May is… National Stroke Awareness Month. Join the conversation!

A stroke, the stop of blood flow to the brain, is a common brain injury: occurring every 40 seconds in America.  While strokes are more common in the 65+ age range, they can happen to anyone and at any time.  By Presidential Proclamation, National Stroke Awareness Month has been recognized in May since 1989, as a time to explain the symptoms of stroke, which requires immediate medical help, and to highlight ways of stroke prevention.

“In observance of National Stroke Awareness Month, NINDS (National Institute of Neurological Disorders and Stroke), Million Hearts, American Academy of Neurology (AAN), and the American Stroke Association are co-hosting a Twitter chat to discuss stroke risk factors, the importance of keeping your brain healthy, and the latest stroke research. #BrainforLife will take place Wednesday, May 2, from 1-2 p.m. ET.  Medical experts, including NINDS Director Dr. Walter Koroshetz and AAN President Dr. Ralph L. Sacco, will be on hand to answer questions.”

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AVs: Salvation or Hazard

Getting an extra 30 minutes of sleep while you’re on the road… finishing yesterday’s homework while you’re on your way to your senior year of high school… caring for your baby while you’re breezing through the highway.  All of these scenarios seemed too good to be true a few years ago, but now America is on the cusp of the age of autonomous vehicles (AVs).  As it is, in 2016, 87.5 percent of people ages 16+ had their driver’s license and spent, on average, a total of 17,600 minutes on the road a year.  The idea of a car that could do the tedious and time-consuming duties of driving is a dream that is quickly becoming a reality.

For the disabled, the benefits of autonomous cars are even greater – if nothing else, it allows for increased independence.  It means the legally blind, for example, will finally be able to safely operate a car by themselves.  A 2012 video of a legally blind man stopping at the Taco Bell drive-thru prompted much positive excitement.  The means with which to allow the blind to safely drive is still in actuality in development, but spokesmen do say, “At Waymo, Google’s self-driving car company that was launched nearly a decade ago, officials say visually impaired employees contribute to design and research. While no specific system for blind riders has been completed, the company says it’s developing a mobile app, Braille labels and audio cues.”  As Americans gets older, a self-driving car could help those who have a, “loss [of] flexibility, vision and hearing,” and delayed reaction time.  Of course, these are some of the same impairments suffered by those with brain injuries.

However, this may seem too good to be true because it is just that.  Car fatalities have been on an almost steady decline, from a high of more than 50,000 in the 1970s to the low to medium 30,000s this decade.  (“An additional 2.35 million are injured or disabled.”)  Though this is still an extremely high number, how will fully autonomous or semi-autonomous cars affect this?  Beyond testing, no one knows if or by how much this will decrease with the use of self-driving cars.

Cars don’t have the same “sense” that people do.  Only a month ago, on March 20, 2018, in Arizona, a homeless woman became the first pedestrian fatality to be attributed to this new technology. “If there is any real-world scenario where it would be seemingly safe to operate in an automated mode, this should have been it. Something went seriously wrong,” said an urban planning professor after the incident.  (The car that caused the fatality was a self-driving Uber.  Uber has since suspended it’s self-driving car tests.)  In Mountain View, CA, headquarters to self-driving car company Waymo, Walter Huang was killed after the sun glare got into his eyes when his Tesla noted that it needed him to take the wheel, resulting in his vehicle driving straight into a highway median.  Two years ago, in Florida, a man was killed when he failed to take the wheel after numerous notifications from a self-driving car.  (The National Transportation Safety Board released a report of findings about the incident.)

In a horrifying test, reported by Psychology Today this month, “some recent demonstrations have shown that a few black stickers on a stop sign can fool the algorithm into thinking that the stop sign is a 60 mph sign.”  As far as accidents go, in Pittsburgh, PA in late February, a “Woman claim[ed a] self-driving Uber struck her car, left the scene.”  Did that driver choose not to stop or did the car leave on its own?

The above are just a few examples of accidents or possible accidents resulting from problems with autonomous cars.  (I am not sure how many more examples there are, if any.)  Tesla said in 2016, “Autopilot is by far the most advanced such system on the road, but it does not… allow the driver to abdicate responsibility.”  Presumably the technology has gotten much safer in the past 2 years because California just legalized testing of fully-autonomous vehicles on public roads.  Nationally, H.R. 3388 passed the House unanimously.  The bill’s subtext says that its intent is, “to provide for information on highly automated driving systems to be made available to prospective buyers.”  Further reading though, one finds that the goal of the bill is, “encouraging the testing and deployment of such vehicles.”  (Read also: California proposes new rules for self-driving cars to pick up passengers.)

Self-driving cars have already been tested in multiple states with positive results.  For example, in California, the state with the most drivers in America and the state that is testing AVs the most, Waymo just applied to the state to do what the above law indicates: test self-driving cars without a back-up driver on public roads.  (Besides California, many other states already have laws or proposed laws on the legality of self-driving cars.) Six months ago, GM announced its plan to start testing its Chevy Bolt EV in Manhattan later in 2018.  In Connecticut, Governor Daniel P. Malloy created a pilot program, which will soon launch, to test fully-automated cars.  And this month, the Pentagon announced that it intends to become the next big AV developer, as it soon plans to use self-driving vehicles in combat.  As Michael Griffin, the undersecretary of defense for research and engineering, states, “52 percent of casualties in combat zones can been attributed to military personnel delivering food, fuel and other logistics.”  Removing humans from this equation will save many lives.

Since there has been no final determination of the safety or legality of self-driving cars for the general population or for the disabled, no conclusion can be made on this post.  Some car manufacturers are addressing the public’s worries about fully autonomous cars by making them just not really that.  For example, one company, Phantom Auto, has developed a remote control car system, in which the car is “driven” remotely by an employee miles away.

But perhaps the worry about autonomous cars is similar to that which arose when America changed from horse-and-buggy to modern cars?  The concern and the extreme testing are understandable, but some states realize that the testing must stop at some point.  Is that time now?  In addition, should we allow those who are currently hindered from driving by their age or disability to get a key?

* Another issue that some have with self-driving cars is that, “AVs will record everything that happens in and around them. When a crime is committed, the police will ask nearby cars if they saw anything.”  For car accidents and other such physical and/or vehicular traumas this is a plus.  However, while a person or their family may want to know what vehicle caused their child’s car accident, do they want to give the government the ability to know exactly when they left for work, went to Walmart, refilled their gas tank, etc.?  Will self-driving cars be the means for social control?

Magic Is An Illusion; Trauma Is Not

For me and many others, David Copperfield is the nation’s foremost illusionist/magician.  He even earned a spot on the Hollywood Walk of Fame in 1995.  From 1974 until last week, his magic has been just that; Copperfield could do what seemed impossible.

In 2013, an audience member was selected to participate in a trick called “Lucky 13”.  The trick required participants to enter a box which is then closed.  Miraculously, the participants would then appear at the back of the theater at the MGM Great Resort and Casino in Las Vegas.  (If you want to understand how the trick was performed, click here.)  The aforementioned audience member, Gavin Cox, had a slip-and-fall during the execution of the illusion and, “was taken to the hospital with a dislocated shoulder. After returning to Britain… he suffered chronic pain [and confusion] and a scan showed a lesion on his brain.”

Most simply described, a brain lesion is an injury or disease affecting the brain.  The cost of the two fusion surgeries, plus a diagnosed traumatic brain injury, has been more than $400,000 for the plaintiff.  (I have found no information regarding the non-surgical treatment Cox received for his tbi.)  Cox filed a multi-million dollar negligence lawsuit in 2014 to cover these medical costs and his pain-and-suffering.  In addition to Copperfield, MGM Grand, show producer Backstage Employment and Referral, and building firm Construction Management were named as defendants in this suit.

Given Copperfield’s popularity, this suit has gained a lot of press.  (I even found an article about it in Golf Digest.)  Two other past participants of the trick have since come forward claiming injury as a result of participating in this trick.    Despite this controversy, though, Copperfield is still performing, albeit without this illusion.

Department of Energy: Who Knew?

I think we are all aware that the Department of Energy is not who sends us our monthly power bills to keep our lights turned on.  However, what exactly do they do?  Earlier this month, U.S. Secretary of Energy Rick Perry addressed this during a speech to the Hopkinsville, Kentucky Chamber of Commerce: “People might be surprised to learn that the Department of Energy oversees the country’s nuclear weapon supply, 17 national labs and research into dealing with post-traumatic stress and traumatic brain injuries.”  While the research supported by the Dept of Energy is targeted towards the military, research that develops new knowledge and new innovations for those in the military with a TBI can help all TBI survivors.  In late March, Perry toured a research facility, Brooke Army Medical Center, in his home state of Texas.  “The real recipients of what we’re doing are future warfighters, our veterans, and citizens who have had either PTSD or a traumatic brain injury,” he said during his visit.  As an Air Force veteran who served both in Europe and the Middle East, Perry is, unfortunately, all too familiar with this, through his fellow veterans.

Contradictory Results Show No Easy Answer

I began this week planning to write an article about the benefits of progesterone for those who have a brain injury.  Progesterone is a natural hormone associated with the menstrual cycle and pregnancy in women and is a precursor to testosterone in men.  Related to brain injury, Phase 1 and 2 tests in two U.S. nationwide studies, as well as in studies in twenty other countries, showed that progesterone aids recovery for animals and select humans.  Donald Stein of Emory University, who studied the effects of progesterone on TBI for two decades, mused in 2013, after these earlier tests proved successful, about the possibility that such a common, natural hormone could be beneficial in recovery from such a terrible injury.  Recent studies have found that animals given progesterone repair brain cells and produce new cells more quickly.    (Similar reports can be found on studies related to increasing estrogen after brain injury.)

Other studies, though, have found no such effect.  For example, the New England Journal of Medicine cites a 2014 study that found that patients treated with progesterone had no more likelihood of a positive result than those treated with a placebo (50.4% and 50.5%, respectively).  As the NIH notes then, the benefit of progesterone for brain injured humans is essentially impossible to determine because, “the trauma of individual patients [cannot] be controlled well in comparison with the animal model. The heterogeneity and variability of TBI [in humans, versus animal models who are given head injuries for the purpose of the study,] may be one of the important reasons.”  The Emory study, for example, was stopped at Phase 3, after only 882 participants, “because safety monitors determined that additional enrollment would be futile.”  (Again, similar results can be found related to increased estrogen after brain injury.)

Progesterone is only one example that shows such contradictory study results about possible brain injury treatments.  Studies are similarly inconclusive as to whether brain injury can cause other problems, such as Alzheimer disease, or helped by new treatments, such as therapeutic hypothermia.  In a column written in 2016 by the aforementioned Emory professor, Donald Stein noted that, “Each and every TBI drug that has reached late-stage clinical trials has failed. This 100 percent failure rate represents a huge human and economic cost.”  As for that economic cost, “the NIH invests nearly $37.3 billion annually in medical research for the American people.”  The majority of this money is given to universities, medical schools, and other research institutions, so paying for TBI studies that have a likelihood of failure may not seem prudent.

No one is saying to stop researching treatments for TBI.  Millions of people rely on treatments that years ago seemed far-fetched, until research and testing was conducted.  Additionally, the care for millions of brain injured people who were not provided the correct treatment would be far more costly than that of research.

(Yes, the progesterone studies are inconclusive.  However, eating foods containing progesterone is never a bad idea.  So, make sure to have some cauliflower, nuts, or a pumpkin pie.)

mTBI, Not So Mild for the Older Generation

Last month, Rep. Louise Slaughter (NY) fell, resulting in a trip to the hospital.  “The Congresswoman is tough as nails and she will bring that same spirit to the recovery,” said her Chief of Staff at the time.  A Google search of “Louise Slaughter brain trauma” results in many links, including one entitled “Rep. Slaughter Announces Nearly $13 Million to Address Traumatic …”.  When clicking this link, however, one is directed to a now defunct personal webpage.  (A further search shows that Rep. Slaughter was a member of the Congressional Brain Injury Task Force, with particular attention paid to military weaponry.)

First elected to office in 1986, Slaughter was assuredly “tough as nails”, as she had to be, working in Congress and dealing with publications/broadcasters for so many years.  The first female chair of the House Rules Committee and the dean of the NY congressional delegation, Slaughter was planning on running for her 17th term.  “Louise was a trailblazer,” said Nancy Pelosi.  Unfortunately, the 88-year-old woman couldn’t recover from the intracranial hemorraging that resulted from the fall and passed away in mid-March.

Besides Rep. Slaughter, other politicians and others involved in politics have suffered such negative results from intracranial hemorraging.   Roger Ailes was a media consultant for President Richard Nixon, President Ronald Reagan, and President George H.W. Bush, as well as for Rudy Giuliani’s first mayoral campaign.  Most recently, he was CEO of Fox News until 2016 and served as a media consultant to Donald Trump’s presidential debates, before he passed away from intracranial hemorraging (subdural hematoma) in May 2017.  Additionally, one of the most respected past Presidents, Franklin Delano Roosevelt, died of intracranial hemorraging that was either caused by cancer or by high blood pressure.

Intracranial hemorraging is an all-encompassing diagnosis for bleeding within the skull that can be further categorized as an epidural hematoma, subdural hematoma, subarachnoid hemorrhage or intracerebral hemorrhage.  It is a form of mild traumatic brain injury (mTBI), that isn’t mild at all.  A concussion, for example, is a mTBI.

In 2012, the CDC reported that, “in the United States, the number of TBIs that occur each year among older adults, ages 65 years and older, is estimated at 237,844.”  Falls, as what happened to Rep. Slaughter, are the primary cause of TBI among the 65+ age range.  Additionally, it’s hard to assess how severe a brain injury is the older generation, because of other age-related issues.  Is a person’s memory loss due to a brain injury or simply a consequence of age?  The number of elderly Americans suffering a mTBI keeps rising, but the reason for this increase is unknown.  Perhaps it is because Americans are living longer?  Perhaps because Americans are living in their homes and generally staying active later in their lives?  Maybe it’s because new research and talk about such issues as sport-related injuries are being more broadly researched and discussed?

Tragedy Yields Action from Senate Sergeant-at-Arms

On September 11, 2001, Frank J. Larkin was working at the Secret Service’s New York City headquarters in the World Trade Center.  “[I was] dodging, unfortunately, folks who were jumping to their deaths, you know, witnessing that, which is something you just never forget,” he recalls.  A Navy SEAL, with nearly a decade in combat, Larkin has also worked for the Maryland State Police, in association with the Department of Defense, and as a Secret Agent for the US Secret Service.  Then, on January 6, 2015, he was nominated and appointed by Mitch McConnell to the position of Senate Sergeant-at-Arms, “its chief law enforcement officer, protocol officer, and executive officer.”

His son, Ryan F. Larkin, also felt this need to serve, following in his father’s footsteps and enlisting in the Navy in 2006.  Once enrolled, Ryan was deployed twice to Iraq, twice to Afghanistan and completed missions in Lebanon and Honduras.  Considered “a renaissance man,” he received many awards.  In March 2016, Ryan received an Honorable Discharge from the Navy.  While he stayed active post-deployment by, for example, attending college, his discharge was assumedly given at least partially because of a recognized brain injury.  On April 23, 2017, Ryan Larkin took his own life.

As someone without children, I cannot imagine what the loss of a child feels like.  However, I have always heard that it is the worst thing that can ever happen to a parent. Specifically related to Sergeant-at-Arms Larkin, it upended his life, including his career.  In March, he sent notice of retirement.  “Now I feel this obligation to help others…. These men and women volunteered to go in harm’s way to protect this nation, and we promised that we’d take care of them.  But we’re not living up to that promise.”  Upon leaving his job, he intends to spend his time advocating for projects related to traumatic brain injury research, particularly research related to military blast exposure, like that experienced by his son.

A VA study, published in September 2017, reported that the suicide rate for veterans is about 20 percent higher than the rate for non-veterans.  (That statistic is debatable.  Some say its lower and others have said its as high as 22 percent.)  “These findings are deeply concerning,” said VA Secretary Dr. David J. Shulkin at that time.  “What’s more, they report that veterans’ suicides account for 18% of the suicide deaths in the country, while they only make up 8.5% of the adult population.”  The National Center for PTSD, part of the VA, knows and notes the relationship between PTSD and suicide.  On January 10, 2017, Rep. Peter King (NY) introduced H.R. 411, the Veteran Suicide Prevention Act.  This bill was referred to the Subcommittee of Health on February 3, 2017 and it seems nothing has been done with it since that time.

[As of April 2018, Larkin is still in office and he has stated that he will not retire until his replacement is found.]

Rep. Smucker Joins Congressional Brain Injury Task Force

The Congressional Brain Injury Task Force states that its mission is, “to increase awareness of brain injury in the United States, supports research initiatives for rehabilitation and potential cures, and strives to address the effects such injuries have on families, children, education, and the workforce.”  This seems that it would be a unifying goal, going beyond political partisanship, and for that reason, most states have one or more Congressman serving on the Committee.  At the beginning of this year, Pennsylvania had 5 Congressmen serving as members.  Now, during Brain Injury Awareness Month and just after the Congressional Brain Injury Fair, Rep. Lloyd Smucker (PA-16) joined.  (Congressman Lou Barletta, who represents Carlisle, PA in the 11th district, where the Brain Injury Association of Pennsylvania is located, is not a member, though that does not mean that he does nothing to support those with tbi.)  At the moment, Smucker’s website does not mention his involvement with the task force and critics cite his support for and from the NRA as an indication of his disregard for American lives.  However, Smucker is a Congressional Republican, so his support for the NRA should be of no surprise.  He should not be told he cannot help brain injured Americans for that reason.   (More members may mean more ideas and more action from the Committee.)

(Above picture, originally published on March 29, 2018, is courtesy of the Facebook page of the Brain Injury Association of Pennsylvania.)

Listening to the Benefit

Last week, an Arizona publication noted what too many TBI survivors know: brain injury can make certain sounds intolerable.  Hyperacusis, an extreme sensitivity to sound, is a common effect of a neurological disorder.  “In hyperacusis, the symptoms are ear pain, annoyance, and general intolerance to many sounds that most people are unaffected by.”  Additionally, hyperacusis is often accompanied by “the hearing of sound when no external sound is present,” known as tinnitus.  It has been found that about 20 percent of the population suffers from this debilitating condition and it is the top service-related compensation for the U.S. Department of Veteran Affairs.  Yes, tinnitus may go away for some, but it’s a lifelong condition for others.  (Notable individuals with tinnitus includes President Ronald Reagan.)

Given that, it’s a surprise that studies have found that music can actually help the brain heal from an injury.  “If you’re trying to restore neuroplasticity in the brain, to re-establish some of the connections that were there before the injury, music can be a big help,” said a neuroradiologist at Wake Forest Baptist Medical Center regarding a study at the hospital last year.  Multiple sources, though, note that what one listens to must already be a favorite tune or a favorite music genre to have the appropriate effect.  “If you love it, it loves you back. Signs of the musically activated brain included increasing the activity and connections in memory and emotional centers.”  With this in mind, the University of New Mexico has started a Neuro Choir that helps those with brain injuries work on their communication abilities, socialize with other members of the choir and gain the benefits of music therapy.  “One of the theories is that it helps to pull along the words especially if it’s been a highly learned song. Whereas if they were just trying to say the words in a conversation it may not come out,” said Richardson of music’s communications benefit.

Music therapy is already an accepted means of treatment for such conditions as autism and PTSD in the military.  Neurologic Music Therapy is still in its earlier stages, though government-based studies note that, “from a neuroscientific perspective, indulging in music is considered as one of the best cognitive exercises.”  (However, it is partially because it is such a cognitive activity that it can be intolerable for those with tbi.)  As doctors learn to better treat veterans and others with hearing problems/ear disorders, by testing such treatments as sleeping with white noise, perhaps the healing benefit of song will have the chance to be experienced by all tbi patients.

(The National Center for Biotechnology Information, part of the National Institute of Health, just posted the results of a study that shows that tbi can cause musical halluciations.  Tinnitus and music hallucinations have the commonality of “hearing” an often intolerable imagined sound, but both stop short of psychosis, as the patients ultimately realize the true source of the “sound”.)

Sit Down and Breathe

The easiest way to heal from a brain injury is simply to replace the injured parts of the brain.  Though this thought may seem both impossible and simply weird, scientists are now learning how to replace, or rather regrow, the brain in the healing of traumatic brain injury.

Specifically, it is well-known that human life depends of the inhalation of oxygen.  Oxygen also helps the body heal, as it is transported through the body in red blood cells.  Leveraging this healing process, hyperbaric oxygen therapy (HBOT) has been developed as a medical treatment in which one is encapsulated in a room or chamber filled with 100% oxygen.  (The air humans typically inhale is only about 20% oxygen.)  Additionally, HBOT has three times more air pressure than is typically experienced.  Increased inhalation of oxygen means that it is not only transported through red blood cells, but also, “into all of the body’s fluids, the plasma, the central nervous system fluids, the lymph, and the bone.”  More oxygen means more opportunities to aid healing, even while appropriate oxygen is still provided to the lungs.

Based on this evidence, it seems that HBOT would be a logical choice for professionals to treat those with certain injuries.  For example, Lake Regional Wound Healing Center in Missouri has been named a Center of Distinction, largely for its work with HBOT.. In New Mexico, a pickleball benefit  was recently held both to honor deceased veterans and to raise funds for Mission 22, an organization that offers HBOT to those with TBI.

More so, the federal government discovered these benefits a few years ago.  In June 2014, for example, the NIH published a study entitled Red blood cell transfusion in patients with traumatic brain injury: a systematic review protocol.  In 2016, they published the results of a study entitled Hyperbaric oxygen therapy for traumatic brain injury: bench-to-bedside, during which they concluded that, “HBOT has been demonstrated to have neuroprotective effects without increased oxygen toxicity in experimental TBI models when administered at pressures less than 3 ATA [atmospheric pressure].”

In recent days, a law to provide HBOT to veterans suffering from injury, including TBI and PTSD, was presented to the Arizona legislature.  Specifically, Hyperbaric Oxygenation Treatment for Veterans with Traumatic Brain Injury was sponsored by Mark Finchem and passed the State House and Senate unanimously.  On Thursday, March 29, HB 2513 was signed into law by Arizona Governor Doug Ducey.  Reading about Arizona’s action reminds one that many other states have also passed such legislation: Oklahoma, Texas, Indiana and Kentucky.

* Two relevant questions regarding HBOT, with helpful answers:

“How does hyperbaric oxygen help brain injury or stroke? When cells in the brain die, either from trauma or lack of oxygen, blood plasma leaks out into surrounding brain tissue causing swelling and reducing blood flow. These otherwise normal cells go dormant because they can’t function without the appropriate amount of oxygen. HBOT dramatically increases the oxygen carried in the blood plasma, making oxygen available to heal damaged capillary walls, preventing plasma leakage and reducing swelling. As the swelling decreases, blood flow can be restored to the dormant tissue (neovascularization) and these cells then have the potential to function again.”

“How does hyperbaric oxygen help a child with cerebral palsy (CP) or traumatic brain injury (TBI)? In CP and TBI patients, some of the injured brain tissues may be “dormant” and non-functioning. HBOT can stimulate these “dormant” tissues and return them to more normal function. In young children, cognitive function and spasticity can be improved.”