Tag Archives: traumatic brain injury

When Bats Attack: New Design Should Improve Safety

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Collegiate ballplayers like this athlete from the U.S. Air Force Academy started using the redesigned bats in 2011. Image courtesy Wikimedia Commons/Danny Meyer, USAF/Public Domain

Doctors  know about concussions from football, lacrosse, hockey, and similar contact sports, but what about baseball? Apparently, aluminum baseball bats have been implicated in severe injuries and even deaths in school-aged children.

How? It comes down to physics. According to researchers at Washington University in St. Louis, the aluminum bats currently in use can cause the baseball to rebound so quickly, and with so much force, that even an attentive pitcher can’t always get out of the way in time.  In a tragic example, they cited the 2010 death of a 13-year-old pitcher in Vermont — killed by a line drive off an aluminum bat — and noted there have been other reports of similar fatalities.

To cut down on the risk of serious injuries and deaths from hard-hit line drives, the National Collegiate Athletic Association last season started mandating the use of a new style of aluminum bat. The new bat is engineered to put less energy behind the ball once it’s hit, so it is less likely to cause serious harm.

Here’s one of the researchers explaining of the features of the new bat:

This year, the new bats will be used by high school players as well. The National Federation of State High School Associations will enforce the use of the new bats, so ideally the hazards of school baseball will be limited to bug bites and sore jaws from hours of gum-chewing in the outfield.

–Heidi Splete (@hsplete on Twitter)

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Sports concussions leave sneaky side effects

When he was a teenage lacrosse player, Dr. Brandon Cornejo suffered a mild concussion. He was awake during the trip to the hospital in his parents’ car. And he painfully recalls the resulting cognitive and emotional side effects that messed him up academically, socially, and psychologically.

Lacross sticks image by Yarnalgo (Wikimedia Commons).

The worst part, though, was that he spent 16 years not even knowing he had suffered the traumatic brain injury, because he had no memory of it. He wasn’t aware of a “before” or “after” the injury, so he didn’t know that his struggles were caused by the concussion. Instead he blamed himself, floundering in anger, confusion and depression.

Now a chief resident in psychiatry at the University of Wisconsin, Madison, Dr. Cornejo told his story at the annual meeting of the American Psychiatric Association to impress upon his colleagues the challenges of helping patients with traumatic brain injury, especially athletes.

“These mild injuries can have profound effects on your self-concept and your experience as a human being. They can change the course of your life,” he said.

In 1991, he was a straight-A student in his junior year at a college preparatory high school and the son of proud Latino parents who had never attended college themselves. He and his family were looking forward to him getting a scholarship to finance college.

Dr. Cornejo (Photo by Sherry Boschert)

After the concussion, his grades tanked. He barely got by with Cs and Ds. His girlfriend dumped him. He became very emotional. He remembers 6-9 months of bad fights with his parents. “The likelihood is pretty high that this was related to the loss of consciousness,” he said. “For years, I considered myself `not good at’ certain things because of my academic performance in my senior year.”

His behavior frustrated and shocked him. One time he exploded in “road rage,” which embarrassed him even though no one was there to witness it. Another time when he was ordering oatmeal in a restaurant, he could not recall the words for brown sugar.

“I developed a significant depression, a huge depression. In retrospect, I have a hard time distinguishing between depression produced by traumatic brain injury and depression because I wasn’t performing academically. My family was counting on” a scholarship, he said. That motivation and a lot of hard work eventually got him back on track academically, and somewhere in his freshman year of college he started to regain some self-esteem.

Years later, in 2007, his father casually said, “Remember that time you got knocked out, and we took you to the hospital?” Dr. Cornejo could dredge up only two memories — one of his coach staring down on him on the field, and the other of being in the back seat of the family car, with his mother saying, “Brandon, you’re really scaring us. Why do you keep repeating yourself?”

At the time of the injury in 1991, understanding of traumatic brain injury was just beginning to emerge, and the primary care physician who saw him for follow-up told his parents that their son should be fine, and they should keep an eye on him for a couple of weeks.

Today, Dr. Cornejo hopes that physicians would not allow young athletes with traumatic brain injury to return to play as quickly as he did, because repeat concussions carry much higher risks. He wishes that helmet designers would improve their products. And he urges all physicians to educate not only patients but their families and significant others about the potential sequelae of traumatic brain injury.

Because the patients may not remember.

–Sherry Boschert  @SherryBoschert on Twitter

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Filed under Family Medicine, IMNG, Internal Medicine, Neurology and Neurological Surgery, Pediatrics, Psychiatry, Sports Medicine, Uncategorized

Mental Health Providers: Uncle Sam Wants YOU

If the sheer volume of returning service men and women in crisis is not compelling enough reason for community-based mental health providers to join their military counterparts in the battle against post-traumatic stress disorder and traumatic brain injury, the opportunity to wear fatigues to work just might be.

“The uniforms have lots of pockets and you don’t have to shine your boots,” quipped Col. Elspeth Cameron Ritchie, M.D., M.P.H.,  the director of behavioral health proponency in the Office of the U.S. Army Surgeon General.

Image via Flickr user Nevada Tumbleweed by Creative Commons License

Clad in Army camouflage, Col. Ritchie made an impassioned recruitment pitch to clinicians and researchers attending a conference sponsored by Massachusetts General Hospital over the weekend titled “Complexities and Challenges of PTSD and TBI.”

In order to meet the increasing mental health needs of soldiers returning from Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom), “we have to partner with the community,” she said. While stressing that the Veterans Administration and the Department of Defense have implemented programs focused on mental health risk assessment, resiliency building, and treatment accessibility, the demand for available services far outpaces the military’s supply. In other words, she said, “We need YOU.”

And if you don’t want to wear a uniform, “there are a variety of different ways to come in,” Col Ritchie stressed. “For example, we’ve been working very closely with the U.S. Public Health Service, which is now giving us [mental health] providers at our facilities, so you could join the PHS,” she said. Or, at the very least, she urged attendees to sign up for TRICARE, the contracted health care plan  for service members and their families. “I know TRICARE is not an easy system to live with, but registering for it can let us get soldiers to you.”

The bottom line, Col. Ritchie stated, is that the U.S. military is at a crossroads with respect to meeting service members’ mental health needs “All of the low-hanging fruit has been picked,” she said. In order to meet the continuing challenges and to forge ahead, “we need to engage in a national dialogue, including the civilian community.”

—Diana Mahoney
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Filed under Family Medicine, Health Policy, health reform, IMNG, Primary care, Psychiatry, Uncategorized

Head Injuries Predict Persistent, Bad Headaches

Like many of the neurologists attending the annual meeting of the American Headache Society, I slipped into the hotel lobby during breaks in the program to watch World Cup soccer in bits and pieces. The images of players heading the ball caught my eye in a new way after hearing a couple of presentations about the associations between head injuries and persistent, more frequent, and disabling headaches.

Soccer cupcakes image by flickr user Ana_Fuji (CC license)

The studies didn’t single out head injuries from soccer or even sports in general. But the National Electronic Injury Surveillance System gives a sense of their numbers, as reported on the American Association of Neurologic Surgeons website. Among the 351,922 sports-related head injuries treated in U.S. emergency rooms in 2008, soccer injuries ranked sixth (19,252 injuries) behind head injuries from cycling (70,802), U.S.-style football (40,825), basketball (27,583), baseball or softball (26,964), and powered recreational vehicles (25,970).

At the meeting, Dr. Sylvia Lucas of the University of Washington, Seattle and her associates reported on prospective 1-year follow-up on 377 patients after acute rehabilitation for moderate to severe traumatic brain injury. Sports or pedestrian accidents caused the injuries in 4% each, with most injuries due to vehicular accidents (56%), falls or flying objects (28%), or violence (9%).

Image courtesy of flickr user Jo Madonna (CC).

What surprised Dr. Lucas was not just the high prevalence of headache after injury but that the prevalence held steady during the year of follow-up after discharge from rehabilitation. Compared with 18% of patients who reported having headaches before their head injury, headache prevalence was 46% soon after injury, 48% at 3 months after rehab, 44% at 6 months, and 46% at 12 months. A greater proportion of patients who reported pre-injury headaches had post-traumatic headache (48%) than did patients with no pre-injury headaches (23% with post-traumatic headache). Women were significantly more likely than men with head injury to report headaches at each time point.

Dr. Gretchen E. Tietjen of the University of Toledo, Ohio and her associates took a different approach. Surveys of 1,348 adults with migraines seen at 11 U.S. and Canadian headache centers found that the 28% of patients with a history of head or neck injury had more frequent and disabling headaches and more comorbid conditions that started at younger ages compared with patients without head and neck injuries.

Chronic headaches were a problem for 42% of the head/neck injury group and 31% of the noninjured migraineurs. Higher scores on the Headache Impact Test reflected more disabling headaches in the injured patients.

“One thing I wasn’t expecting” was the persistent difference between groups in rates of comorbidities, Dr. Tietjen said. Irritable bowel syndrome: 30% in the head/neck injury group compared with 21% in the noninjured. Fibromyalgia: 16% vs. 7%. Interstitial cystitis: 9% vs. 5%. Arthritis: 37% vs. 21%. Depression: 52% vs. 35%. Anxiety: 40% vs. 27%. Sleep apnea: 11% vs. 6%. Uterine fibroids: 17% vs. 10%.

These studies shed some light on the interplay between headache and head injury — sports-related or not — that constitutes a game-changer in ways we haven’t realized before.

– Sherry Boschert (Twitter @SherryBoschert)
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Scientist or Seer?

Last week, I spent one fascinating day at the Eighth World Congress on Brain Injury  in Washington, D.C.  where I heard a compelling talk on the potential benefits of hyperbaric oxygen therapy for brain-injured patients.

Dr. Paul G. Harch described his pilot study: 30 young soldiers, all of whom had sustained blast concussion injuries while fighting in Iran and Iraq. After 40 treatments of hyperbaric oxygen therapy (HBOT), they had significantly improved cognition, memory, and mood, and fewer headaches and symptoms of PTSD. Dr. Harch also showed some brain imaging data that indicated increased blood flow to the brain after these treatments.

SPECT images show increased cerebral blood flow after HBOT. Photo courtesy of Dr. Paul Harch

The injuries occurred an average of 6 months before treatment, suggesting that hyperbaric oxygen (HBOT) may stimulate a natural repair process in the brain as has been seen in other injured tissue, Dr. Harch said. Angiogenesis could bring new blood to damaged neurons that have been idling in neutral, awakening them to full function. Neurogenesis also could be at work, he said, although he had no data to support either of these ideas.

For nearly an hour at the meeting, physicians thronged Dr. Harch asking him about the potential of HBOT for various brain injuries, multiple sclerosis, and other neurologic problems. More often than not, Dr. Harch’s reply to their question was: “That [person] is treatable and will benefit from HBOT.” 

Clearly passionate, Dr. Harch zealously preached the Book of HBOT. But his missal is incomplete, because he did not disclose the details of his practice and commercial interests. Dr. Harch didn’t mention the new book  he just published, which touts HBOT for just about everything from brain injury to Alzheimer’s to wrinkles. Also, he runs a business in New Orleans  that provides hyperbaric therapy for approved uses, like decompression sickness and wound healing, as well as for off-label uses like autism, cerebral palsy, multiple sclerosis, and traumatic brain injury. 

And, while the results of his 30-person observational trial were intriguing, they do not a miracle make. He now hopes to launch a 1,000-person trial. But, again, he plans another single-arm observational study with no comparator group. Bayesian statistics would negate the use of a comparator, he told me.  

That comment, combined with the undisclosed financial information, gave me that weird stomach lump feeling – an irrefutable warning sign familiar to any journalist. For perspective, I turned to Dr. Steven Novella, a fellow blogger and Yale University neurologist who writes NeuroLogica.  Let’s just say he wasn’t impressed by the results of Dr. Harch’s study.

“The claim that with Bayesian analysis you do not need a control group is completely wrong and displays a frightening misunderstanding of scientific methodology,” he told me. “The point of a control group is to control for variables. Bayesian analysis does not replace that. In fact, Bayesian analysis can only be meaningfully done if you have some p-value or other measure of probability based on the study, which you do not have if you don’t have a control group.  It seems to me that he wants to do the kind of study that is guaranteed to show that his treatment works. This is what you do if you want to promote a treatment, not study it.”

The next proper step, according to Dr. Novella, would be a larger, double-blind study. And, in fact, three randomized, sham-controlled trials of HBOT are being planned by the Department of Defense.

Dr. Harch told me the research money should have supported his endeavors. Ironically, two of the principal investigators on the new trials each told me that Dr. Harch refused to assist with their trial’s design. Yet his work – with all its methodological flaws – is the genesis for the very studies that could ultimately substantiate the gospel truth of his preaching that hyperbaric oxygen can heal the wounded brain.

But until data replace simple faith, Dr. Harch remains the prophet crying in the wilderness.

- Michele Sullivan (on twitter @MGsullivan)

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