Monthly Archives: August 2010
How Survivors of Childhood TBI Transition To Adulthood
A recent longitudinal study has analyzed the outcomes of employment, secondary education, and independent living for survivors of childhood traumatic brain injury when they transition into adulthood. They wanted to address not only how the young adults fared in each category, but also if there were any specific variables that affected outcome. Some of their results were:
- Higher socioeconomic status was associated with greater likelihood of enrolling in post-secondary education, slower time to reaching employment (possibly because of being enrolled in college programs or because of the ability of family to care for them), but greater eventual likelihood of employment.
- Female pediatric TBI patients were more likely to later enroll in post-secondary education.
- Older age at time of injury was associated with a greater likelihood of enrolling in post-secondary education and successfully managing independent living.
- There was a surprising discovery that those with more severe injuries were more likely to have been employed early after their injuries, which may be attributable to services available to those individual that are not available to survivors with less severe injuries.
Todis B, Glang An, Bullis M, Ettel D, & Hood D. Longitudinal investigation of the post-high school transition experiences of adolescents with traumatic brain injury. Journal of Head Trauma Rehabilitation. (July 2010).
Depression has “additive effect” on mTBI symptoms
Symptoms of mild traumatic brain injury, such as sleep disorders, memory impairment or attention problems, can overlap symptoms of depression. In the forensic setting, the distinction between symptoms of mTBI and depression is a critical one, but diagnostic mistakes can easily be made.
Recently, a study comparing mTBI patients with depression, mTBI patients without depression, and uninjured depressed patients showed that depression has an “additive effect” on the symptoms of mTBI. The researchers originally hypothesized that, based on past research, uninjured people with depression would report a similar level of symptoms as mTBI patients with depression. They were surprised to discover that the symptoms in depressed mTBI patients were both greater in number and in severity than uninjured depressed patients.
In the forensic setting, clinicians who diagnose patients claiming prolonged symptoms of mTBI can now differentiate those symptoms with the symptoms of depression alone by assessing symptom severity and overall number of symptoms.
Lange RT, Iverson G, & Rose A. Depression strongly influences postconcussion symptom reporting following mild traumatic brain injury. Journal of Head Trauma Rehabilitation. (July 2010).
Visual tracking is a practical screening tool for mTBI
A common feature of mild traumatic brain injury is damage to the white matter tracts that connect one part of the brain to another, or diffuse axonal injury (DAI). DAI is difficult to see in the traditional CT or MRI scans, and while it can be detected using newer technology such as diffusion tensor imaging, these technologies are not yet in clinical practice.
A research team recently hypothesized that certain white matter tracts related to eye movement were frequently damaged in mTBI, and that impaired eye movements could therefore be a reliable clinical marker for mTBI. They tested mTBI patients using a visual tracking device, measuring how smoothly their eyes moved to track a target.
Not only did the mTBI patients show decreased performance in the visual tracking task, but that decreased performance was correlated with white matter damage seen in a diffusion tensor imaging scan. The relatively easy to administer visual tracking task could therefore be used in lieu of diffusion tensor imaging in order to detect DAI related to mTBI.
Visual tracking synchronization as a metric for concussion screening. Maruta J, Suh M, Niogi SN, et al. Visual tracking synchronization as a metric for concussion screening. Journal of Head Trauma Rehabilitation. (July 2010).
QEEG in recovery after sports-related brain injury
Recovery from sports-related injury is an issue made complex by the pressure to return the patient to their game. However, we now know that injured brains have a vulnerable window of time in which they can be more susceptible to recurring injury.
Traditional tests of recovery include the subsiding of symptoms and improved performance in neurocognitive assessment. However, a recent study using qualitative electroencephalography (QEEG) has shown that signs of physiological damage may persist even after symptoms subside and cognitive impairments have improved.
The implication of this study is that patients with sport-related brain injuries may be returning to their sport too soon. Considering the window of vulnerability the brain has to recurrent damage, the QEEG—which is a portable, easy-to-use device—can be used as a more reliable marker of recovery.
McCrea M, Prichep L, Powell MR, et al. Acute effects and recovery after sports-related concussion: A neurocognitive and quantitative brain electrical activity study. Journal of Head Trauma Rehabilitation. (July 2010).
A clinical test to help decide whether to order a CT scan or not
S100B is a type of protein found in neurons, as well as other cells outside of the brain. Its role seems to depend on its concentration. Low levels of S100B are found in healthy brains, indicating a supportive role when in low quantity. Levels of S100B rise considerably after brain injury, and may involve a toxic effect to the brain (this is still being studied, however).
A recent study looked at the predictive value of S100B, specifically to discover if the biomarker could be useful in deciding whether or not to use a CT scan in cases of mild traumatic brain injury. The CT scan often fails to show damage in mild cases of brain injury, and can be a costly and potentially dangerous (exposure to radiation) test. Therefore a reliable biomarker could help in the decision process.
The study found that low levels of S100B accurately predicted normal CT scans, implying that low levels could support a decision to not use a CT scan. However, the S100B sample should be drawn within 3 hours after injury and should also be taken into consideration with other symptoms before making a decision to use a CT scan or not.
Unden J, & Romner B. Can low serum levels of S100B predict normal CT findings after minor head injury in adults? An evidence-based review and meta-analysis. Journal of Head Trauma Rehabilitation. (July 2010).
Repetitive transcranial magnetic stimulation (rTMS) improves spasticity after spinal cord injury.
Transcranial magnetic stimulation (TMS) involves a coil that is applied against the head in order to send weak electrical pulses to the brain. These electrical pulses can temporarily activate or disrupt brain activity.
Repetitive TMS (rTMS) involves continuous electrical pulses to the brain and can create long-term changes in the brain. Recently, rTMS was used in a study to treat spasticity (muscle spasms, exaggerated reflexes) in spinal cord injury patients. After five days of daily rTMS treatment (in which the coil was placed over the motor cortex of the brain), the patients saw significant improvement in spasticity, which lasted at least a week after discontinuing treatment.
TMS and rTMS are in the testing phase for therapeutic purposes in several indications. TMS has currently been approved by the FDA for the treatment of depression, and will likely be approved for other uses—such as spasticity—in the near future.
Kumru H, Murillo N, Samso JV, et al. Reduction of spasticity with repetitive transcranial magnetic stimulation in patients with spinal cord injury. Neurorehabilitation and Neural Repair. July 2010.
Federal Medical Assistance Percentage (FMAP) Update
On Thursday, August, 5, 2010, the Senate approved a $26.1 billion state-aid package that will be considered in the House next week. The measure (HR 1586) would extend enhanced federal Medicaid funding to states. Without the extension, the elevated federal funding will expire on December 31, 2010, halfway through the fiscal year for states causing serious budget short-falls.
Approval of this measure is vital to the brain injury community
BIAA August 6 Update
Dear Advocates,
Look for a special appropriations edition of Policy Corner this Friday, August 6, 2010. BIAA will be analyzing the Senate Labor, Health and Human Services, and Education committee report this week and will alert grassroots advocates on Friday regarding the funding status of TBI programs.
Also, this afternoon, the Senate opted to postpone a vote on an amendment which would extend increased Medicaid payments to states. In the next few days Senator Reid is expected to offer a revised version of the legislation. This extension is vital to people with brain injury and BIAA will alert grassroots advocates when action is necessary.
Implicit and explicit memory in traumatic brain injury
Memory is a difficult concept to define. To remember something requires the complex processing of information such as time, place, emotions, or sensory input (sight, smell, sound, touch), in order have the ability to re-create that information at a later time. Scientists have long tried to define memory by using models to describe this process, but some of the most useful memory models have been derived from studies of impaired memory with brain injury patients.
One important theory of memory that has come (at least partially) from brain injury studies, is the model for explicit versus implicit memory. Explicit memory refers to the memories that we can explicitly remember taking part in. For instance, we may have a strong memory of attending a child’s graduation. We not only know intellectually that the child has graduated, we can pull up the specific emotions, sights, smells, sounds, time, and place that color that memory.
Implicit memory refers to a much more subtle process—one that is difficult to observe outside a psychology lab. Implicit memory implies that a person has encoded some information in his brain, but without consciously knowing how. The information has gotten in under the radar, in other words. For instance, a psychology lab can flash words very quickly in front of a subject—too quickly for the subject to even perceive—and the subject will be surprised to learn that he can correctly guess the word, even when he has no memory of even seeing it.
In the traumatic brain injury patient, depending on what part of the brain was injured, explicit memory can be impaired. Amnesia—either the loss of memories from the past or the lost ability to learn new information—can occur because of an impaired explicit memory system. Without a specific recollection of memory detail such as sight, sound, smell, emotion, time, or place, the patient has no context to help anchor a memory into reality.
Strangely enough, however, implicit memories are very often intact in brain injury patients. These patients can perform just as well as healthy people at the quickly flashing words experiment described above. The implication of this is that rehabilitation professionals (and family members) can use the intact implicit memory system to help get new information through to the brain injury patient. By repeating a piece of specific information over and over (ie, “The coffee cups are in the right cupboard.”), the patient may implicitly remember the information, even if he has no conscious memory of learning it.
Baddeley A. Human Memory, Theory and Practice. Psychology Press Ltd. (2002).
Factors in the delay of returning to work after spinal cord injury
There are various factors that influence how and when a spinal cord injury patient returns to work—such as type of pre-injury employment, amount of family support, or years of education. A recent study focused on the factors that influenced the length of delay between the time of injury and the first post-injury job.
The results of this study found that returning to work for the same employer as before the injury shortened the delay of return to work after injury. In addition, having a higher level of education and being Caucasian were factors associated with a quick return to work. Interestingly, when transitioning from first post-injury job to first post-injury full-time job, Caucasian men were more likely to have a quick transition into full-time work after injury. Non-Caucasians, and women took longer to find full-time work after injury.
The implication of this research is that women, non-Caucasians, and people with lower levels of education may find themselves at a disadvantage when finding post-injury work. This can result in longer intervals of unemployment, lower earnings, and greater difficulty in paying medical and rehabilitation bills.
Krause JS, Terza JV, Saunders LL, & Dismuke CE. Delayed entry into employment after spinal cord injury: Factors related to time to first job. Spinal Cord. (June 2010).
