Traditionally, it has been accepted that hyperglycemia (high blood sugar) at the acute stage of traumatic brain injury is associated with increased mortality and poor outcome. It has also, however, been shown that insulin therapy to reduce this hyperglycemia can induce hypoglycemia (low blood sugar), which is also associated with poor outcome.

Researchers recently completed an animal study in order to get a more precise picture of how hyperglycemia affects the brain in both acute and chronic stages of traumatic brain injury. There were three major outcomes:

1. Hyperglycemia at the time of trauma did not increase cortical contusion volume.
2. There was no adverse effect of hyperglycemia on motor skills or memory at the acute stage of trauma. Short-term memory was actually improved.
3. Sustained hyperglycemia reduced cerebral edema. Insulin treatment was detrimental to this neuroprotective effect.

In conclusion, the authors suggested that neither acute nor sustained hyperglycemia negatively affects outcome in TBI. Furthermore, insulin intervention may increase secondary brain injury (edema).

Hill J, Zhao J, & Dash PK. High blood glucose does not adversely affect outcome in moderately brain injured rodents. Journal of Neurotrauma. (June 2010).

Electroacupuncture, which delivers electrical stimulation through acupuncture needles, has long been used for pain relief and stroke rehabilitation. A recent animal study has found evidence that electroacupuncture may also stimulate neuroprotective function after cerebral ischemia (lowered blood flow to the brain).

The researchers found that acupuncture administered to the “Bai hui” and “ Da zhui” acupoints activated astrocytes (a critical support cell in the brain), which in turn reduced neurodegeneration. In addition to a physiological benefit, electroacupuncture was associated with improved motor skills and sensory integration.

Electroacupuncture may therefore be a potentially beneficial clinical tool for the prevention of secondary brain injury, as well as a rehabilitation tool for motor and sensory impairments.

Han X, Huang X, Wang Y, & Chen H. A study of astrocyte activation in the periinfarct region after cerebral ischemia with electroacupuncture. Brain Injury. (May 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).

SPORTS & CONCUSSIONS

What is a Concussion?

Concussions are a type of traumatic brain injury (TBI) caused by a blow or jolt to the head. The injury can range from mild to severe and can disrupt the way the brain normally works.

An athlete does not need to lose consciousness to sustain a concussion.

You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up days or weeks after the injury. It is best to see a health care professional if you think you might have a concussion. An undiagnosed concussion can affect your abilities at school or work and in everyday activities.

Signs and Symptoms of Concussions

• Nausea (feeling that you might vomit)
• Dizziness or balance problems
• Double or fuzzy vision
• Sensitivity to light or noise
• Headache
• Feeling sluggish or tired
• Feeling foggy or groggy
• Confusion
• Trouble concentrating
• Trouble remembering

If you’ve had a concussion

• Never ignore a bump to the head
• Tell your coach or teammates
• Ask to be taken out of the game
• Pay attention to physical changes
• Watch out for thinking problems
• Talk to your parents or teachers about the troubles you are having
• See a health care professional
• Get plenty of rest
• Return to practice and play only after your brain is healed and your health care professional says it’s okay

When Will I Get Better?

Your concussion symptoms can begin to decrease in the first few weeks/months depending on the severity of your injury. You may notice more difficulty in some situations than others. You might get tired after reading, studying or watching TV. It may be harder to do two things at once, such as talking on the phone and working on the computer.

Take things slow and be patient with yourself. Do not participate in contact sports until your health care professional says it is okay.

Did You Know?

• A concussion is the most common type of brain injury sustained in sports.
• Most concussions do NOT involve loss of consciousness.
• You can sustain a concussion even if you do NOT hit your head. An indirect blow elsewhere on the body can transmit an “impulsive” force to the head and cause a concussion to the brain.
• Multiple concussions can have cumulative and long lasting life changes.
• Concussions typically do NOT appear in neuroimaging studies such as MRI or CAT Scans.
• An estimated 1.6-3.8 million sports- and recreation-related concussions occur in the United States each year.
• During 2001-2005, children and youth ages 5–18 years accounted for 2.4 million sports-related emergency department (ED) visits annually, of which 6% (135,000) involved a concussion.
• Of the 1.4 million traumatic brain injuries sustained by children and adults in the United States each year, at least 75% are mild and/or concussions.
• Among children and youth ages 5–18 years, the five leading sports or recreational activities, which account for concussions, include bicycling, football, basketball, playground activities, and soccer.

The association of a positive blood alcohol level (BAL) and the outcome of traumatic brain injury has recently become a controversial one. Different clinical studies have shown both positive and negative outcomes of brain injury when a positive BAL is present. Although alcohol intoxication increases the risk of brain injury, disability, and mortality, there is some evidence that, in some cases, a positive BAL may contribute to positive outcomes after the injury. Some studies have reported neuroprotective effects of low or moderate levels of alcohol.

Researchers from the University of Southern California recently looked specifically at the effect of a positive BAL in cases of isolated severe traumatic brain injury. Cases of severe brain injury in which there was a positive BAL at intake were compared to those in which there was no or low BAL. They found that the relative risk of mortality was lower in those cases that had high levels of alcohol in their blood than those who had no or low levels.

This difference was only found when the most critically injured patients with major complications were excluded. When the critically injured patients were included in the analysis, there was no difference in mortality between patients with high, no, or low BAL. Therefore, while this study supports the idea that alcohol may contribute to a positive outcome after injury, the risk of death from critical injuries when alcohol is present is still significant.

Talving P, Plurad D, Barmparas G, et al. Isolated severe traumatic brain injuries: Association of blood alcohol levels with the severity of injuries and outcome. The Journal of Trauma Injury, Infection, and Critical Care. (February 2010).

BIAA and our friends at the Wounded Warrior Project are currently working towards enactment of legislation establishing a national program to provide training and critically-needed supports to family caregivers of veterans living with traumatic brain injuries and other severe wounds.

Reported in the Senate, S. 801, the Caregiver and Veterans Health Services Act of 2009, would provide comprehensive supports for caregivers of veterans who sustained severe injuries after September 11, 2001. The bill has been approved by the Senate Veterans Affairs Committee and is awaiting floor action.

To take action and support this bill, click on the link below to be directed to our legislative action center!

http://capwiz.com/bia/home

As reported in an earlier edition of Policy Corner, BIAA submitted comments to the National Institute on Disability and Rehabilitation Research (NIDRR) in June specifically regarding the fourth priority included in the proposed plan for the Rehabilitation Research and Training Centers (RRTCs) entitled, “Developing Strategies to Foster Community Integration and Participation for Individuals with Traumatic Brain Injury.”

BIAA expressed strong support for the inclusion of a brain injury related research priority. However, BIAA also detailed some concerns related to the strategies used in the priority to foster community integration and participation for affected individuals. As proposed, this priority would develop a classification system based on symptoms experienced by individuals with TBI who are living in the community.

BIAA explained that no two brains are alike and each and every individual presents with different symptoms, and each injury results in different challenges. Therefore, trying to categorize these injuries could be counterproductive to the priority’s goal.

In response to BIAA and other stakeholders who also submitted concerns, NIDRR has revised some of its proposed priority to reflect the suggestions that were offered. The discussion and changes made by NIDRR in response to the stakeholder comments are:

Discussion: “NIDRR agrees that there is a great need for community integration and participation (CIP) interventions in TBI. Our reading of the research literature suggests that better characterization of symptom variations within research samples might contribute substantially to improved accumulation of knowledge regarding the effectiveness of interventions. In response to the concerns of commenters that it would be difficult for one RRTC both to develop and test interventions and to develop a TBI classification system, we reordered the priority requirements to emphasize the testing of interventions and we eliminated some of the prescriptive requirements related to the development of a TBI classification system. Although we reduced the number of requirements for the development of a TBI classification system, we expect applicants to propose and justify the steps they will take to accomplish this task. The peer review process will determine the merits of each proposal.”

Changes: “We have revised the priority by reordering the priority requirements, eliminating the requirement for expert input into the classification system, and eliminating the requirement for the development of a manual for use of the classification system. Also, in response to this comment and related comments, discussed below in greater detail, we have revised the priority by decoupling the testing of interventions from the classification system, eliminating the
numerous examples of symptoms, eliminating the requirement for a short version of the classification system, and eliminating the requirement for a literature review.”

BIAA is thrilled to see these changes implemented and will continue to monitor the process going forward. For further reading click on the link below:

http://edocket.access.gpo.gov/2009/E9-17924.htm

Health Care Reform remains in a holding pattern as Senate Finance Chairman Max Baucus announced this week that his Committee would not formally consider health care legislation until after the August recess.

In tandem, the House has also alluded to the fact that their bill will be postponed until September as moderates and liberals from the Energy and Commerce Committee continue to work towards a compromise.

BIAA will continue to monitor new information throughout the August recess.

Leading medical experts at the Sports Legacy Institute (SLI), a nonprofit educational and research organization dedicated to advancing understanding of the long-term effects of brain trauma, announced Tuesday, June 23, 2009, that they have launched the SLI Military Living Donor Registry, a brain and spinal cord donation registry for active and veteran members of the United States military.

In conjunction with The Boston University Center, the Sports Legacy Institute will compare findings from the brains of military personnel with those from their athlete program, which has signed up more than 120 donors in less than a year, and other brain banks around the world.

Col. Michael S. Jaffee, national director of the Defense and Veterans Brain Injury Center, said the Defense Department supported the spirit of the research and could assist in approaching active and retired soldiers to register for brain donation.

BIAA enthusiastically supports this initiative and will continue to advocate on its behalf. For further reading, click on the link below to view the New York Times article: (The official press release will be available shortly on BIAA’s web site: www.biausa.org )

This week Congress leaves for the July 4th recess in the midst of the Heath Care Reform debate. At this time, both the Senate and the House of Representatives is engaging in talks over draft proposals with the hopes of bringing one collective measure to a final vote this fall. BIAA will continue to monitor the situation closely and advocate for the provisions essential to the brain injury community.