Happy and Safe Halloween!!!

Halloween may not be an officially recognized federal holiday, but for many schools and millions of children it may as well be.  While many towns have already celebrated Halloween with trick-or-treating this past weekend, today is the day of costume and candy for the majority of American children.

Online the CDC has “safe and healthy” recommendations for Halloween, which primarily apply to adults.  Related to children, they advise trick-or-treaters to “take precautions to stay safe while trick-or-treating on Halloween night. Watch out for cars, use reflective gear, walk with a group, and carry a flash light.”  Many publications focus on the negative possible consequences of trick-or-treating, particularly that of night trick-or-treating when vision is limited, and adult intoxication is more likely.  A head injury is not something a child should receive from Halloween, so properly accompanying a child or thoroughly teaching an older child to trick-or-treat safely is necessary.

But even though there is parental worry, trick-or-treating is an enjoyable part of being a youth.  After a child has a brain injury that should not be taken away from them.  In Middletown, OH, police delivered Halloween candy to the disabled last week.  (While the article related to this event does not state if the police delivered candy to those with brain injury, one can assume they did, as they did for all children who had limited ability to trick-or-treat.)  Related specifically to brain injury, a UK-based website warns of the issues that Halloween can cause for those with sensory issues (costumes) and noise problems (fireworks).  For those with issues that make trick-or-treating impossible, a Parents magazine online also provides ideas for other ways to celebrate the day.

Since in journalism, sensation traditionally brings in readership, most of the articles related to Halloween seem to focus on danger.  Many state websites note suggestions/guides for parents and children for safe trick-of-treating, such as HeadSmart, published by the Brain Injury Association if Utah.  For those who have a brain injury and have the ability to wear a costume and/or trick-or-treat, I hope you have the chance to do so today.  For those who are medically unable to do so, I hope you are still able to celebrate in a different, but equally enjoyable way.

To Rest or Not To Rest? That is the question…

“It is good news that the brain can recover from a hit if given enough time to rest and recover,” stated a Georgetown University-based research team member regarding the results of a 2016 study.  Two years ago, this medical study was seen as state-of-the-art and ‘first-of-its-kind’.  Early last month, the newly updated mild tbi guidelines released by the CDC retained the advisement that ‘brain rest’ is necessary for successful recovery.  The New York State Department of Health online recommends that adults with brain injuries get plenty of sleep and plenty of rest and avoid physically and mentally demanding activity.  Rest has always been the key word in every recovery advisory.

Doctors and the government, though, seem to be just as perplexed about how to optimize recovery as survivors do: three days before the recommendation for ‘brain rest’ came out, the CDC advised, “Counsel patients and their parents/caregivers to return gradually to non-sports activities after NO MORE than 2-3 days of rest.”  Another 2016 study found that children recover from mild brain injury faster when they are physically active.  Last month, Discover magazine published the results of a Columbia University study of brain injury recovery in mice, which found early reintroduction to activity sped recovery.  This multi-year study on the cerebral cortex of the brain found that this more primitive region of the brain may be more involved/important that previously thought.

However, the results of this study are not all encompassing.  The rats were given a brain injury similar to that of a stroke.  A stroke is just one form of brain injury.  Additionally, while the brain has a “remarkable capacity to adapt in response to trauma,” physical injury or other traumas to the brain, such as coma, may prevent early activity.  The Columbia University scientists note that the results of their study may be groundbreaking for patients “in some cases”.  Given the number of brain injuries incurred annually, “some cases” may be able to help many patients.

The Positive Side of Brain Injury (What?)

When I was in brain injury rehabilitation, all I knew and strived for was to return to my “old self”.  I saw my disability as an almost impassable obstacle in the road of my life, filled with negative consequences.  However, more recently, I have identified mental growth in myself from my injury.  Researching into this, I discovered the idea of post-traumatic growth (PTG):

Brain injury is a life-changing event.  For those who have or know someone who has a brain injury, the effects of it are all too apparent and can include such things as post-traumatic stress disorder, depression, etc.  The negative effects of brain injury are what is published and talked about but are too numerous to list entirely in this article.  What is less discussed, though, is that brain injury can also have a positive effect and be, “a catalyst for positive change,” in an effect known as post-traumatic growth (PTG).

PTG was first recognized as a theory in 1995 by Richard Tedeschi, PhD and Lawrence Calhoun, PhD, both from The University of North Carolina at Charlotte, as something that lets survivors see “new opportunities as possible in life, an increased sense of personal strength, a greater appreciation for life in general and a deepening of spiritual life,” among other such positive effects.  In this millennium, the idea of PTG has gained popularity and has been further explored.  In 2015, for example, the NIH published a study that found that while effects of brain injury related to employment, depression, relationship status, one’s subjective beliefs about their own post-injury recovery and other such factors do have an effect on the possibility of developing PTG, none of them have a large effect on it.

Perhaps the greatest way to study the development PTG is to study the emotional effects that can result from brain injury, such as the best predictor of PTG: “having a high level of ‘purpose’”.  Some studies report that 30 to 80 percent of those with a brain injury identify themselves has having some form of PTG.  While other studies find this percentage lower, the subjective belief of having grown from a brain injury is something that the NIH finds a good predictor.  Believing in yourself is necessary to grow.

Rehabilitation facilities have started to promote this mental growth into rehabilitation, as the theory of PTG has become more widespread.  This year, a study entitled Post-traumatic growth in adult survivors found, “a greater understanding of the development of PTG following ABI may help rehabilitation clinicians to promote better adjustment by focusing on a clients’ potential.”  Also this year, a study called The relations between post-traumatic grown and return to work following mild traumatic brain injury discovered that PTG also occurs in those with mild brain injury.  According to the NIH report, this has, “important implications for rehabilitation planning, individual and family adjustment, and the prediction of long-term outcome as it pertains to return to work, in particular.”

Fixing Grey and White Matter Isn’t So Black and White

Grey matter may be the most explored and discussed part of the brain, as it is involved in “muscle control and sensory perception, such as seeing and hearing, memory, emotions, speech, decision making, and self-control.”  Additionally, grey matter refers to the cells that are on the surface of the brain and, therefore, most associated with it.  Grey matter, however, is only half of the story – found inside the brain is the other half, white matter.  Until recently, white matter was simply thought to control the brain’s executive functioning.  While executive functions are definitely necessary, research within the past decade has found, “the role of the brain’s white matter in active learning and memory may be underestimated.”  In particular, its role in spatial memory, the memory one uses to return to rewarding locations, may be underestimated.  “Learning a new skill is [also] associated with altered white matter structure in mature brains.”

White matter gets its color from its coating with myelin.  Myelin, “allows electrical impulses to transmit quickly and efficiently along the nerve cells.”  Demyelination is the death of brain axons, nerve fibers in the brain that conduct electrical impulses away from the neuron’s cell body.  Neurological disorders are known to induce white matter dysfunction and demyelination.  For example, ischemic strokes, which involve the narrowing or blocking of arteries to the brain and accounts for 80 percent of strokes, are associated with the death of white matter and demyelination.

To prevent this demyelination, medical professionals use recombinant tissue plasminogen activator [rtPA], “a form of tissue plasminogen activator that is made in the laboratory… [and] helps dissolve blood clots.”  (tPA is, “an enzyme made in the body that helps dissolve blood clots.”)  In 1996, rtPA was approved by the FDA to treat stroke patients and it is now also used to treat heart attacks and clots in the lungs.  Brain injury can cause demyelination, as it is described as damage to myelin around nerves.  Given the previous success with rtPA, government-funded studies are now looking to see if it can help repair white matter following a brain injury.

The first study related to white matter damage and cognitive impairment following brain injury occurred in 2011 and found that, “white matter disruption is an important determinant of cognitive impairment after brain injury.”  Given this result, it is surprise that I cannot find another study on the topic until now.  This study, which was published on September 25, 2018, evaluated through electrophysiology the white matter in mice after a brain injury and then after treatment for that brain injury with tPA or rtPA.  Conducted at the public University of Pittsburgh, the Albert Einstein College of Medicine and at the Veterans Administration laboratory, the scientists found that tPA improved long-term special memory.  Specifically, “rtPA treatment makes up for a lack of endogenous tPA and prevents long-term demyelination.”

This scientific finding related to brain cell stability and cell regeneration is important.  However, recovery is never that easy.   “There are conflicting reports of harmful versus neuroprotective effects of tPA in acute brain injury models,“ states the NIH report.  Though a thorough Google search found no studies that found harmful effects, a Google search is far from a professional medical search.  A new, more neurologically-complete recovery from brain injury could soon be available.

NDEAM: Brain Injury Survivors Adapt, Businesses Must Too

Employment has the ability to make you feel like a contributing member of society; the right job has the ability to make you feel generally happy.  Because of the importance of employment for all people, including those with disabilities, National Disability Employment Awareness Month is recognized in October.  However, for about 60 percent of those who acquire a brain injury, starting or returning to work does not occur.  For a variety of reasons, they remain unemployed, a status that promotes such things as depression, already a symptom of brain injury.

The government recognizes this issue, as, if nothing else, it results in fewer taxes paid and more government monetary benefits provided.  Perhaps because of this, but most likely not wholly for this reason, they have funded multiple studies related to employment following brain injury.  After years of study that seem to have concentrated on the neurological and medical difficulty of returning to work for individuals after a brain injury, in 2016 the NIH focused on the employers and completed a study that concluded, “stigma and discrimination in mental health conditions may have an impact on expectations of RTW [return to work], and on RTW outcomes.

Since this discovery from the NIH, which may be all too obvious to many brain injury survivors, government study has continued.  However, from what I can determine, these new studies again focus on the capabilities of those with brain injury, not on the behavior and practices of employers.  In a small 2017 study entitled Opportunities and barriers for successful return to work after acquired brain injury: a patient perspective, “the aim was to increase knowledge of opportunities and barriers for a successful return to work in patients with [acquired brain injury].”  It focused on the need for individually adapted rehabilitation, survivor motivation to return to work and the survivor’s cognitive and social abilities.

Again looking at the abilities of the survivor/jobseeker, this time through medical scans and evaluation, recently a government-funded study by the Kessler Foundation was published: Impact of frontal neurobehavioral symptoms on employment individuals with TBI.  The frontal lobes of the brain are the short-term memory storage sites, direct the motor area [voluntary movement], allow the brain to transfer thoughts into words, among other important things.  “Our results indicate that frontal neurobehavioral symptoms may be predictive of the ability to achieve and maintain employment after TBI… Developing rehabilitative strategies that address these behaviors could improve employment outcomes.”  While Kessler’s conclusion may be important, taking action on the 2016 NIH findings seems just as, if not more, important.  The opportunity for meaningful employment must be there before someone can determine if they are capable of pursuing it.

(The above picture is the official Department of Labor poster for 2018 NDEAM.)

New School Year Brings New Athletic Guidelines

The new school year is well on its way and youth athletics have begun, including for “about 1 million youth between the ages of 6 and 12 [who] play tackle [football].”  However, even though this number may seem high, youth athletic participation has continued its decade-long decline again this year.  Head trauma, specifically concussions, are the major worry.

In response, the CDC has authorized new guidelines on the diagnosis and treatment of concussions and other such mild traumatic brain injuries in children. Published in the medical journal JAMA Pediatrics, and referenced by other publications nationwide since, the guidelines encompass over 25 years of research and include, “19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (i.e., must, should, or may) based on confidence in the evidence.”

Noting the decline in participation and increased parental concern, many states and school districts have updated their guidelines on concussion protocol.  This year, New York State Education Department stated that, “Local boards of education are strongly advised to develop a written concussion management policy.”  In Scarsdale, NY, for example, the school district announced, “the establishment of a Concussion Management Team, training for the Team and appropriate staff, protocol for student evaluation and return to play or activity, accommodations if necessary in academic areas, and a set of procedures that outline the role and responsibilities of all concerned.”  The website of the Central Valley District, NY has a thorough webpage regarding concussion protocol, as “[the] School District recognizes that protecting students from head injuries is one of the most important ways of preventing a concussion.”  (A list of all the webpages dedicated to concussion protocol, and a list of all the concussion protocols that have been recently altered due to increased public concern, is too lengthy to individually recognize.)

* It should also be noted that even with all the negative media coverage and medical concern, many school districts, parents and some publications still see the benefits of organized athletics in a child’s physical and social development.

New Research Center Focuses on Care to Givers

Caregivers and family members play a critical role in the “health and well-being” of traumatic brain injury survivors.  However, this medical and personal care of another can result in an additional toll, specifically on the health and well-being of the caregivers.  Last year, for example, the NIH published a report that concluded, “There is a definitive existence of psychological problems in overburdened caregivers.”  This understanding is why, last month, the VA established a new Center of Excellence focused on caregivers.  “Advocates say [that this Center] could significantly boost research and support for families caring for ailing veterans.”  There are an estimated 5.5 million veteran caregivers in the United States and an unknown millions of other citizen caregivers.

In actuality, this Center is located at four VA sites – Texas, Florida, Utah, California.  Steve Schwab, the Executive Director of the Elizabeth Dole Foundation, whose mission is to “strengthen and empower America’s military caregivers and their families by raising public awareness, driving research, championing policy, and leading collaborations that make a significant impact on their lives,” has high hopes and believes, “This Center is going to own the research in this area and a lot of areas that are still undiscovered.”

Minibus to Provide Relief and Research

Last week, President Trump signed into law a bipartisan minibus of “two critically important funding bills” for fiscal year 2019.  Specifically, the bills cover the financing of the Departments of Defense, the Labor, Health and Human Services and Education.  Included is a $2 billion budget increase for the NIH, which is 5.4 percent raise from the 2018 fiscal year.  The funding for the BRAIN Initiative, under the 21st Century Cures Act, is now set at $429.4 million.

New Jersey Congressman Bill Pascrell, Jr., co-chair of the Congressional Traumatic Brain Injury Task Force (along with Florida Congressman Thomas Rooney), released a statement, in which he notes that his funding requests related to brain injury had been met: “$125 million for the Psychological Health/Traumatic Brain Injury Congressionally-Directed Medical Research Program… as well as $6.75 million for the TBI Act programs.”  (Though the starting paragraphs of Pascrell’s press release follow party lines, the headline on his website expresses the broader view: Pascrell Highlights Budget Victories.)  Congressman Pascrell also cited the increase of brain injury research funding both for the military and the general population, which he championed.

As the Chairman of the House Appropriates Committee Congressman Rodney Frelinghuysen (NJ) remarked, “[This] legislation funds critical programs that will protect and save lives both now and in the future.”