Therapists Try To Find Ways To Help Married Couples Cope With TBI

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Posted on 12th January 2012 by Gordon Johnson in Uncategorized

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I’m been working on a career-capping passion project: Conducting video interviews of those who have suffered traumatic brain injury, as well as their families.

One of the sad refrains I hear again and again, and have heard throughout my many years working as a lawyer,  is that they — TBI victims and their loved ones — want things to be the way they were before the car accident or fall or surgery or bomb blast or whatever that caused their injury.

In some cases, that happens. In most, it does not. 

A few days ago it was the first anniversary of the horrendous supermarket massacre in Tucson,  where Congresswoman Gabrielle Giffords was shot through the head. While Giffords has made amazing progress, it’s doubtful she will ever be the same person she once was. Yet her husband, ex-astronaut Mark Kelly, remains at her side.   

 What is their marriage like now?

The New York Times Tuesday did a fascinating story on the impact, and strain, that life-changing TBI puts on what was once marital bliss. The headline was “When Injuries To The Brain Tear At Hearts: Marriage Counseling Is Evolving To Help Couples Survive Personality Changes And Physical Challenges.” 

http://www.nytimes.com/2012/01/10/health/when-injuries-to-the-brain-tear-at-hearts.html?scp=2&sq=brain%20injury&st=cse

The Times story said, “Contrary to conventional wisdom, many relationships do survive  after a spouse suffers a brain injury.”  In fact, the paper claimed that research indicates that the divorce rate was 17 percent for couples where one spouse had TBI, a statistic that’s below the national average.

But researcher and psychologist Jeffrey Kreutzer of Virginia Commonwealth University in Richmond put a  damper on that good news.  He told The Times that the quality of the relationships two people once had can be “seriously diminished.” Wives and husbands can feel like they are living with a stranger because of the profound impact of brain injury. 

Kreutzer is part of a group of therapists at Virginia Commonwealth who are trying to tailor marriage counseling to couples impacted by TBI.

The story offers two cases studies: One of a couple where the wife is struggling to cope with her husband’s personality changes and depression, and a second couple that seems to be adapting fairly well to the husband’s TBI.     

It circles back to what I said at the beginning of this blog, that most people with TBI will never be the same as they were before their injuries, and that the emotional tenor of their relationships will likely not stay the same.

Kreutzer’s role “means teaching uninjured spouses to forge a relationship with a profoundly changed person — and helping injured spouses to accept that they are changed people.”

The idea is to keep people looking to the future, not the past.

I wish Kreutzner and his colleagues success in their work, helping troubled couples impacted by TBI.


Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

Wisconsin Study Finds Violent Video Games Cause Brain Changes

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Posted on 4th December 2011 by Gordon Johnson in Uncategorized

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Here’s another study that can add fuel to the debate on whether violent video games make real violence less horrific  to those who play them.

The latest research, which was unveiled last week at a meeting of the Radiological Society of North America, is being done at the University of Wisconsin-Madison. The study found that “regularly playing a violent video game for a week lead to brain changes seen in MRI scans that researchers say may desensitize young men to violence,” the Milwaukee Journal Sentinel reported Thursday.

http://www.jsonline.com/features/health/playing-violent-video-games-leads-to-brain-changes-researchers-find-f237mpc-134833403.html

The issue is whether playing violent video games changes, and has a negative impact, on the minds of those who play them.

The study used 22 men aged 18 to 29 who did not play video games. They were split into two groups, with one group assigned to play a violent video game 10 hours a day over a week and a control group that didn’t play any games, according to the Journal Sentinel.

When the week was finished, both groups had MRI scans while they were given word, some of which related to violence, the Journal Sentinel reported.

The test group that played the violent video games “showed much less activation in areas of the brain involved in controlling emotion and aggressive behavior,” the newspaper wrote. The men that were in the control group didn’t’ exhibit any changes in their brains.

There is a bit of good news here. When the group that played the games stopped them for a week, their brains returned to the baseline level of before the test started.

MRI’s gauge changes in blood flow, and the less blood that goes to an area of the brain means less engagement of those brain cells. So some would make the argument that “that lack of brain activation to violent words suggests a desensitization to violence,” one of the study’s co-authors told the Journal Sentinel.

Obviously, this is just one study on a very controversial topic, and is not conclusive of anything. But it is food for thought.

By the way, the researchers wouldn’t say which video game they used for the study.           


Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

Former Green Bay Packer Forrest Gregg Has Parkinson’s Disease, Which Has Been Linked To Head Injuries

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Posted on 24th November 2011 by Gordon Johnson in Uncategorized

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Forrest Gregg, an ex-Green Bay Packer Hall of Famer, has been diagnosed with Parkinson’s Disease. Is that malady linked to he concussions and brain injuries that he sustained during his career?

That’s the intriguing question raised by sports columnist Brooke McGee of the Bleacher Report.

http://bleacherreport.com/articles/943663-forrest-gregg-former-packer-diagnosed-with-parkinsons-caused-by-nfl-career

Right now Gregg has developed hand tremors, a stooped posture and smaller stride, according to McGee.  A Parkinson’s expert, Dr. Rajeev Kumar, has diagnosed Gregg with the disease.

The columnist then goes on to cite research from the Mayo Clinic, which says, “those who have experienced a head injury are four times more likely to develop Parkinson’s Disease than those who have never suffered a head injury. The risk of developing Parkinson’s increases eightfold for patients who have had head trauma requiring hospitalization, and it increases 11-fold for patients who have experienced severe head injury.”

The sounds like pretty convincing data to make one believe that Gregg’s Parkinson’s was prompted by the many concussions that the NFL veteran suffered while playing for Green Bay and Dallas, according to McGee.

And we’d have to agree.

It’s unfortunate that the league stuck its head in the sand, and then was in utter denial for so long, about the long-term impact of head injuries and concussions on players.   

 

 


Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

Prior Combat Stressors Adds One More Trap for TBI

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Posted on 18th June 2010 by Gordon Johnson in Uncategorized

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In our last blog, we introduced the reader to the potentially disastrous combination of TBI and PTSD conditions in a combat survivor. But the problem in combat is not just the intersection of these two “co-morbidities”, but the likelihood that a third complicating factor- preexisting anxiety – will also be found in combat veterans.

As we outlined yesterday, the Limbic System is the part of the brain which regulates anxiety and memory. Just as the corpus callosum is the collection of axonal fibers that connects the two hemispheres of the brain, the uncinate fasciculous is the collection of axonal tracts that connect the principal memory and anxiety centers of the brain to the frontal lobes – the thinking and maturity parts of our brain.

See http://www.waiting.com/limbicsystem.html

The principal structures involved include the following;

Hippocampus. The brain’s save button is the hippocampus. It is the part of the brain most important to converting immediate memory to long term memory.

Amygdala. The brain’s anxiety center is the amygdala. It is the amygdala that protected us from predators in the pre-historic times. It triggers our startle reflex in modern times and is the principal culprit in anxiety disorders.

Frontal Lobes. The frontal lobes are where we learn to become adults, where all activity is initiated, decisions made, emotions modulated and judgment’s made. The orbital frontal part of the frontal lobe, on the underside, is essentially the conductor of the brain’s symphony, the part that tells the other instruments when to start and stop playing. The frontal lobes coordinate all activity.

Uncinate Fasciculous. Connecting the above critical structures is the uncinate fasciculous, the axonal tracts that run from one end of the lower brain structures to the underside of the frontal lobes.

A person with a pre-injury anxiety disorder is far more vulnerable to post concussional problems (PCS). In a person with an anxiety disorder, the amygdala is already overreacting to potential anxious moments. It runs “hot” so to speak. When, as a result of trauma, such as a blast, damage occurs to the hippocampus, frontal lobes and the uncinate fasciculous, the information that gets moved across this lower brain circuit gets garbled. When information between the limbic system and the frontal lobes gets garbled, anxiety can become panic, depression can become organic rather than just reactive and the person’s ability to modulate emotions and make decisions, seriously impaired. The combination of pathologies in these areas -coupled with inefficient communication between them – creates a synergistic pathology far more functionally impairing than any one of those impairments might have been alone.

As serious as this premorbid vulnerability is in a civilian, it is far more serious in a soldier. Think of it this way. The amygdala is there to get us to run, without stopping to think. Fortunately for peace time activities in the modern world, our socialization has taught us when not to panic. A civilian has few times when he or she needs to rely on the amygdala. There are few great predators, few brushes with real danger. Thus, our frontal lobes and other emotional centers have tamed our amygdala, in not so different of a way than we tame a pet.

Yet, the amygdala is needed for combat. To survive, a soldier must rely on his instincts and must put his mind into a hypervigilant state. One of the biggest problems that soldiers have reintegrating into civilian life is learning how to stop this hypervigilance. PTSD is primarily a disease where the traumatic emotional stress has so changed the amygdala that it never entirely goes back to its peace time role.

Thus even before a TBI, a combat veteran is likely to have a heightened anxiety. Without that anxiety- the hypervigilance – the soldier may not survive. Depending on the level of previous battle stresses, that anxiety may have elevated itself to PTSD levels prior to the TBI. Thus, the risk of emotional dysfunction is not only increased by the very battle in which the soldier is injured, but also by the pre-injury emotional state.

The irony of all of this is that this convergence of co-morbities is laid upon those we expect to be the toughest. “The Few, the Proud” are those at greatest risk of becoming the homeless, the disturbed, the arrested. Sadly, I can offer no solution other than peace.

 


Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

D-Day and Second Impact Syndrome

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Posted on 16th June 2010 by Gordon Johnson in Uncategorized

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Yesterday, we talked about the practicalities of TBI and combat. Perhaps the best way to visualize those practical problems is to watch the opening scenes of the movie, Saving Private Ryan.  A clip of the first 10 minutes can be found at YouTube here: http://www.youtube.com/watch?v=kx7dFp0WhN4&feature=related At eight minutes into this clip, the lead character, Captain John Miller, played by Tom Hanks, is near a mortar or artillery shell which explodes upon the Allied troops as they land at Omaha Beach.  Captain Miller clearly suffers a concussion in this blast without any apparent loss of consciousness.

The next minute of this clip is the most honest treatment of concussion I have seen from Hollywood.  Captain Miller struggles to his knees, helmet in hand.  For the next minute he does nothing, seemingly unable to comprehend that he has been hurt, that he is in combat, that he should put his helmet back on.  In almost a childlike gaze, he takes in the horror that surrounds him. His hearing, his balance are impaired.  The viewer gets the sense of this because Director Steven Spielberg cuts all sound, the viewer, like the concussed soldier becomes deaf. Captain Miller, as we watch in horror,  does virtually nothing to defend himself, despite the cataclysm which surrounds him. After 90 seconds, his thinking clears and he regains his ability to command.  He is able to save his life, those of most of his troop and Private Ryan.

This portrayal of concussion by Hanks may be fictional, but it is a classic example of art showing us what is real.  Hanks and director Spielberg have gotten this just right, at least in the acute stage of the concussion.  What I believe is most important about this portrayal of concussion is that it demonstrates the combat challenges in avoiding second impact syndrome and simultaneous PCS and PTSD.

Second Impact Syndrome. The big impetus for the sport and concussion movement that has so changed how the world views concussion, was a 1991 description of the “second impact syndrome.  See Kelly, JP, JAMA.  1991 Nov 27;266(20):2867-9.  “Concussion in sports. Guidelines for the prevention of catastrophic outcome.” http://www.ncbi.nlm.nih.gov/pubmed/1942455 The concern in second impact syndrome is that a concussed brain is no better at defending against a catastrophic increase in brain blood pressure, than the Captain is in avoiding bullets.  For the sake of illustration, the brain becomes confused as to how to regulate its blood pressure by the first concussion.  When the second impact puts an added strain on such regulatory apparatus, the brain has no remaining defenses.  Death or severe injury results.

What makes second impact such a practical problem in combat is the increased risk of second concussion because of the disorientation and confusion from the first concussion.  While such is also true in sports, the risk factors of the second injury are so much greater in combat. No injury timeouts in combat. As you watch Saving Private Ryan, you realize how vulnerable a soldier with a 90 second disorientation is.  He is in the line of fire, without his helmet, completely confused as to what to do, what has happened. There is probably nothing we can practically do to reduce the risk of the contemporaneous second concussion in combat. But what me must do is make sure we don’t send the soldier back into a combat zone in the days and weeks afterwards. That is where battlefield screening would be so important.p>

Interplay Between Concussion and PTSD. While the science in this area is still evolving, I am completely convinced that Post Concussion Syndrome (PCS) has as its core problem, a compromised attentional capacity.  When compromised attentional resources are combined with emotional stressors (of which combat based PTSD would be among the worst) the likelihood of a disability multiplies.

The least understood but potentially most serious pathology after a mild traumatic brain injury  (MTBI) is compromised brain signaling between limbic structures like the amygdala and hippocampus and the frontal lobes.  Communication in the brain is electrical, with the electrical impulse being carried from one neuron to another down axons.  Fiber tracts are the bundles of axonal fibers that connect one part of the brain to other part of the brain or to the nervous system.  See http://www.subtlebraininjury.com/neuron.php One of the most exciting new developments in the last decade is the capacity to see damage axonal tracts on MRI through the use of Diffusion Tensor Imaging (DTI).   Even though axons are far too small to be seen on MRI, DTI can see the cumulative effect of axonal injury because of its ability to see an interruption in the fiber tracts.  See http://www.tbilaw.com/blog/tag/dti

Unfortunately, not enough DTI research is being done on what I believe to be the biggest culprit in PCS, the uncinate fasciculus. The uncinate fasciculus is a fiber tract that connects the limbic system to the frontal lobes. http://www.ajnr.org/cgi/content-nw/full/25/5/677/F11 Add structural injury to either the limbic or frontal lobes to damage to this fiber tract and the brain dysfunction can  hit critical mass.

One issue this week  has been what the Pentagon has done with the $1.5 billion that has been spent on TBI.  I can categorically say that if war is anything like Saving Private Ryan, the U.S. military owes it to its soldiers and Veterans to prioritize research into the limbic system, uncinate fasciculus and frontal lobe injury.  Lt. Col. Michael Russell, head of the Army’s ANAM program says there are too many “false positives” for TBI when administering the test mandated by Congress.  One of the reasons there are so many  is that the emotional stress of combat alone could impact the brain’s panic and emotional centers.  Add diminished attentional capacity and compromised axonal tracts which arise from MTBI and the risk of a catastrophic result will still be there when the bullets stop flying.


Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

Should Baseball Pitchers Wear Helmets?: Debate Renewed After Cleveland Pitcher Gets Beaned

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Posted on 3rd June 2010 by Gordon Johnson in Uncategorized

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 It hasn’t even been a week since New York Yankee slugger Alex Rodriguez hit Cleveland Indians pitcher David Huff in the head with a line drive. But Huff seems to have emerged magically uninjured by that heart-stopping accident.

http://www.nytimes.com/2010/05/30/sports/baseball/30yankees.html?ref=sports

 Huff, who had to be carried out of Yankee Stadium on a stretcher after getting beaned May 29, is back playing ball. The pitcher, who never lost consciousness after A-Rod’s hit struck him, didn’t sustain a concussion, or get so much as a headache, from being hit. His CT scan came back negative.

 http://bats.blogs.nytimes.com/2010/05/30/day-after-being-hit-in-head-huff-is-feeling-good/

 The evening of the day he was hit, Huff tweeted, “Everything is good. Was a little scary, but I’m out of the hospital and with my family.”

http://www.cleveland.com/tribe/index.ssf/2010/05/cleveland_indians_left-hander.html

 That’s all pretty remarkable, in that Rodriguez hit the ball with such force that it after it struck Huff’s head it flew and landed roughly 275 feet from home plate.

http://sports.yahoo.com/mlb/blog/big_league_stew/post/He-s-OK-folks-Indians-David-Huff-takes-A-Rod-?urn=mlb,244510

 Although the Huff case had a happy ending, the scary incident has some sports writer bringing up a question that’s been debated in baseball: Should pitchers be required to wear helmets for protection, like catchers?

 The knee-jerk reaction might be to say yes, pitchers should don helmets. After all, they face hardballs shooting back at race car-like speeds, more than 90 mph.

 And some players who have been hit in the head like Huff didn’t fare as well as him. The Cleveland Indians seem to be particularly jinxed. In 1920 Cleveland Indians shortstop Ray Chapman was killed by a pitched ball. And Indians pitcher Herb Score’s promising career ended when he was hit in the face with a line drive in 1957.

 But how far do you go to eliminate risk in sports? By their very nature, sports involve all kind of risks. You can’t eliminate them all.

 And if you believe baseball pitchers should wear helmets, then it follows that you would want to mandate that basketball players wear helmets, as well. In a recent week there were two concussions in just one basketball game. Basketball has a much higher frequency of concussions than baseball, except when it comes to batting.

 That said, the biggest risk of severe brain injury in baseball is not a pitcher taking a line drive in the head. It’s two outfielders going after the same ball and then colliding at a very high speed, head on head. Each year, some player dies as the result of such a collision.

 My answer to making baseball safer for pitchers isn’t a helmet, but rather a ban on aluminum bats. A player can swing an aluminum bat faster than a wooden bat, accelerating the speed the ball comes off the bat – and at the pitcher. That’s why for at least a decade the use of aluminum bats has been a controversial issue.

 Back in 2000, ESPN Magazine did a story headlined “Bat Controversy Lingers Over NCAA.”  In part, that article described how player stats soared as “hot” aluminum bats became more prevalent in the game. In the College World Series championship, from 1994 to 1998 there were 105 runs scored, versus only 33 in 1989 to 1993.  

http://espn.go.com/gen/s/2000/0329/453294.html

 Last year a Montana jury awarded a family $850,000 for the death of their son, who was killed in a 2003 baseball game where aluminum bats were used. The jury found that Louisville Slugger didn’t properly warn people about the potential dangers of the bat.

http://www.roundupnews.com/sports/aluminum-bats-still-safe-despite-lawsuit-against-bat-maker-1.861272

 But even that jury award didn’t convince people like New Mexico State University baseball coach Ricky Ward that aluminum bats were unsafe. In an interview, Ward said that deaths from batted baseballs were very uncommon.

 Ward suggested that instead of worrying about the aluminum bat, that the specifications on baseballs themselves be changed.

 That’s a new answer to an old problem, but we don’t know if it would work.

 


Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.

The Difference Between Life And Death: Bret Michaels’ And Gary Coleman’s Brain Hemorrhages

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Posted on 2nd June 2010 by Gordon Johnson in Uncategorized

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The New York Daily News Wednesday posed a question that may have crossed many people’s minds: Why did former child star Gary Coleman die last week of a brain hemorrhage, while rocker Bret Michaels lived?

http://www.nydailynews.com/lifestyle/health/2010/06/02/2010-06-02_brain_injuries_like_the_ones_suffered_by_bret_michaels_and_gary_coleman_can_have.html

Coleman, who had a lifelong history of health problems, suffered an intracranial brain hemorrhage when he slipped and fell in his Utah home last Wednesday after undergoing his usual dialysis treatment. Only 42 years old, Coleman went into a coma in the hospital on Thursday, and his family ended his life support on Friday.

Michaels, on the other hand, was at his Arizona home when he suddenly felt an incredible pain in his head. His wife rushed the singer to the hospital, where he was diagnosed with a subarachnoid brain hemorrhage. After some shakey moments, 47-year-old Michaels pulled through, and appeared on the finale of “Celebrity Apprentice,” which he won.

Reporter Rosemary Black explains the difference between the two brain hemorrhages. An intracranial hemorrhage takes place inside the brain, while a subarachnoid hemorrhage is bleeding into the lining around the brain.

Black interviewed physicians who said that the location of brain hemorrhage will determine if it will kill or not, if it will disable a patient in some way, or if they will fully recover. Of course, that’s just common sense: If the part of your brain that controls your breathing is damaged,  let’s face it, it’s unlikely you’re going to have a good outcome. 

One doctor added that Coleman’s poor health, he had two kidney transplants during his life and was on dialysis, likely made his prognosis grim after his brain injury. 

But then Michaels wasn’t a particularly well man. He had just had his appendix removed and he was a lifelong diabetic. And I believe that Michaels’ physician is jumping the gun by telling the press that the singer has fully recovered, that he is part of the small group of people — only 20 percent — who bounce back like new from this type of brain hemorrhage. 

I have written extensively on my blog, http://subtlebraininjury.com/, about apparent full recovery brain injury. Problems can develop later on with people who have sustained brain injury and appear to be back to normal. For example, those who have jobs that require their minds to have a high processing speed may find it harder to claim “full recovery” than those with less taxing jobs.  

And in a recent interview Michaels himself said, “I’m just not back to where I want to be just yet.” http://www.popeater.com/2010/06/04/bret-michaels-health-american-idol/?ncid=webmaildl2

 He performed Memorial Day weekend, and in the interview said, “On stage, normally, I go completely insane and kick ass. This time, I gave 100 percent of my 75 percent.” 

 

 

 

 

 

 

 

 


Attorney Gordon Johnson
Past Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.