle – drawn by the patient.  You can appreciate what effort went into the clock as small as it was – only 8 millimeters across.  Micrographia is a term given to drawings that are tiny – a syndrome often assigned to dysfunction in the frontal lobe of the brain.  Just to be sure, I consulted with Lezak – 3rd Edition.  Micrographic written output is seen in patients with Parkinson’s Disease. In another blog published in 2016, I shared a similar clock and describe this interesting syndrome.

Clock of the Week

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Dr. Michael Sefton at Boston Museum of Fine Arts
WESTBOROUGH, MA September 15, 2017  Much has been published about the utility of the clock drawing in making preliminary assumptions about the cognitive health of an individual who may be referred for neuropsychological assessment.  I use it all the time and those of you who have submitted clocks for publication here agree with my assumptions.  The photograph at the left was taken at the Boston Museum of Fine Arts by a colleague Dr. David Kent, a neuropsychologist from Worcester, MA. There are several posts that identify some of the literature behind the assumptions I make about clock drawing and cognition.  Here is another link: Clocks and cognition

 

 

Click and see the interesting “Clock of the week

The results of postmortem examination of over 100 brains of NFL athletes are in

WESTBOROUGH,MA July 25, 2017 The laboratory at the Boston University School of Medicine has recently completed its initial examination of over 100 brains donated by the family members of those athletes who have died because of marked behavior and personality changes attributed to playing football.  The results confirm the presence of destructive proteins that have come to be known as chronic traumatic encephalopathy.  This was first reported over 10 years ago and was featured in the movie Concussion released in 2015 starring Will Smith as Bennet Omalu, M.D. who first reported on the syndrome.

Multiple Sclerosis: And it’s insidious impact on thinking

WESTBOROUGH, MA May 15, 2017 Multiple Sclerosis is a demyelinating disorder that affects the brain and spinal cord of those so afflicted. MS is a disease that causes the immune system to attack the protective covering around the nerve fibers (Reference.com). Many of the nerves in the brain and spinal cord are covered with a myelin sheath – something like insulation on wire.  This permits the instantaneous transmission of nerve impulses from one part of the body or brain to another. In patients suffering with MS their myelin is deficient sometimes having reduced efficiency or not working at all. It is a condition that for many gets better and gets worse.  As you can see from this image taken from Google images the myelin sheath is the outer layer or membrane of fatty Schwann cells and other neuroglial support cells. MS may be linked to a virus and/or immunological compromise but its true etiology is not known.
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Google images
We see a fair number of persons afflicted with M.S. in the rehabilitation hospital here in Massachusetts. MS is known to be relapsing and remitting in its quality which adds to treatment complexity and frustration for patients. They are a fiercely independent group of people and I can certainly understand why that might be.  On some days they are able to get themselves out and into their cars for the drive to work something we might take for granted.  While on other days, they may have difficulty putting on their their shoes and making lunch.  Many are frustrated and angry that they cannot take care of themselves and sometimes wind up in our hospital getting physical therapy and other restorative therapies.  Aquatic therapy is a great resource we offer at Whittier in Westborough, MA.  I encourage people to become familiar with aquatic programs
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Clock drawing by patient with early onset MS
in their area. They can provide support, pain management and effective physical therapy for those who may have limited energy resources.  Fatigue becomes a problem in nearly all patients who suffer with multiple sclerosis.  Cognitive changes are common in patients who experience long-term MS that sometimes make subtle changes in personality and all higher order problem solving, reasoning, and other executive functions.  Some believe there are distinct personality features in those with MS
In addition to frustration and anger, some patients are resistant to restorative solutions suggested by rehabilitation team members who want to help.  Some say “they want to do things their way” and resist rehabilitative suggestions that might offer energy conservation strategies or innovative methods for greater independence.  Medication is used to reduce inflammation associated with MS and prevent relapse.

Reference.com. (2017) https://www.reference.com/health/treatments-multiple-sclerosis-2ed87c70dcd71896. Taken May 6, 2017

What happens to the brain when concussed? See for yourself in CDC video just published

WESTBOROUGH, MA April 21, 2017  There has been a great deal of research published recently about the cumulative impact of concussion.  Every athlete who experiences a concussion has a unique trajectory toward recovery.  It is well-known that athlete’s who experience  a second or third concussion may be at risk for long-term cognitive symptoms unless they rest until the symptoms are fully resolved. It is now expected that each recovery is different and should be tailored for the presenting symptom profile and the athlete’s medical history. A combination of rest and controlled exertion seems to work best for recovery.  Balance and vestibular changes from concussion require physical therapy in the days after injury. We offer these services at Whittier Rehabilitation Hospital. In cases of second or third concussion the recovery can be very different and often prolonged.
There are dozens of You Tube videos that I have posted in these pages illustrating the brain as it becomes concussed. On my first website nearly 20 years ago I purchased a .gif program to illustrate the movement of the brain during a concussion – like the one below.  It cost me nearly $100 to download and post on my website.  Now they are available free of cost and easily posted to social media.
A concussion is a traumatic brain injury resulting from force causing energy to pass through the brain resulting in the brain shaking within the skull.  A study published in January 2016 in the Journal of Pediatrics suggests that preadolescent boys are at higher risk of concussion when playing on varsity ice hockey teams.  The study at Hasbro Children’s Hospital in Providence, RI also suggested that girls playing ice hockey who are heavier may be at greater risk for concussion.  On average, the preadolescent boys in the study took 54 days to become symptom free.
Here is a link to another very useful video produced by a Canadian physician Dr. Mike Evans. I often have families watch this 10 minute video before initiating our conversation.  The point is that the brain is seriously impacted by energy pulsating through the skull from whatever cause.  I have seen several snow boarders this winter. Spring sports usually see an uptick of concussions in lacrosse and girl’s softball.  Concussion can be expected to effect all cognitive functioning including concentration, speed of mental processing, problem solving, memory, and behavior.