Today is Brain Injury Awareness Day on Capitol Hill!

March 13th is Brain Injury Awareness Day on Capitol Hill.  Today, there will be an awareness fair, a congressional briefing and reception in Washington D.C.  While a presentation of these events would be interesting, until that becomes available, it is good to remember that the whole month of March is federally-designated Brain Injury Awareness Month.  As was last year, the theme of the month is Change Your Mind about brain injury.  Publications have again presented news articles related to brain injury.  (Unfortunately, though, these articles just seem to be reiterating statistics about brain injury, that have been presented an enumerable amount of times, in order to showcase the commonality of the issue.  However, it is good to remember that for many people, brain injury is still an unknown topic – a topic of no interest to them because it doesn’t affect them personally.  However, they need to understand.)

Even if you cannot travel to D.C. for the day’s events, you can still participate.  Various websites note what you can do throughout the month to increase awareness and to learn more yourself.

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Call for More Studies, Not Solutions

At the start of 2019, Congress sought to showcase its “great concern” for brain injury, with Congresswoman Joyce Beatty’s (OH) introduction of H.R.280, the Concussion Awareness and Education Act of 2019.  Cosponsored by 36 others, the Bill seeks, “to provide for systemic research, treatment, awareness, and dissemination of information with respect to sports-related and other concussions.”  Specifically, it focuses on children, aged 5 to 21.  It is an admirable goal to care for America’s children, but just like similar bills that seem to go through Congress every year, it just calls for research.  Additionally, once introduced on January 8, the bill was referred to the House Committee on Energy and Commerce, where it still sits without action.

Citizens have expressed their concern over what they see as a lack of concern for the youth, but stateside, similar government pseudo-action seems to be present.  For example, the Salt Lake Tribune wrote, “there’s a dirty little secret plaguing high school sports in Utah.”  According to the newspaper, that “dirty little secret” is the incidence of concussions in high school sports.  In Washington, S.R. 5238, which is currently being considered in State Congress, “would require UW Medicine to publish and maintain a website making… research available to parents,” – again, the government is proposing research, not action.  (Some states have taken legislative action, though, by eliminating certain sports and certain actions in sports.  A bill introduced to Congress in Maryland this month, for example, “would… prohibit cheerleaders age 12 and younger from engaging in aerial stunts.”)

As I have noted in the past, this heightened concern (and, perhaps, this seeming lack of federal action) may be the cause of the decreased sports enrollment in schools.  While that is unfortunate, a positive outcome of this current parental concern could be a heightened concern for sports safety from school districts.  Even without legal mandate, this could lead to a lower concussion percentage rate for the millions of American children who, theoretically, stay on the field and court.

Sex in the Brain: Asexuality

Sometimes, when you’re without a partner, it may seem that it would be easier if you had no sex drive at all.  For those with brain injuries, who, for example, are in the hospital or have an inability to safely leave their homes, a lack of sexual urges may seem even more desirable.  However, for those who suffer from asexuality, a.k.a. a loss of sexual urges, this reality is anything but desirable.

In a 1995 report, it was “understood” that, “asexuality typically results from extreme fear of bonding with others, extreme narcissism which results in an inability to genuinely care for or empathize with others and/or severe repudiation of one’s genitals, sexual arousal or gender.”  This millennium, more research and some understanding into post-traumatic asexuality has occurred.  “Individuals post-TBI report frequent physiological, physical and body image difficulties which negatively impact sexual activity and interest,” a 2000 NIH study reports.  This statement, however, is very broad and suggests that post-TBI asexuality was not then fully understood.

Since then, few studies have followed on the topic and those that have been done have contradictory results.  In 2014, though, the NIH reported that “nervous system damage… impairs physiological aspects of sexual response.”  Physical limitations, such as fatigue, resulting muscle weakness, and having different physical abilities than one had prior to their brain injury can also have an effect.  Certain medications may also limit sexuality.  Oft-prescribed antidepressants, for example, can block certain brain chemicals, resulting in ejaculation failure, impotence and decreased libido.  Lastly, stereotypical sexual assumptions towards those with disabilities can have a negative effect.  The public perception that all those with physical and/or neurological disorders must be asexual can lead to psychosocial and emotional issues that inadvertently may cause someone to be asexual, due to lack of opportunity or lack of satisfaction.

Though research into asexuality has broadened, “the particular needs of LGBTQIA+ individuals living with a neurological disorder are neglected in clinical practice and research. The invisibility of LGBTQIA+ individuals with neurological disorders reflects the historical exclusion of marginalized identities and creates disparities of access to healthcare.”  Lack of medical understanding of neurosexuality and a botched medical treatment that left a man with a brain injury and without sexual urges resulted in a hospital being sued for $1.2 million by a now widowed Australian woman this month.  Maybe, if nothing else, it will be a fear of being sued that increases acceptance.

(For those who became asexual following a brain injury or who just want to know more about the topic, visit the Asexual Visibility and Education Network or read The Invisible Orientation: An Introduction to Asexuality.)

A Noble Treatment for TBI on the Table

Following a physical trauma, a person may become comatose or ostensibly inert.  It is through the use of an inert gas, though, that the effects of this trauma may be lessened in the brain.

The inert noble gas xenon (Xe) has been found to be a possible first treatment for brain injury, lessening the progression of the injury.  (Traumatic physical trauma causes both primary and secondary injuries.)  The study in which this discovery was made, published by the NIH in 2018, found that, “Xenon applied 1h after blast exposure reduced injury 24h, 48h, and 72h later, compared with untreated control injury.”  Of course, this study was focused on brain injuries obtained in combat and was tested only in mice, but it seems probable that the effects of xenon would apply to humans who suffer physical traumas, as well.

Beyond being a possible first treatment, xenon has been found to have other benefits related to brain injury.  For example, last year it was reported that when xenon is used in the treatment of cardiac arrest, brain damage is lessened or even prevented.  Xenon provides analgesia, a pain killer, to the body.  Also, Xenon activates TREK-1 channels.  TREK-1 channels have an “important role in neuroprotection against epilepsy,” a common negative side effect of brain injury.  Additionally, inhalation of Xe has been used effectively to eliminate the fear-inducing memories that result from PTSD.

However, Xenon is not a miracle drug.  The World Anti-Doping Agency (WADA), which creates the list of prohibited drugs for the Olympic and Paralympic leagues, has xenon on its Prohibited List.  Xenon can enhance athletics performance likely because it, “stimulates the synthesis of erythropoietin (EPO) by increase of hypoxia inducible factor.”  (EPO is a hormone needed to form red blood cells.  Hypoxia-Inducible factor regulates oxygen consumption.)  Xe, though, is not prohibited by the NCAA or any professional sports league in the United States.

Sex in the Brain: Homo/Heterosexuality

As has been discussed in my previous blog posts, head trauma can affect someone’s sexual preferences in a number of ways.  While uncommon, such things like hypersexuality, an infatuation with pornography and public sexual innuendo can have extremely negative effects.  Another possible effect may not be negative, but rather confusing to the person it happens to is a change from heterosexuality to homosexuality, or vice versa.

The concept of changed sexual orientation post-brain injury was first examined by UCLA and reported to the NIH in 1986.  The study evaluated the medical cases of four people with various types of altered sexual behavior following a brain injury.  Altered sexual behavior is a broad term and implies everything from hypersexuality to pedophilia.  Specific to this article, though, one of these cases followed a married, previously heterosexual woman who, following a brain injury, “made both oral and manual sexual advances to female attendants in the hospital.”

Recently, new evidence was found to promote the idea of the possibility of a change in sexual orientation due to a brain injury when former NFL star and convicted murderer Aaron Hernandez committed suicide.  After his death, letters were found in which he expressed his homosexual urges, which he says followed the head trauma he was subjected to as a player in the NFL.  A post-humorous examination of Hernandez’s body discovered that he did suffer from CTE.  (Hernandez’s wife says that she saw no signs of his new urges and that she and her husband had a healthy sexual life.  Others state that they knew of his sexual orientation and that his urges greatly preceded his head trauma.)

Investigating the medically-defined reason for changes in gender-related sexual orientation has found a number of answers.  Predominantly, injury to the basal frontal area and the temporal lobes of the brain are defined as the reason for changes in sexual orientation.  A condition known as the Kluver-Bucy Syndrome is also identified as a reason.  Also a rare behavior impairment that can be caused either by a head trauma and by herpes, this syndrome involves the sex hormones produced in the brain.  Studies have also found that homosexual men and heterosexual women have a similar smaller volume of hypothalamic nucleuses, among other things.  The size and/or location of amygdia connections and the location of the cerebral hemispheres may also have an effect.

Above I have noted four brain cell alterations that can occur following a brain injury and may affect sexual orientation as it relates to preference.  The fact that the subject of gender sexual orientation after brain injury has been studied by the government for over 30 years, in both animals and humans, is evidence that no definitive reason for the change has been found.  Additionally, while studies seem to all focus on brain injuries changing someone’s orientation from hetero to homosexuality, the opposite must also be true.  Also, others do not believe it is possible for a brain injury to alter one’s sexuality at all.  As homosexuality has gained and will continue to gain more cultural acceptance, perhaps more research and, therefore, more scientific understanding of the topic will be found.

A Broader Definition of Day Care

No one wants a life of twiddling their thumbs, with little to occupy their time.  For this reason, the concept of adult day programs was created.*  As the geriatric population becomes larger, the idea of providing appropriate funding to attend these adult day centers has become more popular.  This year, on January 8**, Rep. Barbara Lee (CA) introduced the Adult Day Center Enhancement Act to broaden the idea of who may benefit and should receive funding for adult day center attendance.  The purpose of the Act is to provide funding for, “a program that provides comprehensive and effective services to individuals living with neurological diseases or conditions… that may result in a functional or degenerative disability and to their family caregivers and that may assist participants.”  (This bill funds daytime assistance to the young adults who are disabled, however I can find no information regarding the age limits.)

Related to its assistance to the participant, “adult day programs can offer services, including medical care, rehabilitation therapies, dignified assistance with the activities of daily living, nutrition therapy, health monitoring, social interaction, stimulating activities, and transportation.”  First introduced in 2013, and re-introduced every other year thereafter, H.R. 320 seeks to maintain the quality of life of the disabled population.  As with inflation, the allowed funding will increase every year until 2023.  (The Veterans Home Adult Day Health Care Improvement Act, to which I assume partially refers to veterans with brain injuries, was signed into law on March 27, 2018.)

On January 8, the Adult Day Center Enhancement Act was referred to the House Committee of Energy and Commerce, of which Rep. Lee is a member.  (Last time the Act was introduced, it was referred to the Subcommittee on Health.)  Due to the shutdown, this bill currently has no co-sponsors nor does it have a summary on congress.gov.  Now that the shutdown is over and before the bill may be enacted, it must be evaluated by the Assistant Secretary of Aging.

* On some sites, I have found it titled “adult day care”.  However, it is generally titled “adult day programs” assumedly because “daycare” has a youth connotation.  If one is to think about it though, that inaccurately marks toddlers as the only segment of the population that needs activity during the day.

** I find it heartening that a bill was introduced in Congress during the partial shutdown, which officially began December 22, 2018.

Sex in the Brain: Sexual Disinhibition

One of the major negative effects of a TBI is disinhibition, which can manifest itself in many ways.  Social disinhibition, the most common and most discussed, is the result of an injury to the prefrontal cortex, which can be found in the frontal lobe of the brain.  Less discussed, but equally important, is sexual disinhibition, which involves taking action on sexual impulses, such as through the previously-mentioned hypersexuality, as well as through other behaviors.

The biological human need for sex is instinctual, developed in the most primitive part of the brain, the brain stem.  Sexual arousal, however, is formed in the prefrontal cortex, which controls executive functioning.  While most studies begin the summary of their findings by noting that “little research has been done”, many arousal locations have been found: “Activation of numerous frontal regions, including the right prefrontal cortex, anterior cingulate cortex and gyrus and orbitofrontal region has been observed during sexual arousal involving masturbation induced orgasm. Orbitofrontal activation has been interpreted as being related to the representation of pleasant bodily sensations, while dorsal anterior cingulate activation has been attributed to the modulation of skeletomotor activities that characterize sexual arousal and the perceived urge to act.”

Behavior control, including impulse control, is also formed in the prefrontal cortex of the brain.  When you combine increased sexual arousal with decreased self-control, foresight, attention and reasoning, the consequences may include inappropriate, illegal and/or harmful behavior.  Sexually offensive behavior, for example, is always inappropriate and known to appear in 3.5 to 9% of adults affected with brain injury.  A preoccupation with sexual thoughts presumably led two women with brain injuries to become dominatrixes.  “[One woman] began working as a stripper, then as a dominatrix, using the name Sasha Mizaree. She even built a dungeon in her apartment but said she doesn’t have sex with her clients. She was paid $250 an hour to dominate them,” reported ABC News.

While those with TBI may have an increased libido, they also have a decreased sense of self-awareness and awareness of what is appropriate.  One may no longer be able to neurologically control their aggression and other impulsive behaviors like grabbing or compulsive masturbation.  Lack of sexual control can result in such behaviors as attempted rape.  In Australia, a man who had a motorcycle accident, decades ago, was sentenced to jail for 19 years as a pedophile and child rapist.  Interestingly, many of those with TBIs who have extreme sexual behavior report no enjoyment in the activity.

Unfortunately, even with a multitude of studies that reference it, the NIH recently reported that doctors and rehabilitation facilities do not generally know how to treat the thoughts and actions that may come from from sexual disinhibition.

Skiing Into a Head Injury

Gliding down a ski slope at 60 mph, taking a ramp that lifts you up in the air with a heavy board attached to your feet and just snow below, or racing against others while doing both.  These three activities are all part of the winter routine for individuals who enjoy the extreme sports of freestyle skiing, snowboarding or snowcross.  Extreme sports are, by definition, dangerous.  A Google search of snowboarding, for example, found two pages of articles related to snowboarding deaths and accidents this year alone.

First coming into existence either in the 1950s, 1960s or 1970s, depending on which source you reference, extreme sports tap into a person’s sense of adventure.  Head and neck injuries due to winter extreme sports are common, when compared to other sports, partly because, “many extreme sports take place in environments where medical care may not be readily available.”

Throughout the years, extreme sports have become more popular, perhaps as the opportunity for adventure and physical risk of everyday life goes down and mental stress goes up.  Head and neck injuries due to winter extreme sports have also significantly increased through the years.  There is a cost to these injuries, both emotionally for the individual and monetarily for both the individual and the government through evacuation costs, rehabilitation costs and community costs in the future.  This month, the government pays more attention to these risks, as well as the needed research, as January is National Winter Sports Traumatic Brain Injury Awareness Month.

Although finding new means to treat traumatic brain injury in extreme winter sports is very important, “prevention is the top priority”.  The Office of Disease Prevention and Health Promotion reminds people to always wear a helmet and to make sure to watch your surroundings by staying in the boundaries in ski slopes and watching for obstacles and hazards on your path.  Just as importantly, “make sure medical care is close.”  Additionally, Dr. Pickett of the National Intrepid Center of Excellence reminds people that, “It’s important to consider how weather conditions… increase the risk for these injuries.”  While equipment is now safer and access to medical care has improved, prevention should always come first.  If you enjoy the thrill of extreme winter sports, I hope you enjoy it this winter, but know and use all available information to make it safe.

Weighing In On Insomnia

Sleep is crucial for humans to survive and thrive.  “Emerging evidence implicates sleep in the most basic of neurological functions, namely the exchange of metabolic wastes associated with neurological homeostasis…  sleep is integral in the function of the glymphatic system… Natural sleep or anesthesia accounts for an increase in interstitial space that facilitates the subsequent exchange of cerebrospinal fluid (CSF) with interstitial fluid.”  All people have been told to get at least 8 hours of sleep a night.  While this number is actually higher for the young, 7-8 hours is the recommended hours of sleep needed for those 18 and up.  For those with brain injuries, an energized brain is necessary to perform at their best.  However, about 30 to 70 percent of those with brain injuries have sleep disorders including deprivation, deficiency, disruption, etc.  (Although fatigue may be the most obvious side effect of a sleep disorder, “the consequences of disrupted sleep following injury range from deranged metabolomics and blood brain barrier compromise to altered neuroplasticity and degeneration.”)

The above links are all from government studies into brain injury and sleep disorders.  While they may be interesting and informative, methods of curing these sleep disorders are what really matter to those afflicted with them.  So far, many means to induce sleep and reduce the activity of a restless mind have been explored and written about, such as cognitive behavioral therapy, the use of activities, etc.

My advice is to read the results of these studies while you’re in bed, using one of the recommended sleep aids: a weighted blanket.  Weighted blankets have gained popularity in the past few years.  So named because the weight of the blanket equals about 10 percent of the user’s weight, the extra weight that this blanket provides the user is soothing, rather than encapsulating.  They are a form of deep pressure touch stimulation, which can help with one of the more common symptoms of TBI, anxiety, among other things.  (I am not promoting weighted blankets more than cognitive behavior therapy or any other means of ridding one’s self of a sleep disorder, I’m just on the search for a new sleep strategy.)

Sex in the Brain: Hypersexuality

During the winter, when the cooler weather keeps people indoors, sex may have a more prominent part in the lives of many couples.  Since the feelings that ultimately result in sex are developed in the brain, they can be altered by a brain injury.  Additionally, since the desire for sex is neurological, if, when and with whom someone wants to have sex can be changed by a brain injury.  Finally, how someone expresses their feelings following a brain injury may be altered.  Today, I present the first of several articles that showcases federal research and other important information regarding the expression of libido in those with brain injuries in an article series entitled Sex in the Brain:

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A 43-year-old man was in an auto accident.  The accident left the man in a coma and having seizures for three weeks.  Upon regaining full consciousness, while still in the hospital, he masturbated multiple times a day for the next 2 weeks…. A 33-year-old married woman with children was in a car crash that caused a moderate head injury.  Though it was 2 weeks until she regained full consciousness and though she had aphasia for 4 weeks, X-rays of the skull showed no abnormalities in the brain.  However, while at the hospital, she flashed a female visitor and consistently, “demanded to go home to fulfill her sexual urge.”

The above two stories are some of the clinical data from a 2008 study regarding hypersexuality, also known as compulsive sexual behavior, following brain injury.  Hypersexuality, previously termed nymphomania in men and satyriasis in women, is, “the inability to regulate one’s sexual behavior that is a source of significant personal distress.”  It is about the object of sex, as opposed to the relationship.  Sexual fantasies, urges and behavior become a preoccupation that is difficult to control, causes distress and ultimately has negative effects on one’s health and life.  Its presentation can be in numerous ways, such as through excessive and public masturbation, an excessive number of sexual partners, an excessive use of pornography and/or paying for sex.  If this occurs for over 6 months, it is considered an addiction, specifically a process addiction like gambling, binge eating or compulsive spending.

Also, like any other addiction, hypersexuality has a neurological basis and, therefore, can be either a primary diagnosis or secondary diagnosis caused by another disorder, such as bipolar disorder, dementia or traumatic brain injury, among other disorders, or caused by medication, like dopamine agonist.  Neurologically, it is caused by an injury to the frontal lobe.  Though it may be a sensational topic, it is rare(It is more common among those arrested for exhibitionism than it is for the general public.  “Between 5 and 35% of those arrested for exhibition are found to be suffering from organic disorders to which the behavior can be at least partially attributed.”)  Additionally, it is more common in men.

Despite all the federal research to prove it as a unique impulse control issue, when the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) came out in October 2017, hypersexuality was not included.  (Hypersexuality and compulsive sexual behavior both fell under the “sexual disorders not otherwise specified” category in DSM-4.)  That year, though, the NIH did develop a new defining phrase to explain actions that occur due to the disorder: the sexhavior cycle of hypersexuality.