Coping with the negative effects of traumatic brain injury is an important aspect of a person’s ability to rehabilitate, as well as adapt to a changed lifestyle. There are different coping strategies that a patient can use. One is to actively confront a challenge by gathering information, cultivating skills, or changing a situation in order to adapt. Another, more passive, coping strategy is to regulate one’s emotional response to a challenge by suppressing negative thinking, distracting one’s thoughts, or learning to accept a negative situation.

A recent study found that people who used a passive coping strategy had a greater number of subjective complaints, and were less likely to seek social support to help with their challenges. People whose injury had occurred a long time before were more likely to use a passive coping strategy, suggesting that, over time, people may stop actively trying to change their situation and instead enter a more passive, emotion-based frame of mind.

Additionally, people with higher education more readily used active coping strategies in order to directly deal with their challenges, and people with lower levels of education tended to use passive coping strategies. Since passive coping strategies tend not to be as effective as active coping strategies, rehabilitation professionals might consider guiding their patients towards more active participation.

Wolters G, Stapert S, Brands I, & van Heugten C. Coping following acquired brain injury: Predictors and correlates. Journal of Head Trauma Rehabilitation. (July 2010).

This week, BIAA joined Congressman John Adler in support of a bill that would ensure a method be in place when applying for Federal or Private student loans to designate who will make decisions on your behalf regarding all medical, financial, and legal matters in the event you are catastrophically ill, catastrophically injured, temporarily disabled, permanently disabled or deceased.

On June 17, 2004, 23 year old Christopher Bryski fell forty five feet to the ground in a recreational accident.  He sustained a severe Traumatic Brain Injury and was in a coma for approximately 4 weeks.  After emerging from the coma Christopher remained in a persistent vegetative state for almost two years before passing away on July 16, 2006.

At the time of Christopher’s accident, he was in his third year of academic study at Rutgers University and needed to supplement his federal student loans with a private alternative education loan through a private lender, in which his father was a co-signer and is still liable after his death for the amount of the loan.

The bill introduced by Congressman Adler would address this important issue for parents and caregivers in the following ways:

Any private educational lender (i.e Citibank, Wells Fargo, Chase, PNC, etc.) shall:

• Discuss with the student and the cosigner of the loan the benefits of creating a power of attorney, in the event of the death of incapacity of the student or cosigner
• Define clearly and concisely the obligations of the cosigner, including the effect of death or incapacity of the student or cosigner
• Discuss with the student and the cosigner the benefit of credit insurance in connection with the loan, however the private educational lender may not require credit insurance or deny a loan on the basis that the borrower or any cosigner has not obtained credit insurance
• Gives power to the Federal Reserve to define death or incapacity in conjunction with the Secretary of Education and institute standards regarding the borrower’s or cosigner’s obligation if the borrower or cosigner were to die or become incapacitated
• Federal PLUS Loans and Federal Consolidation Loans:
• Discuss with the prospective borrower the uses and benefits of creating a durable power of attorney in the event of the death or incapacity of the borrower or the student on whose behalf the loan is borrowed by the parent borrower
• Amends Entrance Counseling requirements for Federal Loans:
• Provide information during entrance counseling that describes the loan discharge rules in the case of death of disability, and the possibility that private loans may not be discharged upon death or disability
• Provide information with respect to creating a durable power of attorney and its benefits and uses

On May 5, 2010, The Senate Veterans Affairs Committee held a hearing examining the efforts of the Department of Veterans Affairs in responding to the rehabilitation needs of veterans with TBI since the passage of the TBI-related provisions as part of the National Defense Authorization Act of 2008.  BIAA passed its slot to testify to the Brain Injury Association of Michigan (BIAMI) because of their in-depth involvement with the veteran population in Michigan.

Mike Dabbs, President of BIAMI, testified about the need for an increased public/private partnership between the VA and private health care providers in order to insure that veterans can access the best care possible.  For further reading, the full testimony is available on BIAMI’s Web site.

As many of you know, this hearing comes after the Veterans’ Health Care Authorization Act that was cleared last month.  Because of the specific language in the bill regarding veterans with brain injury and access to non-VA providers, in which BIAA and the Wounded Warrior Project advocated for tirelessly, BIAA is hopeful that the provisions in the bill as well as the outcomes of the May 5^th hearing will serve to dramatically increase access to care for the veteran population across the country.

Although it is not completely understood why, cases of mild traumatic brain injury are more often associated with new-onset depression than those of moderate or severe traumatic brain injuries. Studies have shown that rates of depression prior to injury are associated with rates of depression after injury, but the risk factors for those who have never experienced depression prior to the injury have not previously been made clear.

In a preliminary study, researchers recently found that there were two significant indicators of new-onset depression in cases of mild traumatic brain injury. These indicators were increased age (in relation to the controls, not necessary a certain age) and the presence of a subdural lesion in the left frontal lobe. The prevalence of new-onset depression was 18% and was found up to a year after the trauma.

These two indicators could help identify high-risk individuals so that proper treatment could be administered earlier.

Rao V, Bertrand M, Rosenberg P, et al. Predictors of new-onset depression after mild traumatic brain injury. The Journal of Neuropsychiatry and Clinical Neurosciences. April 2010).

Serum S-100B is a type of protein that is related to glial cells (a type of cell that helps regulate and support neurons). Past studies have shown that an increase in S-100B is a sensitive indicator of brain injury in adults.

Evaluating mild traumatic brain injury is difficult in any situation, but it is especially so with children. There are increased complications with obtaining a CT scan, and it is challenging to obtain an accurate history or reliable measures of cognition.

A recent study in Sweden has shown that testing for S-100B is an accurate and reliable tool for determining mild traumatic brain injury in not only adults, but also children. Levels of S-100B can be easily obtained using urine or serum samples. Although the study used a cutoff time of six hours after injury to obtain a sample, the researchers suggested that by testing both urine and serum samples for S-100B, a reliable measurement might be obtained up to 24 hours after the trauma.

Although larger clinical studies would verify cutoff levels and times, it is useful to know that a sensitive marker could predict traumatic brain injury in an otherwise challenging population.

Hallen M, Karlsson M, Carlhed R, et al. S-100B in serum and urine after traumatic head injury in children. The Journal of Trauma: Injury, Infection, and Critical Care. (April 2010).

A ketogenic diet (high fat, low protein and carbohydrates) can make significant changes to the way the brain metabolizes energy. It is well known that the ketogenic diet can reduce seizure activity, and more recent research has suggested that it also increases neuroprotective effects in brain injury.

In one animal study, the administration of a ketogenic diet after traumatic brain injury showed a reduction in secondary brain injuries such as neuronal death and brain edema (swelling). Secondary brain injuries can often cause more damage than the primary injury, and much brain injury research has focused on the reduction of these secondary processes.

A research review of the relationship between the ketogenic diet, the protein adenosine, and brain activity illustrated the metabolic process in which ketosis may effectively treat brain disorders. Ketosis can increase ATP and adenosine, both of which are important elements of brain activity. This change in brain activity could not only increase neuroprotective factors and decrease seizure activity, but also improve sleep quality, alleviate pain, and reduce rates of diabetes.

Although we still need clinical research in humans to verify the benefits of a ketogenic diet for traumatic brain injury, there is potential for a wide-range of benefits from a relatively simple therapy.

Hu Z-G, Wang H-D, Qiao L, et al. The protective effects of the ketogenic diet on traumatic brain injury-induced cell death in juvenile rats. Brain Injury. (May 2009).

Masino SA, Kawamura Jr. M, Wasser CA, Pomeroy LT, & Ruskin DN. Adenosine, ketogenic diet and epilepsy: The emerging therapeutic relationship between metabolism and brain activity. Current Neuropharmacology. (September 2009).

Post-concussive syndrome, or mild traumatic brain injury, often presents as a complex tangle of symptoms. Untangling these symptoms into more precise and reliable categories has been a challenge for both researchers and clinicians. In research, having reliable categories of symptoms would help to better differentiate those who are injured and those who are not. When research results are more reliable, the chance of developing effective treatments is more likely. And in a clinical setting, the challenge of educating patients and their families could be improved by using a simpler, more consistent outline of symptoms.

The Neurobehavioral Symptom Inventory (NSI) is a 22-item assessment commonly used to determine mild traumatic brain injury. Symptoms such as “Decision making difficulty” or “Change in taste/smell” are rated on a scale of 0-5. Government researchers from the National Institute of Mental Health and Veterans Brain Injury Centers across the country recently found that clustering these 22 symptoms into three general categories was a more efficient and practical use of the NSI.

The symptom categories they found to be most useful were: somatic/sensory (such as hearing loss or numbness), affective (such as anxiety or depression), or cognitive (such as memory loss or slowed thinking). By structuring symptoms into these three major categories, researchers might conduct more reliable studies and clinicians could more easily educate patients and their families.

Structuring symptoms into major categories helps to organize the understanding, interpretation, and education of the complex symptoms of mild traumatic brain injury.

Caplan LJ, Ivins B, Poole JH, et al. The structure of postconcussive symptoms in 3 US military samples. Journal of Head Trauma Rehabilitation. (March 2010).

It is estimated that nearly one-quarter of deployed service members have sustained a traumatic brain injury, with mild brain injury being the most diagnosed severity. A short screening assessment that is given to service members after deployment has been used to identify the presence of mild traumatic brain injury, and has helped to identify many injured individuals. However, it has not been effective at singling out symptoms from brain injury when there is a potential for post-traumatic stress, pre-existing psychological conditions such as depression, or other co-morbid symptoms such as insomnia or pain. And this has become a challenge for military researchers and clinicians.

The challenges of screening for mild traumatic brain injury in the military are similar to the challenges found in the civilian population. Dr. Grant Iverson, a member of the Defense Health Board, recently recommended some changes to the military screening assessment. Some of his recommendations are also applicable to the civilian population.

For example, loss of consciousness is impossible to verify or quantify unless there was a witness to the event. Another screening item that asks whether an individual was “dazed or confused,” is problematic because it fails to determine if the confusion came from a concussion, stress, or other physical injury.

With many millions of dollars currently being spent on military-related traumatic brain injury research, it would be wise for civilian researchers, clinicians, and other professionals to follow and adapt to any updates in military screening and diagnostic practices.

Iverson GL. Clinical and methodological challenges with assessing mild traumatic brain injury in the military. Journal of Head Trauma Rehabilitation. (April 2010).

Don’t forget that this year’s Brain Injury Awareness Day on Capitol Hill is set to take place on March, 17, 2010. For those of you who are participating and have made appointments to speak with your members of Congress, there will be a “home base” set up on the 4th floor of the Rayburn Building (rm. 2456) between 11:00 am and 2:00 pm for you to congregate between appointments and also to pick up any materials you may need. If you have any questions, feel free to contact Sarah D’Orsie, sdorsie@biausa.org, BIAA’s Director of Government Affairs.

Below is the schedule of events for the day:

10:00 AM – 1:00 PM – Brain Injury Awareness Fair, First Floor Foyer of the Rayburn House Office Building

2:30 PM – 4:00 PM – Briefing: “From the Playground to the Pros: A Heads-Up on

Concussion”, Capitol Visitors Center – Congressional Meeting Room South

5:30 PM – 7:30 PM – Reception Celebrating Brain Injury Awareness Month, First Floor Foyer of the Rayburn House Office Building

Hope to see you there!

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).