We are now beginning to understand that traumatic brain injury may often include damage to the pituitary gland—a small, pea-sized area of the brain that can easily be sheared or obstructed by the bony cradle it sits in. The result of pituitary gland damage can be hypopituitarism (a condition in which the pituitary gland doesn’t produce sufficient amount of hormones), more specifically, a growth hormone deficiency.

Clinical studies are now underway to determine the various effects of growth hormone replacement therapy on traumatic brain injury. One such study has found that growth hormone replacement therapy for a year can reverse some of the cognitive deficits common to TBI. As compared to the placebo group, patients who received growth hormone replacement therapy showed improvements in memory, information processing speed, motor speed, and executive functioning tests.

Patients did not report negative side effects of growth hormone replacement therapy, even after a year of continued therapy. It may therefore be a viable addition to rehabilitation efforts in the future.

High WM, Briones-Galang M, Clark JA, et al. Effect of growth hormone replacement therapy on cognition after traumatic brain injury. Journal of Neurotrauma. (June 2010).

Among the multiple skills required to drive safely is the ability to visually scan one’s surroundings in order to adapt and respond to unexpected situations. In a study that compared traumatic brain injury patient to controls, subjects were connected to an eye-tracking device that mapped their visual field while completing a driving simulation.

The study found that people with traumatic brain injuries did not explore as many visual areas as the controls. Additionally, these deficits were associated with reduced scores on neuropsychological tests of attention. The study therefore provided an excellent model of how cognitive impairment translates to practical life. When making a decision to return to driving after a traumatic brain injury, neuropsychological tests of attention may be a useful tool.

Milleville-Pennel I, Pothier J, Hoc J-M, & Mathe J-F. Consequences of cognitive impairments following traumatic brain injury: Pilot study on visual exploration while driving. Brain Injury. (April 2010).

A recent retrospective study of cognitive assessment in traumatic brain injury patients found no clear pattern of cognitive ability associated with neurological impairment.

Cognitive assessment—in the form of tests such as the WAIS (in various versions) or the HRB (Halstead-Reitan Neurological Test Battery)—is often administered early to traumatic brain injury patients in order to determine cognitive functioning, diagnosis, and rehabilitation requirements. However, this study concluded that age and employment status was more strongly associated to cognitive assessment results than neurological findings, such as injury severity.

The researchers looked specifically for clear patterns of cognitive impairment —such as lowered cognitive results associated with lowered neurological results. And there were some sub-groups of cognitive testing did show such as association (such as processing speed). However, their overall finding was that demographics played a stronger role in cognitive assessment results than neurological factors.

Goldstein G, Allen DN, & Caponigro JM. A retrospective study of heterogeneity in neurocognitive profiles associated with traumatic brain injuries. Brain Injury. (April 2010).

The area of the brain associated with attention is the frontal lobe, which means that many survivors of traumatic brain injury will experience attention deficits. Attention is important for wide range of self-management—for instance focus, processing speed, or multi-tasking. Attention deficits can therefore slow down rehabilitation efforts and recovery because of the patient’s inability to stay on task.

Rehabilitation specifically for attention deficits has traditionally been cognitive-based and time-consuming. A recent study reviewed the effectiveness of pharmacological treatment for attention disorders in traumatic brain injury patients. They found that only one pharmacological treatment—methylphenidate—was effective, and only for improving processing speed.

There was little evidence that other pharmacological treatments were clinically effective for attention deficits, which suggests that: 1) patients with attention problems may still require time-consuming cognitive rehabilitation, 2) pharmacological treatments should only be considered in patients that do not respond to cognitive treatment, and 3) further clinical studies may be warranted.

Sivan M, Nuemann V, Kent R, et al. Pharmacotherapy for treatment of attention deficits after non-progressive acquired brain injury. A systematic review. Clinical Rehabilitation. (March 2010).

One of the most defining elements of an American’s perception of independence is driving. And yet, when a person suffers from traumatic brain injury, the decision (by both patient and family) to return to driving is a difficult and complex one. Motor and cognitive challenges create a concern for family members, but the independence and freedom that it represents can be a boost to rehabilitation efforts.

In a recent study using a large database of moderate and severe traumatic brain injury survivors, researchers found the following:

1. One year after injury, only 10% of patients had returned to driving. By five years, this number had increased to more than 53%.
2. Those with less severe injuries returned to driving more quickly than those with more severe injuries (usually within a year).
3. Race, employment, education, and residence were also factors in whether or not a patient returned to driving, and when. This suggests that socio-economic factors could influence return to driving.
4. Surprisingly, chemically paralyzed patients (ie, an induced coma) returned to driving more quickly and at a higher rate than other patients.

Although the variables are complex, the decision to return to driving is often made—even by survivors of severe traumatic brain injury.

Novack TA, Labbe D, Grote M, et al. Return to driving within 5 years of moderate-severe traumatic brain injury. Brain Injury. (March 2010).

Recent studies have shown that the pituitary gland is particularly susceptible to traumatic brain injury. Since the pituitary gland is responsible for hormone release, hormone deficiency is a common problem in brain injury survivors.

Growth hormone deficiency is the most common hormone deficiency found after TBI, regardless of severity. Growth hormone deficiency is related to muscle weakness, diminished lean muscle mass, increased fat mass, and reduced bone density. TBI survivors with this deficiency may also experience extreme fatigue, sleep disturbances, metabolic changes, as well as an increased risk of cardiovascular disease and mortality.

In a recent case study of a woman with mild TBI, recombinant human growth hormone replacement was administered for a year. Before the replacement therapy was administered, she had complained of a weight gain of 25 pounds, poor concentration, and fatigue. After the therapy, she showed decreased weight, increased lean mass, decreased fat mass, increased some muscle strength, and improved aerobic capacity.

However, the hormone replacement therapy did not seem to improve her cognitive complaints. Furthermore, the researchers suggested that more significant improvement required a combination of both hormone therapy and physical exercise.

Bhagia V, Gilkison C, Fitts RH, et al. Effects of recombinant growth hormone replacement in a growth hormone deficient subject recovering from mild traumatic brain injury: A case report. Brain Injury. (March 2010).

Skimboarding is a popular water sport that involves “skimming” a wave from shore to ocean. As it has become more competitive and extreme, the risk of injury has increased. Past medical research has shown an increase in fractures and sprains, but a recent study has shown that there is also a significant risk of spinal cord injury.

In a series of case studies from Emory University in Georgia, medical researchers presented three cases of skimboarding accidents that resulted in spinal cord injury. In each case, the patient had flipped his board in shallow water so that his head made contact with the ocean floor. The resulting injuries affected areas C3-C5 and resulted in partial to complete paralysis.

As compared to similar sports, such as traditional surfing, there is a significant risk of spinal cord injury in skimboarding due to the potential for landing head first in shallow water. Skimboarders, their families, and clinicians should be aware of this increased risk.

Collier TR, Jones ML, & Murray HH. Skimboarding: A new cause of water sport spinal cord injury. Spinal Cord. (2010).

The release of stress hormones (such as cortisol or norepinephrine) after a traumatic injury can induce stress hyperglycemia. Past research has shown that this state of elevated glucose has been related to increased medical complications and mortality rates.

A recent study from New York verified that serum glucose levels were useful in distinguishing major from minor traumatic injury at admission. Stress hyperglycemia was a sensitive predictor for major injury (just as sensitive as base deficit or lactate), suggesting that appropriate treatment could be administered earlier. In the early stages of traumatic brain injury, when complications such as secondary brain injury can quickly lead to further damage or death, a reliable diagnosis is critical. Glucose level is a potentially sensitive indicator of major injury that should be considered at admission.

Paladino L, Subramanian RA, Nabors S, Bhadwaj S, & Sinert R. Triage hyperglycemia as a prognostic indicator of major trauma. The Journal of Trauma: Injury, Infection, and Critical Care. (April 2010).

On Thursday, April 22, 2010, the Senate cleared an omnibus veterans’ health care measure that provides important assistance to both veterans and caregivers. S. 1963, as modified by the House, includes nearly $1.6 billion in authorizations for programs designed to aid caregivers of eligible veterans.

The measure, which now goes to the White House for President Obama’s signature, is intended to strengthen the health care support system for veterans and to expand services in rural areas. The measure will also expand caregiver programs, making them eligible for training and education assistance.

The bill also authorizes VA hospitals to contract with non-VA providers, as stated in the bill:

“The Secretary may contract with appropriate entities to provide specialized residential care and rehabilitation services to a veteran of Operation Enduring Freedom or Operation Iraqi Freedom who the Secretary determines suffers from a traumatic brain injury…”

Both BIAA and the Wounded Warrior Project have long advocated for approval of this measure and yesterday’s final passage signified a great victory for service members who suffer from TBI and their families.

Health Care Reform Update

After several weeks of delving into the final text of the health care reform bill, our partners at Powers, Pyles, Sutter & Verville, PC, sponsored by BIAA’s Business and Professional Council, have prepared an analysis http://www.biausa.org/elements/policy/2010/hcr_anayliticalmemo.pdf of the major provisions that impact our community.

BIAA will continue to work to identify and advocate for favorable regulations to ensure access to brain injury care as the process moves forward.

On Thursday, April 22, 2010, the Senate cleared an omnibus veterans’ health care measure that provides important assistance to both veterans and caregivers.  S. 1963, as modified by the House, includes nearly $1.6 billion in authorizations for programs designed to aid caregivers of eligible veterans.

The measure, which now goes to the White House for President Obama’s signature, is intended to strengthen the health care support system for veterans and to expand services in rural areas. The measure will also expand caregiver programs, making them eligible for training and education assistance.

The bill also authorizes VA hospitals to contract with non-VA providers, as stated in the bill:

“The Secretary may contract with appropriate entities to provide specialized residential care and rehabilitation services to a veteran of Operation Enduring Freedom or Operation Iraqi Freedom who the Secretary determines suffers from a traumatic brain injury…”

Both BIAA and the Wounded Warrior Project have long advocated for approval of this measure and yesterday’s final passage signified a great victory for service members who suffer from TBI and their families.

Health Care Reform Update

After several weeks of delving into the final text of the health care reform bill, our partners at Powers,  Pyles, Sutter & Verville, PC, sponsored by BIAA’s Business and Professional Council, have prepared an analysis of the major provisions that impact our community.

BIAA will continue to work to identify and advocate for favorable regulations to ensure access to brain injury care as the process moves forward.