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[BLOG POST] Stuck at Home? Resources to Stay Active and Engaged – Collection Spotlight from the National Rehabilitation Information Center

Life is looking very different right now, thanks to the coronavirus outbreak. Many people are staying close to home, teleworking or telelearning, and restricting their social interactions significantly. During this unprecedented time, people may want to explore opportunities to learn and interact online, and they may be looking for activities they can participate in while keeping up the recommended social distancing. We’ve gathered some resources from the NIDILRR community and elsewhere which we hope will help you stay engaged, active, and connected to your community.

Keep Learning

Online courses, webinars, and programs can help you stay mentally engaged. Many of these learning tools also offer continuing education credits which can be applied toward certifications, memberships, and professional licensing.

Stay Active and Engaged Close to Home

We may not be able to go to our favorite gym or exercise class, but we can still be active and stay within the recommended guidelines.

Connect to the Community Virtually

Many of us are turning to our social media feeds and our email inboxes to stay connected to friends, family, and coworkers. It can also be useful for researchers who want to get their research results into the community without traveling to conferences and meetings.

Consider Online Participation in Research

From surveys to phone or web interviews, there are many ways to participate in ongoing research that can benefit you and your community without leaving home. We regularly feature these opportunities in our News and Notes from the NIDILRR Community and Beyond weekly newsletter. Here are just a few currently recruiting participants:

In addition to these resources from the NIDILRR grantee community, you might want to explore these websites from other agencies, organizations, and national sites:

  • National Park Service – find and virtually explore national parks nearby and far away, learn about discount programs for seniors and people with disabilities.
  • Smithsonian Institutions – virtually explore the Smithsonian’s collections and exhibits, plan a future trip, visit the Science Education Center for fun games to play online.
  • National Gallery of Art – virtually explore the exhibits, find lessons and online courses for adults and kids.
  • National Center on Health, Physical Activity, and Disability – find articles, videos, and more to keep you healthy, active, and engaged.
  • 211.org – the Information and Referral community is fully engaged in helping people connect to help in their community. Call 211 or visit 211.org to find your local help line, speak with a community resource specialist, and find the support you need.
  • National Library Service for the Blind and Print Disabled – NLS is a free braille and talking book library service for people with temporary or permanent low vision, blindness, or a physical disability that prevents them from reading or holding the printed page.

We hope you and your community remain healthy, active, and connected during this stressful time. Please contact our information specialists if we can be of any assistance!

 

via Stuck at Home? Resources to Stay Active and Engaged | Collection Spotlight from the National Rehabilitation Information Center

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[WEB PAGE] Definition of a Disability – Great Plains ADA Center

ADA-AA Definition of a Disability

The Americans with Disabilities Act (ADA) defines disability as a“physical or mental impairment that substantially limits one or more major life activities.” This is a legal definition, rather than a medical definition. The ADA definition of disability does not apply to disability-related services such as Social Security.  The definition of disability was expanded and clarified by the ADA Amendments Act in 2008.

The ADA definition of disability does not include a list of required medical conditions or categories. There is no “national registry” or any other type of certification process that people must complete to qualify as a person with a disability under the ADA.

At first glance, determining whether a person has a condition that meets the ADA definition of a disability may seem complicated and confusing.  However, the determination is based on three fairly straight-forward questions.

1) Is there a condition/impairment that impacts major life activities or body system functions?

  • When active-does not have to be a daily 24/7 impact.

2) Is the impact on major life activities or body system functions substantial?

  • Based on the level of impact when not using medication, an assistive device, receiving treatment, etc. (mitigating measure).
  • Based on comparison with the general population and peers.

3) Is the condition/impairment permanent or long-term?
The purpose of this article is to clarify this process by explaining the definition’s terminology and providing several real-life examples.

Major Life Activities

Major life activities are basic activities that most people can perform with little or no difficulty. These activities may be physical such as walking, seeing, hearing, standing, use of hands, etc.  Cognitive and social/emotional activities such as memory, paying attention, processing information, and maintaining well being and moods are considered major life activities.

Major life activities also include the activities required for body system functioning. Conditions which affect the functioning of the digestive, neurological, immune, and circulatory systems, etc. would be considered conditions that affect major life activities.

The definition of a disability was specifically expanded to include conditions or impairments that affect body functions (such as diabetes or rheumatoid arthritis) to ensure people with all types of disabilities are included in the definition and receive protections under the ADA.

Episodic Conditions and Remission

Some conditions and/or impairments have symptoms that are not always present. These types of conditions are called episodic. Disability is assessed on the impact of these conditions on major life activities and body functions when the symptoms are active.

If a person’s active symptoms meet the definition of a disability, then the individual is always covered by the ADA, even when the symptoms are not present. This reasoning also applies to conditions that may go into remission such as cancer.

Example:

Marla has multiple sclerosis and uses a wheelchair. At work, there are times when she walks short distances with a cane. When her condition is in remission, she only uses a cane. Some of Marla’s co-workers think she shouldn’t receive accommodations because she doesn’t always use a wheelchair.

Marla is considered a person with a disability at all times.  She does not have to use a wheelchair daily to receive accommodations related to using a wheelchair.


Jamal has completed chemotherapy and, at his last follow-up appointment, was told his cancer is in remission, but will still require follow-up care. Jamal is concerned that he will no longer be able to use his flex schedule to make-up time for follow-up appointments and continued treatments.

Jamal condition is in remission, but without continued treatment, the cancer would have a substantial impact on major life activities.  Jamal’s condition is considered a disability under the ADA.


Linn has Seasonal Affective Disorder. His symptoms of depression only affect major life activities at certain times of the year. Because Linn’s condition is long-term and impacts major life activities when present, it is considered a disability under the ADA, even though the condition is not always present.


Invisible Disabilities

A condition does not have to be visible or “readily apparent” to be considered a disability.  Many conditions that are not readily apparent to the general population still affect major life activities.  Whether or not a condition is “visible” is not a consideration when determining whether a person is covered by the ADA.  It is the impact of the condition on major life activities that determines disability.

Examples:

Maria has dyslexia. She uses assistive technology to get information and prepare reports. Because reading and writing are major life activities, Maria is a person with a disability.


Joshua has been diagnosed with PTSD and receives treatment.  Joshua is outgoing and physically fit and probably would not be perceived as a person as a disability. However, based on how his condition affects his major life functioning (anxiety), Joshua is a person with a disability covered by the ADA.


Substantially Limited

Once it is determined that a person has a condition or impairment that affects major life activities, the next step is to assess the impact of the condition/impairment. The impact of the condition/impairment on a major life activity must be substantial to be considered a person with a disability under the ADA. The criteria used to determine whether or not the impact of a condition is substantial is based on two factors:

  • The nature and severity of impact on major life activities.
  • How long the impact will last or is expected to last (permanent or long-term).

A common sense assessment should be used to determine the nature and severity of a condition based upon comparing the person’s ability to perform a specific major life activity with that of most people in the general population. The same criteria is used for assessing body system functions.

Example:

Tamra is in her thirties. She has poor vision without glasses and must wear them to see clearly and function. Since wearing glasses or contacts to correct vision impairments is common in the general adult population, Tamra would not be considered a person with a disability.

Jean, on the other hand, is also in her thirties and has low vision and difficulty seeing contrast. She wears glasses, but still cannot see clearly and requires assistive technology to use computer screens and her smart phone. Jean’s level of visual difficulty is not typical for her age group in the general population. She would be considered to have a disability under the ADA.


Example:

Two employees have the diagnosis of asthma:

  • One employee uses an inhaler occasionally, and his asthma is very mild.
  • The other employee uses an inhaler occasionally, but flare-ups are severe and could be life-threatening.

In this example, the frequency that the condition occurs is the same, but the severity of the condition is different. The severity of asthma is the basis of determining which employee has a disability under the ADA.


Example:

Two employees experience migraine headaches.

One employee has a severe migraine headache two to three times a year, causing her to miss up to three days of work annually.

Another employee has a severe migraine headache 3-4 times a month, causing him to miss up to four days of work each month.

In this scenario, the severity of the condition is similar, but the frequency and impact on major life activities is different. While experiencing a migraine headache is not uncommon in the general population, the severity and frequency of the second employee’s migraines result in a substantial impact on major life activities.


Assessment of Disability and Mitigating Measures

Actions taken to eliminate or reduce the impact of an impairment/condition are called mitigating measures. This includes, but is not limited to, medication, treatments, assistive devices, hearing aids, wheelchairs, and therapies. The extent that a condition impacts major life activities is based upon how the condition affects a person without using a mitigating measure.

Example:

Bill has Type II diabetes, and insulin is his “mitigating measure.”  Bill has no limitations on his major life activities when he monitors his blood sugar and uses insulin. However, he uses insulin because his endocrine system is substantially impaired. Without insulin, the impact on his major life activities and overall body functions would be severe. Bill is covered by the ADA as a person with a disability.


Takeaway: Whether or not a person has a disability is based upon the impact of the condition or impairment on major life activities and body functions without the use of a mitigating measure.  A person does not have to use a reasonable accommodation in the workplace or other modifications to be covered by the ADA.


Length of Time or Duration of a Disability

Conditions and/or impairments that are short-term do not meet the definition of a disability under the ADA, even if the condition meets the other criteria:  substantial impact on major life activities.

Example:

Evan injured his back and is required to limit most physical activities for at least a week. He is in pain and must take medication.  However, he is expected to fully recover in 2 weeks.

Even though the impact of Evan’s condition is substantial, the impact is short-term and would not be considered a disability under the ADA.


Example:

Shawna became very ill with a life-threatening infection. She spent two days in the hospital before returning to work 1/2 days for a week. She then returned to work full time. Her infection is gone and she requires no extended treatment.

Although the impact of the condition was life-threatening, the impact was short-term with a full recovery.  Shawna would not be considered a person with a disability under the ADA.


Example:

Glenda was in a car accident. Her injuries were severe and she will require rehabilitation. Although Glenda is expected to fully recover, she will use a wheelchair and then a cane for at least six months.

Glenda’s injuries will not have a permanent impact on major life activities. However, she is covered under the ADA because of the length of time that her condition impacts major life activities.


Other Factors Covered by the ADA

ADA protections are provided to people who don’t have a disability, but may experience disability related discrimination based upon:

  • Having a record of a disability that is no longer present.
  • Having a condition or appearance that is regarded as a disability, but actually has no impact on major life activities.

Example: Record of Disability

Tim has been cancer-free for five years and is considered to be in complete remission. His employer does not promote him as expected because the employer says the “cancer may come back”.

Under the ADA, Tim is protected from discrimination that is based solely on his history of having a disability.


Example: Regarded As

Jenna has noticeable burn scars on her face.  Her scars have no impact on major life activities and require no medical care. However Jenna is turned away from a job interview because of her facial scars. The employer believes her scars will “make her unable to work with customers.”

Under the ADA, Jenna would be protected from discrimination because her employer regarded her scars as a disabling condition.


Definition of a Disability and Employment

A person with a condition that meets the definition of a disability under the ADA is protected from employment discrimination, but they must also be:

  • Qualified for the position they seek.
  • Able to perform the essential functions of the job with or without reasonable accommodations.

In other words, Title I of the ADA protects qualified individuals with disabilities who can perform the essential functions of the job with or without reasonable accommodations.

A person with a disability may be asked to provide documentation from their medical professional if their disability is not “readily apparent.”

Summary: Key Concepts

  • The definition of a disability is a legal definition rather than a medical definition.  The definition does not apply to qualifying for disability-related services such as Social Security.
  • There is no list of required medical conditions or categories included in the law. There is also no “national registry” or any other type of certification process that people must complete to be considered to have a disability under the ADA.
  • The ADA applies to all ages.  Children with disabilities are covered by the ADA.
  • The ADA makes no distinction between types of disabilities.  Individuals who meet the definition of a disability all have have the same rights under the ADA.
  • The criteria used to determine disability is based on the impact of the condition/impairment on major life activities instead of just the presence of the condition.
  • The impact of a condition on major life activities is assessed by how the condition affects major life activities without the use of mitigating measures (actions taken to alleviate symptoms or improve functioning such as medication, therapy, or hearing aids.)
  • The ADA protects people who have a past record of disability from discrimination.  The ADA also protects people who do not have a disability, but are “regarded as” having a disability.
  • The ADA protects people with disabilities from discrimination in the workplace, but they must be qualified for the job they hold or are seeking.

via Definition of a Disability | Great Plains ADA Center

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[BLOG POST] 14 Things You Need to Start Doing for Your Emotional Health

What does it mean to be emotionally healthy and what can we do to improve our emotional health?

According to familydoctor.org, “People who are emotionally healthy are in control of their thoughts, feelings, and behaviors. They are able to cope with life’s challenges. They can keep problems in perspective and bounce back from setbacks. They feel good about themselves and have good relationships.”

As a psychotherapist, I help people increase their emotional health. This includes healing from trauma, understanding their emotions, communicating their needs, pursuing their goals, creating healthier relationships, and increasing their self-esteem and confidence. How we go about making these changes is a more difficult question (and could easily fill an entire book). In this article, I hope to give you a place to start – some things to focus on, that when done consistently, will help improve your emotional health.

13 Things you can do for your emotional health

  1. Forgive yourself for past mistakes. It’s time to stop beating yourself up for things you did wrong, for missed opportunities, for not knowing what you know now. We all have regrets, but dwelling on them weighs us down unnecessarily. Self-forgiveness begins with acknowledging your mistakes, making amends (if appropriate), learning from your mistakes, and deciding to focus on the present and future rather than the past.
  2. Treat yourself with the same love that you give others. For most of us, it’s easier to be kind to others – even strangers – than it is to be kind to ourselves. We hold ourselves to mercilessly high standards and feel undeserving of a kind word or even basic self-care. Try treating yourself like a valued friend. Notice when you’re being cruel or withholding comfort from yourself and instead give yourself what you’d give a friend – a hug, validation, encouragement, or a treat.
  3. Have fun. Hobbies, play, and laughter are all good for our mental health. Be sure your calendar includes activities that you do purely for enjoyment. If you’re not sure what you like to do for fun, read more here.
  4. Trust yourself. In order to trust ourselves, we must consistently meet our needs; we have to show up for ourselves in times of need with kindness and comfort. We need to feel confident that we’ll act in our own best interest, value ourselves, and protect ourselves. You can start building self-trust by committing to do one small thing for yourself today and following through. It’s essential that this commitment is doable, so don’t choose something that’s a stretch. It might just be saying you’re going to bed at 10 O’clock and then doing it. Consistently keeping your promises to yourself builds self-trust.
  5. Rest when you’re tired. Rest is essential and the appropriate response to both physical and emotional depletion. At yet, so many people feel guilty for resting, for not being productive all the time. Rest or taking a mental break improves productivity, memory, creativity, and concentration. It allows us to integrate what we’ve learned, rejuvenate, and clear our minds. It’s certainly not a waste of time!
  6. Set boundaries. Boundaries protect your time, energy, and personal safety. They communicate your expectations and help others understand what’s okay with you and what’s not. However, when you’re not used to setting boundaries, it can be scary and confusing. Take it slow. Learning to set boundaries is a skill that we learn with practice. Start by identifying what you need, how you want to be treated, and remind yourself that your needs are valid and communicating them assertively is healthy. Read more here.
  7. Let go of resentments. Are you holding onto anger and grudges? This sucks up energy that you could be using for more positive and productive pursuits. Letting go of anger doesn’t mean you’re forgiving or choosing to continue in a relationship with someone who has hurt you. It only means that you’re choosing not to put any more mental energy into negative thoughts and feelings. Write (or talk with a therapist) about what happened and how it has affected you, identify what feelings you have beyond anger, acknowledge how you may have contributed to the problem, practice self-compassion, and consciously choose to release your anger.
  8. Say goodbye to negative, difficult, or unsupportive people. Ending a relationship – even an unhealthy or conflicted one – is painful. Spending time with people who are consistently negative, judgmental, critical, or unsupportive can contribute to anxiety and depression, deteriorate your self-esteem, make it difficult for you to pursue your goals and take good care of yourself. Sometimes ending relationships with such people is the only way to restore our emotional health. Ending unfulfilling relationships also makes room for healthier people in your life.
  9. Accept your feelings without judgment. How often do you dismiss or minimize your feelings or even tell yourself that your feelings are wrong? Your feelings are messengers trying to tell you something important and when you ignore them, they contribute to health problems, unhealthy coping behaviors like overeating or drinking, and stress. Instead, make space for your feelings. Invite them in without judgment. Be curious about why they are there, comfort yourself in healthy ways if they are difficult, and remember that feelings don’t last forever.
  10. Take responsibility for your life. Others may have hurt you or held you back in various ways, but ultimately you are responsible for your own life — and blaming others (or circumstances) doesn’t help you create a more satisfying life. Own your mistakes and choices; don’t blame others for your problems or get stuck in a victim mindset. Learn from what isn’t working and take responsibility for changing what you can.
  11. Focus on what you can control. Many things in life aren’t in our control, especially what other people think and do. And when we put our time and energy into trying to change people or situations that are beyond our control, we usually end up frustrated and resentful. It’s wiser to differentiate what we can control (namely ourselves) and what we can’t and then focusing on changing our thoughts and behaviors.
  12. Take chances rather than always playing it safe. Perfectionism and fear of failure can keep us from trying new things and taking chances. We just do what we’ve always done (even if it causes problems) because it’s comfortable and safe. We don’t want to fail, or be criticized, or look foolish, so we only do things we’re already good at. The problem is that we miss out on opportunities and we limit our success, creativity, and fun when we play it safe. I’m not suggesting that you abandon reason, but that you step out of your comfort zone from time to time. Try something new and consider the possibility that things may turn out better than you think – and if they don’t, you can probably bounce back.
  13. Notice the positives in your life. It’s easy to notice everything that goes wrong, what we don’t have, our problems, failures, and frustrations. It’s much harder to notice what’s going right, how much we have, our joys, successes, and progress. But with intention (and perhaps some reminders), we can cultivate an attitude of gratitude which actually strengthens neural pathways that promote contentment.
  14. Speak up for yourself. Many of us fail to be assertive because we think it’s rude or selfish, so we stay silent. We allow others to mistreat us, we don’t voice our ideas and opinions, and we build resentments because we expect others to know what we want or need – even when we don’t communicate our wants/needs. When we’re passive, we don’t respect and value ourselves. Assertive communication shows respect for ourselves and for others. It’s thoughtful, polite and calm. And we owe it to ourselves to speak up!

Which of these changes will help you improve your emotional health? You don’t need to tackle them all at once. Small changes build on each other. So, make a commitment to start with one small change today and let that be the beginning of a healthier you!

via 14 Things You Need to Start Doing for Your Emotional Health | Happily Imperfect

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[WEB SITE] Sexual Dysfunction Following Brain Injury – CNS

SEXUAL DYSFUNCTION FOLLOWING BRAIN INJURY

By CHARLES N. (NICK) SIMKINS, Attorney at Law

Although we live in a society where people freely discuss toilet paper, hemorrhoids, and all sorts of quite personal issues, without bashfulness or hesitation, the problem of sexual dysfunction following lightning strike, electric shock, or traumatic brain injury is so “hush hush” that not even the treating physicians inquire about possible sexual dysfunction in their usual history-taking from the patient. It is well known and well recognized, in all of the literature and research, that sexual dysfunction can be the result of chronic pain, medications, injury to the brain, psychological injury, depression, and a whole host of common problems that those surviving electric shock, lightning strike, or traumatic brain injury may have, yet it seems to be a well-kept secret and people are left to deal with problems related to sexual dysfunction on their own.

In a society where sexuality seems so important in our humor, television commercials, politics, and sometimes the very core of our culture, it is a shame that people are left to suffer on their own, without knowing why, and without knowing that there may be some kind of care, treatment, or therapy that could be of help. This article is an attempt to pull back the curtain of darkness in an effort to give comfort to those in that it is not “their fault,” and maybe to educate so that people can get real and available help.

Let me be clear that it was not my idea to write an article about sexual dysfunction following injury. I must confess that when I was first asked to write an article about sexual dysfunction following injury, my first thought was “whoa, sex is a very sensitive subject,” and then I thought, “whoa, whoa, talking about sex is a very, very sensitive subject,” and then I thought “whoa, whoa, whoa, writing about sexual dysfunction is going to be a really sensitive subject and there is no way that I am going to do that.”

As I thought about responding to the request to write this article about sexual dysfunction following injury, I realized that in my over 25 years of representing persons and families surviving various types of injury, including traumatic brain injury, lightning strike, or electric shock injury, that one of the very real consequences of those injuries, directly or indirectly, has been sexual dysfunction. But I still thought, no way am I going to write about this, and there is no way that I want to be introduced at seminars, or be known, as an expert in sexual dysfunction.

Suffice it to say that those who know me best would not consider me as the poster child for openness in discussion of sexual issues. Then, I thought it was perhaps the type of attitude that I had in terms of reluctance to discuss sexual issues or sexual dysfunction issues, that formed part of the weave of the cloak of darkness and silence that surrounds the very real issue and problem of sexual dysfunction following injury.

It just so happened that right about this time, I came across a booklet put out by Pfizer, Inc., U.S. Pharmaceuticals entitled “Putting Sexual Health Into Practice”, that was published in August, 1999 for physicians. As I read through the booklet, I began to think that maybe an article of this type could be help to some people.

At page one of the booklet, under the heading of “Breaking the Silence Around Sexual Health”, it says:

Having a healthy sex life is one factor that may contribute directly to the quality and longevity of an individual’s life, according to the Duke First Longitudinal Study of Aging. In a World Health Organization (WHO) Report, sexual health is defined as the integration of the somatic, emotional, intellectual, and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication, and love. The international group of experts convened by WHO take the position that the notion of sexual health implies a positive approach to human sexuality, and the purpose of sexual healthcare should be the enhancement of life and personal relationships and not merely counseling and care related to procreation or sexually transmitted diseases. But sexual health, primarily in men, is frequently overlooked as an integral part of overall health. ? For various reasons, millions of men are not discussing the sexual health problems with their physicians. By keeping these issues to themselves, they suffer silently.

In a survey of 500 adults, 94 percent of those polled said that sexual satisfaction added to the quality of life at any age. Marianne J. Legato, M.D., commented, “As human beings our sexuality is inextricably linked to our overall health, happiness, and sense of wellness.” Furthermore, the American Medical Association lists “participating in desired sexual activity” as one of many important activities of daily living.”

At page three of this booklet and remembering that it is a booklet written for doctors, it says:

One of the most rewarding aspects of treating sexual health is that you can impact two lives. Often, a sexual problem can make partners feel that they are no longer attractive or that the problem is a reflection on them.

The fact is that the world health organization and the American Medical Association consider sexual function to be in the category of an important daily activity. There are many studies that relate a number of health benefits to a healthy sexual life. There may be millions of people in the United States and around the world who are suffering from some aspect of sexual dysfunction as a result of injury and maybe at least one of those people could benefit from receiving at least the knowledge that they are not alone.

For those persons who may be shy, reserved, or reluctant to bring up sexual issues with their doctor, at the end of this article is a form that can be filled out in advance of the doctor’s appointment, and simply handed to the doctor to sort of help break the ice about any discussions with regard to sexual issues.

This has been the most difficult article that I have ever written, and I have tried to be as careful as I could so as not to offend anyone. While some aspects of this article may focus on male issues, that is simply because much of the available literature and research deals with male sexual dysfunction as opposed to female. Every word in this article is intended to help women as much as men.

Purpose

As basic as is the human sexual desire and function, we all know, from research, medical literature and, most of all, life and experience, that the sexual function is a highly complicated process. It depends upon emotion, feelings, timing, mood, words, and so many other factors, and when injury and consequences are added to the mix, the process can become impossible.

The purpose of this article is not only to discuss these issues, but more importantly, to accomplish one or more of the following:

  1. To let people know that they are not alone in their situation;
  2. To empower people to have the knowledge, ability, and courage to bring this type of information to the attention of their treating physician;
  3. To provide help as to what type of information to have available, even written out, in advance, to provide to the physician to be the most helpful in understanding the problem;
  4. To let people know that there are various types of treatment and therapy available; and
  5. To provide a starting place for discussion.

Since the beginning of time, and at whatever stage of the civilization humanity was, and whether people lived outside, in a cave, in a hut, in a barn, or in a mansion, the common historical thread of a man was that he could always do what had to be done in order to get food for himself and his family, to do what was needed to be done to have shelter for himself and his family, and at the same time, to have the energy and imagination to dream and plan for better days for himself and his family. Women and men are taught and raised to be self-reliant, and if fortunate, are able to go through their entire lives taking care of themselves, raising their children, paying their bills, and persevering regardless of their lot in life.

When injury strikes, all of this changes because all of a sudden, instead of being self-reliant, the family may now have to rely on an insurance clerk to mail a check on time to pay their bills, or rely on a doctor to send a certain report to an insurance carrier to get bills paid and the focus of the family’s financial security may literally shift from the wage earner to the mailbox. This alone may have an impact on a person’s sexual function. While this is going on, and just as suddenly, the entire focus of the family’s social life may change, or disappear, and now the time that was spent working, enjoying social and leisure activities, enjoying children, is replaced with time in therapy, sitting in doctors’ offices, worrying and wondering about when things will get back to normal.

With all of this going on, it is no wonder that the delicate balance of life that leads to human sexuality is upset and disturbed, but the suffering in silence, in terms of any sexual dysfunction issues, only adds to the cycle of frustration, problems, and everything else that is going on.

In the United States, men seem to have, on one level or another, the image of themselves as the “Marlboro Man,” with a very macho image of themselves. Women may equate their own sexuality with attractiveness, beauty, and personality, all of which may suffer when there is sexual dysfunction following injury. Men and women may be reluctant to even discuss issues related to sexual dysfunction with their treating physicians, and they are left to suffer in silence.

Sometimes, regardless of what our problem may be, we think we suffer alone. There is comfort, as well as knowledge, knowing that many other people are in the same situation, and it is the purpose of this article not only to distribute that information about the possible causes of sexual dysfunction, but to let people know that there may be help in the form of medical treatment, care, or therapy that can alleviate some of these problems. In this situation of sexual dysfunction, in order for the person to be able to get help, there must be a bridge between the person’s knowledge of their own sexual dysfunction, and the doctor’s knowledge of the patient’s sexual dysfunction. That bridge is sometimes not built because of shyness or reservation, on the part of either the doctor or the patient, or both, and part of the purpose of this article is to help build that bridge, and one of the recommendations, at the end of this article, is a written form that can be filled out in advance and given to the doctor.

The Problem

Several years ago, Dr. George Zitnay, then president of the National Head Injury Foundation, testified before congress, and started his prepared remarks with the following statement:

Ladies and gentlemen, I am here today to talk about the largest and most important sex organ in the human body – the brain.

As Dr. Zitnay spoke those words, everyone in the hearing stopped talking and paid strict attention to what he had to say.

Amazingly enough, all of the following have one thing in common:

  1. Depression;
  2. Brain injury;
  3. Post traumatic stress disorder;
  4. Amputation;
  5. Chronic pain;
  6. Disability from work;
  7. Sleep difficulties;
  8. Frustration;
  9. Changed perception of self;
  10. Medication;
  11. Changed personality;
  12. Change in sense of humor;
  13. Physical injury;
  14. Scarring;
  15. Fatigue;
  16. Increased stress;
  17. Getting behind in bills;
  18. Reduced recreational activities;
  19. Elimination or reduction of social life;
  20. Elimination or reduction of recreational activities;
  21. Loss of job.

What all of these have in common is that any or all of these can have an impact upon a person’s sexual functioning. For example, many medications have, as a side effect, a potential impact on a person’s libido which may not be known to the patient or their family.

Following the injury, it may be weeks or months before the person experiences the romance of a sexual encounter, which may not be the same as it was before the injury. This may lead to embarrassment, and depending upon how the situation is dealt with, may lead to humiliation, particularly on the part of the man. This humiliation may, in and of itself, lead to stress, and in and of itself, lead to an avoidance of the next romantic sexual encounter, which may then engender some feelings of guilt on the part of the uninjured spouse. This may snowball and become a vicious cycle of frustration for both parties.

Where the woman experiences a lack of libido, for any number of reasons related to the injury, the man may feel unloved and unwanted, which leads to stress, arguing, and again, can snowball and become a vicious cycle of frustration for both parties.

The uninjured spouse may then begin to think that the injured spouse no longer cares about them, or no longer has romantic feelings, and is unable to provide an explanation for the cause of the problem. It may very well be that as of that point in time, no one in the health care system has taken the time to explain to either of the parties that any aspect of the injuries may have an impact upon sexual function.

In the book Neuropsychological Assessment, Third Edition, by Dr. Muriel D. Lezak, at page 42, she writes:

One significant personality change that is rarely discussed but is a relatively common concomitant of brain injury is a changed sexual drive level. A married man or woman who has settled into a comfortable sexual activity pattern of intercourse two or three times a week may begin demanding sex two and three times a day from the bewildered spouse. More frequently, the patient loses sexual interest or capability. This leaves the partner feeling unsatisfied and unloved, adding to other tensions and worries associated with cognitive and personality changes in the patient. For example, some brain damaged men are unable to achieve or sustain an erection, or they may have ejaculatory problems secondary to nervous tissue damage. Patients who become crude, boorish, or childlike as a result of brain damage no longer are welcomed bed partners and may be bewildered and upset when rejected by their once affectionate mates. Younger persons brain damaged before experiencing an adult sexual relationship may not be able to acquire acceptable behavior and appropriate attitudes. Adults who were normally functioning when single often have difficulty finding and keeping partners because of cognitive limitations or social incompetence resulting from their neurological impairments. For all of these reasons, the sexual functioning of many brain damaged persons will be thwarted. Although some sexual problems diminish in time, for many patients they seriously complicate the problems of readjusting to new limitations and handicaps, by adding another stage of frustrations, impulses, and reactions.

There may be an escalating cascade of problems which can be, for example:

  1. The first problem is that it happens, and then, through embarrassment, reluctance, or other feelings, how is it dealt with? As we all know, while some people may joke and talk about sexuality, when it comes to the individual, there may be reluctance to talk about personal sexual issues, and it may be that this is especially true in term of one’s own partner. It may be that the entire relationship has flourished before injury without there having been a discussion about sexual issues, and now, any discussion must revolve around sexual dysfunction about which both may be ignorant.
  2. The second problem may be that no one will admit it, not even one partner to another.
  3. That where it is the woman who has had a loss or decrease of libido, following injury, the man may assume that her lack of interest means that she no longer cares for him, and this leads to another whole set of problems.
  4. People may not even suspect that the injury or medication or consequence of the injury is causing the problem, and they may not have received any such advice or information from the treating health care providers.
  5. The relationship begins to deteriorate.
  6. The doctor may not know about it because people may not initiate discussion about sexual issues, let alone sexual dysfunction issues, and doctors do not routinely ask about sexual function as part of their history, or as a part of a routine examination.
  7. The next problem is that the doctors may not know what to do, or just say something like “it will be all right,” and leave the patient without any recommendations.
  8. The next problem is that if the person is in a managed care situation, there may be a financial incentive for the primary care physician not to make referrals for an extensive sexual dysfunction work-up that may be appropriate, or, in some cases, the doctor may not care.
  9. The next problem is that there are doctors who have the attitude that so long as the person is alive, they should be grateful.
  10. Another problem is that if the person initiates discussion, and the doctor does not handle it appropriately, the patient may be embarrassed, humiliated, and the cycle could repeat itself.

One of the concepts in psychology is the concept of what is called a stroke as being a unit of recognition, or a form of stimulation. This is far different from the medical concept of a stroke, and this discussion is related solely to the psychological concept of stroke. In psychology, strokes can be physical, verbal, or non-verbal, and as a person grows older, new ways are discovered to receive and exchange strokes. For example, some may enjoy making presentations at church, or at local groups, because they enjoy the recognition, and the recognition would, in psychology, be called a stroke. The need for stimulation becomes at least, in part, a need for recognition, and this is a very basic human need and, as stated in the book entitled Transactional Analysis by Woollams, Brown & Huige, at page 16:

Since the need for strokes is inherent in each person, exchanging strokes is one of the most important of all human activities.

Further, at page 16:

Since strokes are necessary for survival, a person will do whatever she thinks necessary in order to receive the strokes she needs. A person will develop a style of giving and receiving strokes based on her life position.

Again, remember that the concept of strokes in this context is a psychological term. Now think about the psychological concept of strokes in the context of a relationship between a loving couple, having sexual relations prior to injury. Human sexuality certainly encompasses far more than just the act of sex between two people. When we think of the delicate balance necessary for human sexuality, in terms of mood, physical, mental, emotional, and timing, and then remember that all of this must exist in a multiple of two, the psychological concept of what are called strokes is very applicable.

With the intimacy of the couple’s knowledge of each other, they have developed a concept of strokes for each other, and how they receive strokes in the world, through their work, recreational activities, and things. Now, with injury, all of this has changed not only for the injured person, but then in consequence, also for the uninjured person. Just looking at this psychological concept of strokes alone, one could think that there must be a proper balance of strokes, from an emotional point of view, in order for there to be a loving sexual relationship, and if that emotional framework becomes unbalanced and distorted, as it does, that alone can impact on the sexual function.

Consider, for example, a young couple who would typically enjoy going out to dinner, a little dancing, and each other’s personality, filled with a sense of humor, as a prelude to sexual relations. Now, following injury, a partner is in pain, has very little sense of humor, does not enjoy eating in the noisy atmosphere of a restaurant, and it is easy to see that the emotional framework of this couple has become unbalanced and distorted, and without help, the relationship may become further unbalanced and distorted through the silence of sexual dysfunction.

Medical Literature

As I researched and thought about what to say and include in this article, I was amazed to discover that just about every medical textbook that I reviewed had at least some information about sexual dysfunction, whether neurology, psychiatry, orthopedics, neuropsychology, or other areas, somewhere in each book there was some discussion about relationships between trauma, medications, emotions, injury, or something to sexual dysfunction.

I decided to include this section with just quotes from the medical literature not, in any way, to try and teach the medical substance of the quotes, but rather, for the purpose of making the reader aware of how extensively this topic is discussed in some of the very same medical books that may well be on your doctors’ shelves. This knowledge may help people feel a little more comfortable about discussing issues of sexual dysfunction with a doctor.

It is also important to remember that there are physicians, specialists, and health care providers who specialize in working with people with sexual dysfunction and people have the right to request such referrals.

Rehabilitation of the Adult and Child with Traumatic Brain Injury, Second Edition, by Rosenthal, Griffith, Bond, and Miller, 1990. At page 206, the chapter is entitled “Sexuality and Sexual Dysfunction.”

Human sexuality conceptually embraces the composite of those factors that result in our capacity to love and procreate. A related aspect of sexuality is the individual’s perception and expression of “womanliness” or “manliness.” By these terms, it is predictable that a catastrophic event such as brain injury will almost ineluctably affect the sexuality of the survivor. Sexual disabilities may include disturbances of any of the component functions of sexuality: sexual drive, interests, beliefs, attitudes, behaviors, identity, activities, responses, and fertility.

In this chapter, they refer to:

Disabilities resulting from physical or organic factors as primary dysfunction, and secondary sexual dysfunctions resulting from brain trauma are those disturbances of psychosocial abilities or sexual responses due to the mental deficits in psychologic reactions consequent to the injury. Secondary sexual dysfunctions may arise in the partner, if one exists, as the consequences of reactions to the disabled person and the altered life situation.

Current evidence indicates that secondary factors account for the great majority of sexual dysfunctions in brain injured subjects. However, more recent data suggest that primary factors may be less rare than previously surmised . . . In contrast to the growing body of general information on psychosocial aspects of brain trauma, very little has been written about sexuality.

Page 207:

Sexual responses – erection, vaginal lubrication, ejaculation, orgasm, and fertility – are not altered as a direct consequence of brain injury unless the hypothalamic-pituitary function has been disturbed or disrupted. The resulting endocrinopathies have received increasing attention, with recognition that testicular and ovarian hypofunction can occur. Some women with mesial temporal lobe foci of seizures have recently been reported to have hypogonadotropic hypogonadism. Women often become temporarily amenorrheic following severe trauma, but menses should ordinarily resume within 4 to 6 months. Persistent amenorrhea should alert the clinician to the possibility of pituitary dysfunction. Similarly, men frequently have transient impotence, but the ability to achieve an erection should reappear after several months.

Page 207:

Trauma to the craniofacial area, primary or secondary sexual organs, and orthopedic injuries resulting in amputation, contractures, deformities, and chronic pain are potential sources of dysfunction . . . Abdominal or pelvic vascular injuries can compromise circulation to the genitalia, producing impotence or other alterations in sexual responses.

Recurrent medical complications, sustained bed rest, and inactivity with its many consequences cause deconditioning and other effects that impinge upon sexual activity. A multitude of drugs produce side effects that influence sexual acts and responses . . .

Finally, pre-existing disorders may become additive factors contributing to the primary sexual dysfunction. Cardiac, vascular, pulmonary, or other types of diseases may already have compromised sexual function of the elderly before injury.

In the book Principals of Neurology by Adams, Victor, and Ropper, Sixth Edition, at page 517, under the heading of “Altered Sexuality” it states:

The normal pattern of sexual behavior in both male and female may be altered by cerebral disease quite apart from impairment due to obvious physical disability or to diseases that destroy or isolate the segmental reflex mechanisms.

Hypersexuality in men or women is a rare but well-documented complication of neurologic disease. Kleist pointed out that lesions of the orbital parts of the frontal lobes may remove moral-ethical restraints and lead to indiscriminate sexual behavior, and that superior frontal lesions may be associated with a general loss of initiative which reduces all impulsivity, including sexual.

At page 518:

In our clinical work we find that hyposexuality, meaning loss of libido, is most often due to a depressive illness. Certain chemical agents – notably antihypertensive, anticonvulsant, serotoninergic antidepressant and neuroleptic drugs – may cause a loss of libido. A variety of cerebral diseases may also have this effect.

At page 545, under the heading of “Disturbances of Sexual Function,” it says:

Sexual function in the male, which is not infrequently affected in neurologic disease, may be divided into several parts: (1) sexual impulse, drive, or desire, often referred to as libido; (2) penile erection, enabling the act of sexual intercourse (potency); and (3) ejaculation of semen by the prostate through the urethra, whereby impregnation of the female may be accomplished.

The arousal of libido in men and women may result from a variety of stimuli, some purely imaginary. Such neocortical influences are transmitted to the limbic system and thence to the hypothalamus and spinal centers.

The difference aspects of sexual function may be affected separately. Loss of libido may depend upon both psychic and somatic factors. It may be complete, as in old age or in medical and endocrine diseases, or it may occur only in certain circumstances or in relation to a certain situation or individual.

. . . sexual desire may be present but penile erection impossible to attain or sustain, a condition called impotence, in which nocturnal erections are usually preserved. The commonest cause of impotence is a depressive state.

Comprehensive Textbook of Psychiatry, Volume I, Sixth Edition, by Kaplan and Sadock, at page 1296:

Innervation of the organs of sexuality is mediated primarily through the autonomic nervous system. It is generally assumed that the parasympathetic system activates the process of erection via impulses that pass through the pelvic splanchnic nerves (S2, S3, S4) which caused the smooth muscles of the penile arteries to dilate.

Recent evidence implicates the sympathetic (adrenergic) system as being responsible for ejaculation . . . In women, the sympathic system facilitates smooth muscle contraction of the vagina, urethra, and uterus that occurs during orgasm.

The autonomic nervous system functions outside of voluntary control and is influenced by external events (for example, stress, drugs) and internal events (hypothalamic, limbic, and cortical stimuli). It is not surprising, therefore, that erection and orgasm are so vulnerable to dysfunction.

At page 1298:

Experimentation with animals has demonstrated that the limbic system is directly involved with elements of sexual functioning. In all mammals the limbic system is involved in behavior required for self-preservation and the preservation of the species.

Page 1298:

A vast array of neurotransmitters are produced by the brain. They include dopamine, epinephrine, norepinephrine, and serotonin. All have effects on sexual function. For example, an increase in dopamine is presumed to increase libido. Serotonin produced in the upper pons and mid-brain is presumed to have an inhibitory effect on sexual function.

At page 1300, it says:

Seven major categories of sexual dysfunction are listed in DSM-IV: (1) sexual desire disorders, (2) sexual arousal disorders, (3) orgasm disorders, (4) sexual pain disorders, (5) sexual dysfunction due to a general medical condition, (6) substance-induced sexual dysfunction, and (7) sexual dysfunction not otherwise specified.

At page 1300:

The sexual cycle is divided into four phases: desire, excitement, orgasm, and resolution. The essential feature of the sexual dysfunctions is inhibition in one or more of the phases, including disturbance in the subjective sense of pleasure or desire or disturbance in the objective performance. Either type of disturbance can occur alone or in combination. Sexual dysfunctions are so diagnosed only when such disturbances are a major part of the clinical feature. They can be lifelong or acquired, generalized or situational, and due to psychological factors or due to combined factors. If they are attributable entirely to a general medical condition, substance use, or adverse effects of medication, then sexual dysfunction due to a general medical condition or substance-induced sexual dysfunction is diagnosed.

With the possible exception of premature ejaculation, sexual dysfunctions rarely are found separate from other psychiatric syndromes. Sexual disorders may lead to or result from relational problems, and patients invariably develop an increasing fear of failure and self-consciousness about their sexual performance. Sexual dysfunctions are frequently associated with other mental disorders, such as depressive disorders, anxiety disorders, personality disorders, and schizophrenia. In many instances, sexual dysfunctions may be diagnosed in conjunction with the other psychiatric disorders. In some cases, however, it is but one of many signs or symptoms of the psychiatric disorder.

A sexual disorder can be symptomatic of biological problems, intrapsychic conflicts, interpersonal difficulties, or a combination of these factors. The sexual function can be affected by stress of any kind, by emotional disorders, and by a lack of sexual knowledge.

At page 1302:

Hypoactive sexual desire disorder is experienced by both men and women; however, they may not be hampered by any dysfunction once they are involved in the sex act. Conversely, hypoactive desire may be used to mask another sexual dysfunction. Lack of desire may be expressed by decreased frequency of coitus, perception of the partner as unattractive, or overt complaints of lack of desire. In some cases there are biochemical correlates associated with hypoactive desire. A recent study found markedly decreased levels of serum testosterone in men complaining of this dysfunction when they were compared with normal controls in a sleep-laboratory situation. Also, a central dopamine blockage is known to decrease desire.

Page 1303:

Patients with desire problems often have good ego strengths and use inhibition of desire in a defensive way to protect against unconscious fears about sex. Lack of desire can also be the result of chronic stress, anxiety, or depression. Abstinence from sex for a prolonged period sometimes results in suppression of the sexual impulse. It may also be an expression of hostility or the sign of a deteriorating relationship.

The presence of desire depends on several factors: biological drive, adequate self-esteem, previous good experiences with sex, the availability of an appropriate partner, and a good relationship in nonsexual areas with one’s partner. Damage to any of those factors may result in diminished desire.

Page 1304:

Male erectile disorder is also called erectile dysfunction and impotence . . . In acquired male erectile disorder the man has successfully achieved vaginal penetration at some time in his sexual life but is later unable to do so.

Page 1305:

The percentage of all men treated for sexual disorders who have impotence as the chief complaint ranges from 35 to 50 percent. The incidence of psychological as opposed to organic impotence has been the focus of many recent studies. Physiologically, impotence may be due to a variety of medical causes. In the United States it is estimated that two million men are impotent because they suffer from diabetes mellitus; an additional 300,000 are impotent because of other endocrine diseases; 1.5 million are impotent as a result of vascular disease; 180,000 because of multiple sclerosis; 400,000 because of traumas and fractures leading to pelvic fractures or spinal cord injuries; and another 650,000 as a result of radical surgery, including prostatectomies, colostomies, and cystectomies. In addition, the clinician should be aware of the possible pharmacological effects of medication on sexual functioning. The increased incidence of organic etiologies for this dysfunction in the past 15 years may, in part, reflect the increased use of psychotropic and antihypertensive medications. Statistics indicate that 20 to 50 percent of men with erectile dysfunction have a medical basis for their problem.

Page 1306:

Sexual dysfunction due to a general medical condition. The category covers sexual dysfunction that results in marked distress and interpersonal difficulty when there is evidence from the history, the physical examination, or the laboratory findings of a general medical condition judged to be causally related to the sexual dysfunction.

Male erectile disorder due to a general medical condition. The incidence of psychological as opposed to organic male erectile disorder has been the focus of many studies. Statistics indicate that 20 to 50 percent of men with erectile disorder have an organic basis for the disorder. The medical causes of male erectile disorder are listed in Table 21.1a-10 which include, as general categories, infectious and parasitic diseases, cardiovascular disease, renal and urological disorders, hepatic disorders, pulmonary disorders, genetics, nutritional disorders, endocrine disorders, neurological disorders, pharmacological contributants, poisoning, surgical procedures, and miscellaneous including “any severe systemic disease or debilitation condition.” Side effects of medication may impair male sexual functioning in a variety of ways. Castration does not always lead to sexual dysfunction, depending on the person. Erection may still occur after castration.

A number of procedures, benign and invasive, are used to help differentiate medically caused impotence from psychogenic impotence. The procedures include monitoring nocturnal penile tumescence (erections that occur during sleep), normally associated with rapid eye movement; monitoring tumescence with strain gauge; measuring blood pressure in the penis with a penile plethysmograph or an ultrasound (Doppler) flow meter, both of which assess blood flow in the internal pudendal artery; and measuring pudendal nerve latency time. Neurological impairment of penile function may be indicated if vibratory perception is increased in the penis. Other diagnostic tests that delineate organic bases for impotence include glucose tolerance tests, plasma hormone assays, liver and thyroid function tests, prolactin and follicle-stimulating hormone (FSH) determinations, and cystometric examinations. Invasive diagnostic studies include penile arteriography, infusion cavernosography, and radioactive xenon penography. Invasive procedures require expert interpretation and are used only for patients who are candidates for vascular reconstructive procedures.

Page 1306:

A good history is crucial in determining the etiology of the male erectile disorder. If a man reports having spontaneous erections at times when he does not plan to have intercourse, having morning erections or only sporadic erectile dysfunction, or having good erections with masturbation or with partners other than his usual one, then organic causes for his impotence can be considered negligible, and costly diagnostic procedures can be avoided. In those cases in which a medical basis for impotence is found, psychological factors often contribute to the dysfunction, and psychiatric treatment may be helpful. In some diabetics, for instance, erectile dysfunction may be psychogenic. In general, the psychological conflicts that cause impotence are related to an inability to express the sexual impulse because of fear, anxiety, anger, or moral prohibition.

Many developmental factors have been cited as contributing to erectile disorder. Any experience that hinders the ability to be intimate, that leads to a feeling of inadequacy or distrust, or that develops a sense of being unloving or unlovable may result in impotence. In an ongoing relationship, erectile dysfunction may reflect difficulties between the partners, particularly if the person cannot communicate his or her needs or angry feelings in a direct and constructive way. Successive episodes of impotence are reinforcing, with the man becoming increasingly anxious about his next sexual encounter. Regardless of the original etiology of the dysfunction, his anticipatory anxiety about achieving and maintaining an erection interferes with his pleasure and sexual contract and with his ability to respond to stimulation, thus perpetuating the problem.

Page 1307:

Hypoactive sexual desire disorder due to a general medical condition. Desire commonly decreases after major illness or surgery, particularly when the body image is affected after such procedures as mastectomy, ileostomy, hysterectomy, and prostatectomy. Illness that deplete a person’s energy, chronic conditions that require physical and psychological adaptation, and serious illnesses that may cause the person to become depressed can all result in a marked lessening of sexual desire in both men and women.

In some cases, biochemical correlates are associated with hypoactive sexual desire disorder.

Other male sexual dysfunction due to a general medical condition. The category is used when some other dysfunctional feature is predominant (for example, orgasmic disorder) or no feature predominates. Male orgasmic disorder may have physiological causes and can occur after surgery on the genitourinary tract, such as prostatectomy. It may also be associated with Parkinson’s disease and other neurological disorders involving the lumbar or sacral sections of the spinal cord. The antihyptensive drug guanethidine monosulfate (Ismelin), methyldopa (Aldomet), the phenothiazines, the tricyclic drugs, and fluoxetine (Prozac), among others have been implicated in retarded ejaculation. Male orgasmic disorder must also be differentiated from retrograde ejaculation, in which ejaculation occurs but the seminal fluid passes backward into the bladder. Retrograde ejaculation always has an organic cause.

Page 1308:

Acquired female orgasmic disorder is a common complaint in clinical populations. One clinical treatment facility described nonorgasmic women as about four times more common in its practice than patients with all other sexual disorders. In another study 46 percent of the women complained of difficulty in reaching orgasm, and 15 percent described an inability to have orgasm.

Page 1308:

Male orgasmic disorder. In male orgasmic disorder (previously inhibited male orgasm and called retarded ejaculation) the man achieves climax during coitus with great difficulty, if at all. A man suffers from lifelong orgasmic disorder if he has never been able to ejaculate during coitus. The disorder is diagnosed as acquired if it develops after previous normal functioning.

Page 1314:

Almost every pharmacological agent, particularly those used in psychiatry, has been associated with an effect on sexuality. In men those effects include decreased sex drive, erectile failure (impotence), decreased volume of ejaculate, and delayed or retrograde ejaculation. In women decreased sex drive, decreased vaginal lubrication, inhibited or delayed orgasm, and decreased or absent vaginal contractions may occur. Drugs may also enhance the sexual response and increase the sex drive, but that effect is less common than are adverse effects.

Talk about the male ego being associated with sex, and the male ego being associated with the ability to make a living, as 19th century as that may sound. When the man is all of a sudden transformed from the wage earner, and head of the family, to someone who is reliant upon the system for his living, or a workers compensation carrier for money, this does tremendous damage to the male ego.

Page 1316:

Under the heading of Treatment of Sexual Dysfunction:

Various corrective therapies are now used to treat sexual dysfunctions . . .

In addition to making the determination of which type of therapy to use, the clinician must evaluate whether or not the disorder has a physiological cause. It is assumed that prior to entering psychotherapy, a patient will have had a thorough medical evaluation, including a medical history, physical examination, and appropriate laboratory studies when necessary. If a medical cause for the disorder is found, treatment should be directed toward ameliorating the cause of the dysfunction.

Page 1319, under the heading of Biological Treatment Methods, it says:

Pharmacotherapy. Penile injections produce a transient increase in penile blood flow, which allows the patient to become tumescent or gain an erection. The physician usually administers a test dose of the drug, and if the patient responds favorably, he is then taught to inject himself. Hormone therapy is listed, antiandrogens and antiestrogens, male prosthesis (at page 1320): Surgical treatment is rarely advocated, but improved penile prosthetic devices are available for men with inadequate erectile response who are resistant to other treatment methods or who have medically caused deficiencies.

Page 751:

The course and prognosis of secondary sexual dysfunctions vary widely, depending on the etiology . . . Dysfunctions due to neurological disease may run protracted, even progressive, courses. The treatment approach similarly varies widely, depending on the etiology. When reversal of the underlying cause is not possible, supportive and behaviorally oriented psychotherapy with the patient (and perhaps the partner) may minimize distress and increase sexual satisfaction (for example, by developing sexual interactions that are not limited by the specific dysfunction). Support groups for people with specific types of dysfunction are available.

Organic Psychiatry, the Psychological Consequences of Cerebral Disorder by Dr. William A. Lishman, Third Edition, 1988. At page 271 under the heading of Sexual Disorder in Epilepsy:

Sexual disorder attracted little attention in epileptic patients until relatively recently. Several reports, however, now stress the frequency of sexual disturbance in patients with temporal lobe epilepsy. Hyposexuality has emerged as the commonest abnormality, with perversions of sexual interest and outlet occurring in a much smaller number.

Gastaut and Collomb (1954) were the first to draw attention to hyposexuality after specific inquiry in 36 patients with temporal lobe epilepsy. More than two-thirds showed marked diminution or absence of interest, appetite or sexual activity. Other forms of focal and generalized epilepsy appeared to be unassociated with such problems. There was often a remarkable lack of sexual curiosity, fantasies or erotic dreams, yet little to suggest inhibition since the patients talked easily and without reserve about such matters. Indeed they appeared to be quite indifferent about the subject.

By detailed interviews it was established that 41% of the male temporal lobe epileptics were hyposexual, compared to 8% of the males with generalized epilepsy. The corresponding figures for females were 38% and 5% respectively. On restricting attention to patients over the age of 15 and where adequate information was available these differences were accentuated, reaching statistically significant levels. Among the males the disorder was manifest as a global lack of interest, failure of erections and nocturnal emissions, and absence of fantasies or dreams of a sexual nature. The females remained totally passive in sexual relations and failed to reach orgasm . . . The lack of concern evidenced by the patients, and their failure to make complaints, probably accounted for the problem having attracted so little attention in the past. Toone et al (1989) found that temporal lobe epileptics and other focal epileptics recruited from general practice were equivalently impaired, both more often lacking sexual interest and activity than patients with primary generalized epilepsy.

From the Textbook of Clinical Neurology by Goetz and Pappert, at page 369, under the heading of “Sexual Dysfunction” it says:

Treatment of organic impotence includes treatment of secondary psychological problems and reducing or eliminating aggravating factors such as poor sleep, chronic pain, malnutrition, alcohol use, and some medications. Yohimbine can be used orally to increase penile arterial vasodilatation and enhance relaxation of the cavernous trabeculae. Direct injection of papaverine (direct smooth muscle relaxant), phentolamine, or prostaglandin E1 into the corpora cavernosa may be effective but poses the risks of priapism and scarring of the tunica albuginea. A vacuum device may also be used to enhance corporal filling.

In the book Head Injury and Post Concussive Syndrome by Rizzo and Tranel, at page 312, under the heading of “Sexual Disorders” it says:

Symptoms of sexual dysfunction can be noted after TBI. These symptoms can be grouped into changes in sexual interest or performance and the development of inappropriate or unusual sexual behaviors. A syndrome of apathy can extend to apathy in sexuality, with diminished desire and reduced frequency of sexual intercourse. Impotence can also develop after TBI. Finally, inappropriate sexual behavior and speech have been noted, especially in patients with significant frontal lobe dysfunction. This can include suggestive remarks or unwanted sexual advances toward health professionals. Increased interest in pornography has also been noted.

Under DSM-IV Classification, it says:

When sexual apathy is a target of evaluation and interest, the appropriate classification comes under the sexual dysfunction due to head trauma category. The subclassification would be 608.89 Male (or 625.80 Female) hypoactive sexual desire due to head trauma. Male impotency following TBI would be denoted by 607.84, male erectile disorder due to head trauma.

Inappropriate sexual behavior problems can be clinically important enough for diagnosis. Inappropriate sexual behaviors believed to be due to frontal lobe damage would be designated as personality change due to head trauma – disinhibited type.

Under the heading of “Differential Diagnosis” it says:

Disorders of sexual desire can be primary (i.e., present prior to head trauma or unrelated to the injury). Medications can have significant effect on sexual interest and performance. A variety of causes for impotence should be reviewed, including vascular disorders, diabetes, and psychological disorders impairing male sexual function.

Suggestions

The only way that your doctor is going to have the information about your situation following injury is if it is provided by you, or someone on your behalf. Since the doctor may not inquire about it, as a part of the history, and since it is important to provide complete information, the following is suggested. It is suggested that you actually make a copy of this form, fill it out, and hand it to your doctor at your next appointment to start the conversation that may lead to a more fulfilling life for you and your partner.

Dear Dr. _________:

Since my injury, I have noticed a change in my sexual functioning, and I am providing you with this information, and any other information that you might need to evaluate my situation. Can you help me, or refer me to a doctor or health care provider who could help me with this change in my sexual functioning?

Then, provide in that same letter, the following information:

  1. A brief description of your sexual pattern in the year before injury;
  2. A description of your sexual pattern since the injury;
  3. An honest appraisal as to your desire for sex since the injury;
  4. How has the sexual situation been handled between you and your partner since the injury, in terms of any discussion;
  5. List all of your medications that you have been on since the injury, and ask “could any of these be affecting my sexual function?”
  6. Are there any specialists to whom you could refer me for evaluation of my sexual dysfunction, and treatment;
  7. Is there any information that I can provide to you, at this appointment, or at the next appointment, to help you in evaluating, diagnosing, and treating my condition?

Any other information that you think would be helpful for the doctor should be written down and given to the doctor.

This should help break the ice about any discussion of sexual dysfunction.

Dedication

This article is dedicated to my friend, Mr. Steve Marshburn, founder and president of Lightning Strike & Electric Shock Survivors International. If this article dealing with sexual dysfunction after injury is of any help or comfort to anyone, such persons owe a great debt of gratitude to Mr. Steve Marshburn. When God chose Steve Marshburn to be at the forefront of the fight for better understanding, medical care, and legal representation for persons and families surviving electric shock and lightning strike injury, obviously He chose wisely. The courage, persistence, determination, and wisdom of my friend, Mr. Steve Marshburn, can never be underestimated.

It has been a real privilege working with Steve and Joyce Marshburn over the years. When Steve told me that many members had requested an article and information on sexual dysfunction following injury, and asked me to write such an article, I was somewhat taken aback with shyness and awe at the complexity of the task. But, as anyone who knows Steve Marshburn knows, no one ever says no to Steve Marshburn.

About the Author

CHARLES N. (NICK) SIMKINS, is a trial lawyer specializing exclusively in representing persons and families surviving traumatic brain injury, spinal cord injury, and brain dysfunction, and electric shock and lightning strike survivors. Mr. Simkins has served as a consultant to Lightning Strike and Electric Shock Survivors International, is an elected board member of the Brain Injury Association, editor of the National Head Injury Foundation book entitled “Analysis, Understanding, and Presentation of Cases Involving Traumatic Brain Injury,” author of “Can Long Term Cognitive and Emotional Problems be Caused by Electric Shock and Lightning Strike Accidents, or Is Anything That I Know About Brain Injury Applicable to Electric Shock and Lightning Strike Victims?,” Editor, Melvin Belli Society Newsletter, and he has represented injured persons and served as a consultant for trial lawyers throughout the United States on cases involving traumatic brain injury, brain dysfunction, and electric shock and lightning strike injuries. During his career, Mr. Simkins, whose office is in Northville, Michigan, has achieved numerous seven-figure plus verdicts and settlements in cases involving traumatic brain injury, brain dysfunction, and issues related to post traumatic stress disorder.

Charles N. (Nick) Simkins
Attorney at Law
200 North Center St.
Northville, Michigan 48167
(248) 349-6030
Facsimile: (248) 349-8982

 

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[WEB SITE] A Manifesto for being InCredible – ACNR | Online Neurology Journal ACNR | Online Neurology Journal

A Manifesto for being InCredible

Posted in Industry News,News Review on 25th Nov 2019

The British Neuroscience Association (BNA) is officially launching its ‘Credibility in Neuroscience Manifesto today, Monday 25th November, at an evening reception at the House of Commons.

The manifesto has been published in response to current threats and challenges to credible research across life sciences. Currently, there is a huge pressure to publish as many papers as possible, with an emphasis on dramatic, novel findings. This in turn has led to increasing levels of non-reproducible research[i], which can skew scientific understanding, contribute to hyped expectations, and jeopardise the translation of research to real-world applications.[…]

Continue —-> A Manifesto for being InCredible – ACNR | Online Neurology Journal ACNR | Online Neurology Journal

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[WEB SITE] CT head scan: Uses, procedure, risks, and results

A computed tomography (CT) scan of the head is an imaging scan that uses X-rays to develop a 3D image of the skull, brain, and other related areas of the head.

CT scan of the head can provide more detail than a traditional X-ray, which is particularly useful when a doctor wants to check the blood vessels and soft tissues in the body.

In this article, we explain why a doctor may order a CT scan of the head and what a person can expect if they need to undergo this procedure.

When do people need a CT head scan?

a man having a CT head scan

A person may have a CT head scan after trauma to check for damage.

Some of the reasons why a doctor may order a head CT scan include:

  • looking for possible damage after trauma to the head, such as soft tissue injuries, brain bleeding, and bone injuries
  • assessing a person having stroke-like symptoms to see whether there are signs of a blood clot or brain bleeding
  • looking for a possible brain tumor or other brain abnormality
  • checking the effectiveness of medical treatments in shrinking a brain tumor
  • assessing birth conditions that cause the skull to form abnormally
  • evaluating a person with a history of hydrocephalus, a condition in which an accumulation of cerebrospinal fluid causes the enlargement of the brain ventricles

If a person is having brain-related symptoms, such as changes in personality or affected movement, a doctor may order a head CT scan to make sure that a brain abnormality is not the underlying cause.

Test procedure

A doctor should provide specific instructions for the day of the CT scan. These will include whether or not to refrain from eating or drinking for a certain period before the scan.

The doctor will also usually ask the person to take off any jewelry, removable dental work, or hairpins because these can affect the scan’s images.

Sometimes, people who take metformin (Glucophage) may need to refrain from using it for a few days before getting a CT scan with contrast dye. The combination of this drug and the dye can cause a severe reaction in some individuals.

Contrast dye is a substance that the person may receive by injection before a scan. It makes certain areas of the body show up more easily on a scan. However, not all CT scans require contrast dye.

The person will often complete a checklist before undergoing the scan. The checklist includes a medical history of conditions that can affect a person’s health, such as kidney disease, heart diseaseasthma, and thyroid problems. Some health issues may affect a person’s ability to receive intravenous (IV) contrast.

The scanner usually looks like a circle shaped machine that has a hole in its center. In the center, there is a bed on which a person lies during the procedure. The scanner is usually open, which helps the person feel less claustrophobic.

radiology technician may ask the person to change into a gown before going into the room with the CT scanner.

Before the scan, a radiology technician may put an IV line in place, usually in the person’s arm, if the scan uses contrast dye.

During the scan, the radiology technician will talk to the person via a speaker to let them know them when the scan is starting. The scanner will direct X-ray beams at the person’s head. The X-rays will come back to the scanner, transmitting the images back to a computer.

After the initial scan, the radiology technician may deliver the IV contrast material. They will then restart the CT scan. The technologist will review the images to ensure that they are of high quality and are free of blurring in any key areas.

The average CT scan of the head takes no more than 10 minutes.

CT head scans in children

a doctor preparing a child for a CT scan.

Children are sensitive to radiation, so a doctor may only order a CT scan when necessary to confirm a diagnosis.

As a CT scan is relatively quick, many children can stay still long enough for the technician to complete the scan. However, if a child cannot remain still for the scan — as is the case for babies — it may be necessary to perform the procedure with the child under anesthesia.

Children are typically more sensitive to radiation than adults. As a result, doctors tend to reserve CT scans for when they are necessary to make a diagnosis. A radiology technician can usually adjust the settings on a CT scanner to deliver the lowest possible dose of radiation.

Risks

The CT scan is a painless, noninvasive procedure, and doctors generally consider it to be safe. However, it carries some possible risks.

As a CT scan exposes a person to radiation, there is a risk that the person could develop cancer from excessive radiation doses. However, the risks for this after one CT head scan are minimal. A person can ask their doctor if they should be concerned about the radiation dose from a CT head scan.

Doctors will usually recommend that women avoid CT scans during pregnancy. However, as one CT scan is unlikely to pose a significant risk, a doctor can offer advice on whether the benefits outweigh the risks.

Read about the safety of X-rays here.

A CT scan can be noisy. Sometimes, this noise or the fear of being in an enclosed space can provoke anxiety in a person. For this reason, doctors may sometimes give a person sedating medicines before they go into the CT scanner.

If a person receives a contrast dye during the procedure, they could be at risk of experiencing an allergic reaction to the dye.

Contrast dye can also cause other symptoms that may be temporarily unpleasant but are not an allergic reaction. These may include a warm feeling throughout the body, a burning sensation, or a metallic taste in the mouth. Sometimes, a doctor may prescribe a steroid or advise a person to take diphenhydramine (Benadryl) before undergoing the scan.

Results

A medical specialist called a radiologist will examine the imaging scans, looking for any abnormalities in the brain and surrounding tissues. They will write a report of their findings and send it to the doctor who ordered the scan.

If a person is in the hospital and undergoing the scan as an emergency, the radiologist will report any immediately concerning results as quickly as possible.

CT scan vs. MRI scan

a doctor showing a patient information on an ipad

A person’s doctor can advise on which type of scan is best to diagnose a certain condition.

While a CT scan is helpful in displaying some aspects of the head and brain, an MRI scan sometimes has higher sensitivity. As a result, it may be more effective in revealing disease processes in the brain and inflammation in the membranes covering the brain, which are known as the meninges.

Doctors will consider the advantages of each type of scan for scanning the head. The benefits of a CT scan compared with an MRI scan include:

  • A CT scan is faster than an MRI scan, so doctors usually use it for emergencies.
  • A CT scan generally costs less than an MRI scan.
  • Doctors can perform a CT scan on a person who has metal devices, such as a pacemaker, nerve stimulator, or cochlear implant. A person with these devices cannot undergo an MRI because of the magnet’s attraction to metal.

The benefits of an MRI scan compared with a CT scan include:

  • An MRI does not involve radiation exposure, making it preferable for children who may require multiple scans.
  • MRI scans can show soft tissues and structures that bone may hide in a CT scan.
  • A person requires a smaller amount of IV contrast for an MRI scan than for a CT scan.

People can talk to their doctor to evaluate the aspects of each scan and determine which is most appropriate for them.

Summary

A CT scan of the head is useful for helping a doctor assess damage after an accident or head trauma. It also allows them to look for brain abnormalities, such as tumors and skull defects.

Doctors consider CT scans to be relatively safe and noninvasive procedures, even though they involve exposure to radiation. People can discuss any possible risks with their doctor.

 

via CT head scan: Uses, procedure, risks, and results

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[REVIEW] Repetitive transcranial magnetic stimulation in stroke rehabilitation: review of the current evidence and pitfalls – Full Text

Acute brain ischemia causes changes in several neural networks and related cortico-subcortical excitability, both in the affected area and in the apparently spared contralateral hemisphere. The modulation of these processes through modern techniques of noninvasive brain stimulation, namely repetitive transcranial magnetic stimulation (rTMS), has been proposed as a viable intervention that could promote post-stroke clinical recovery and functional independence. This review provides a comprehensive summary of the current evidence from the literature on the efficacy of rTMS applied to different clinical and rehabilitative aspects of stroke patients. A total of 32 meta-analyses published until July 2019 were selected, focusing on the effects on motor function, manual dexterity, walking and balance, spasticity, dysphagia, aphasia, unilateral neglect, depression, and cognitive function after a stroke. Only conventional rTMS protocols were considered in this review, and meta-analyses focusing on theta burst stimulation only were excluded. Overall, both HF-rTMS and LF-rTMS have been shown to be safe and well-tolerated. In addition, the current literature converges on the positive effect of rTMS in the rehabilitation of all clinical manifestations of stroke, except for spasticity and cognitive impairment, where definitive evidence of efficacy cannot be drawn. However, routine use of a specific paradigm of stimulation cannot be recommended yet due to a significant level of heterogeneity of the studies in terms of protocols to be set and outcome measures that have to be used. Future studies need to preliminarily evaluate the most promising protocols before going on to multicenter studies with large cohorts of patients in order to achieve a definitive translation into daily clinical practice.

Background

Stroke is a common acute neurovascular disorder that causes disabling long-term limitations to daily living activities. The most common consequence of a stroke is motor deficit of variable degree,1 although nonmotor symptoms are also relevant and often equally disabling.2 To date, to the best of the authors’ knowledge, there is no validated treatment that is able to restore the impaired functions by a complete recovery of the damaged tissue. Indeed, stroke management basically consists of reducing the initial ischemia in the penumbra, preventing future complications, and promoting a functional recovery using physiotherapy, speech therapy, occupational therapy, and other conventional treatments.3,4

Ischemic damage is associated with significant metabolic and electrophysiological changes in cells and neural networks involved in the affected area. From a pure electrophysiological perspective, however, beyond the affected area, there is a local shift in the balance between the inhibition and excitation of both the affected and contralateral hemisphere, consisting of increased excitability and disinhibition (reduced activity of the inhibitory circuits).3,5 In addition, subcortical areas and spinal regions may be altered.3,5 In particular, the role of the uninjured hemisphere seems to be of utmost significance in post-stroke clinical and functional recovery.

Different theoretical models have been proposed to explain the adaptive response of the brain to acute vascular damage. According to the vicariation model, the activity of the unaffected hemisphere contributes to the functional recovery after a stroke through the replacement of the lost functions of the affected areas. The interhemispheric competition model considers the presence of mutual inhibition between the hemispheres, and the damage caused by a stroke disrupts this balance, thus producing a reduced inhibition of the unaffected hemisphere by the affected side. This results in increased inhibition of the affected hemisphere by the unaffected side. More recently, a new model, called bimodal balance recovery, has been proposed.3,5 It introduces the concept of a structural reserve, which describes the extent to which the nondamaged neural pathways contribute to the clinical recovery. The structural reserve determines the prevalence of the interhemispheric imbalance over vicariation. When the structural reserve is high, the interhemispheric competition model can predict the recovery better than the vicariation model, and vice versa.3

Repetitive transcranial magnetic stimulation

One of the proposed interventions to improve stroke recovery, by the induction of neuromodulation phenomena, is based on methods of noninvasive brain stimulation. Among them, transcranial magnetic stimulation (TMS) is a feasible and painless neurophysiological technique widely used for diagnostic, prognostic, research, and, when applied repetitively, therapeutic purposes.69 By electromagnetic induction, TMS generates sub or suprathreshold currents in the human cortex in vivo and in real time.10,11

The most common stimulation site is the primary motor cortex (M1), that generates motor evoked potentials (MEPs) recorded from the contralateral muscles through surface electromyography electrodes.11 The intensity of TMS, measured as a percentage of the maximal output of the stimulator, is tailored to each patient based on the motor threshold (MT) of excitability. Resting MT (rMT) is found when the target muscle is at rest, it is defined as the minimal intensity of M1 stimulation required to elicit an electromyography response with a peak-to-peak amplitude > 50 µV in at least 5 out of 10 consecutive trials.11 Alternatively TMS MTAT 2.0 software (http://www.clinicalresearcher.org/software.htm) is a free tool for TMS researchers and practitioners. It provides four adaptive methods based on threshold-tracking algorithms with the parameter estimation by sequential testing, using the maximum-likelihood strategy for estimating MTs. Active MT (aMT) is obtained during a tonic contraction of the target muscle at approximately 20% of the maximal muscular strength.11

The rMT is considered a basic parameter in providing the global excitation state of a central core of M1 neurons.11 Accordingly, rMT is increased by drugs blocking the voltage-gated sodium channels, where the same drugs may not have an effect on the gamma-aminobutyric acid (GABA)-ergic functions. In contrast, rMT is reduced by drugs increasing glutamatergic transmission not mediated by the N-methyl-D-aspartate (NMDA) receptors, suggesting that rMT reflects both neuronal membrane excitability and non-NMDA receptor glutamatergic neurotransmission.12 Finally, the MT increases, being often undetectable, when a substantial portion of M1 or the cortico-spinal tract is damaged (i.e. by stroke or motor neuron disease), and decreases when the motor pathway is hyperexcitable (such as epilepsy).13

Repetitive (rTMS) is a specific stimulation paradigm characterized by the administration of a sequence of consecutive stimuli on the same cortical region, at different frequencies and inter sequence intervals. As known, rTMS can transiently modulate the excitability of the stimulated cortex, with both local and remote effects outlasting the stimulation period. Conventional rTMS modalities include high-frequency (HF-rTMS) stimulation (>1 Hz) and low-frequency (LF-rTMS) stimulation (⩽1 Hz).11 High-frequency stimulation typically increases motor cortex excitability of the stimulated area, whereas low-frequency stimulation usually produces a decrease in excitability.14 The mechanisms by which rTMS modulates the brain are rather complex, although they seem to be related to the phenomena of long-term potentiation (LTP) and long-term depression (LTD).15

When applied after a stroke, rTMS should ideally be able to suppress the so called ‘maladaptive plasticity’16,17 or to enhance the adaptive plasticity during rehabilitation. These goals can be achieved by modulating the local cortical excitability or modifying connectivity within the neuronal networks.10

rTMS in stroke rehabilitation: an overview

According to the latest International Federation of Clinical Neurophysiology (IFCN) guidelines on the therapeutic use of rTMS,10 there is a possible effect of LF-rTMS of the contralesional motor cortex in post-acute motor stroke, and a probable effect in chronic motor stroke. An effect of HF-rTMS on the ipsilesional motor cortex in post-acute and chronic motor stroke is also possible.

The potential role of rTMS in gross motor function recovery after a stroke has been assessed in a recent comprehensive systematic review of 70 studies by Dionisio and colleagues.18 The majority of the publications reviewed report a role of rTMS in improving motor function, although some randomized controlled trials (RCTs) were not able to confirm this result,1923 as shown by a recent large randomized, sham-controlled, clinical trial of navigated LF-rTMS.24 It has also been suggested that rTMS can specifically improve manual dexterity,10 which is defined as the ability to coordinate the fingers and efficiently manipulate objects, and is of crucial importance for daily living activities.25 Notably, most of the studies focused on motor impairment in the upper limbs, whereas limited data is available on the lower limbs.18 Walking and balance are frequently impaired in stroke patients and significantly affect the quality of life (QoL),26,27 and rTMS might represent a valid aid in the recovery of these functions.28,29 Spasticity is another common complication after a stroke, consisting of a velocity-dependent increase of muscular tone,30 and for which rTMS has been proposed as a rehabilitation tool.31

Dysphagia is highly common in stroke patients, it impairs the global clinical recovery, and predisposes to complications.32 It has been pointed out that rTMS targeting the M1 area representing the muscles involved in swallowing may contribute to the treatment of post-stroke dysphagia.33

Nonmotor deficit is also a relevant post-stroke disability that negatively impacts the QoL. Aphasia is a very common consequence of stroke, affecting approximately 30% of stroke survivors and significantly limiting rehabilitation.34 According to the IFCN guidelines, to date, there is no recommendation for LF-rTMS of the contralesional right inferior frontal gyrus (IFG). Similarly, no recommendation for HF-rTMS or intermittent theta burst stimulation (TBS) of the ipsilesional left IFG or dorsolateral prefrontal cortex (DLPFC) in Broca’s aphasia has been currently approved.10 The same is true for LF-rTMS of the right superior temporal gyrus in Wernicke’s aphasia.10

Neglect is the incapacity to respond to tactile or visual contralateral stimuli that are not caused by a sensory-motor deficit.35 Although hard to treat, rTMS has been proposed as a tool for neglect rehabilitation.36 However, the IFCN guidelines state that currently there is no recommendation for LF-rTMS of the contralesional left posterior parietal cortex, or for HF-rTMS of the ipsilesional right posterior parietal cortex.10 In a recent systematic review, most of the included studies supported the use of TMS for the rehabilitation of aphasia, dysphagia, and neglect, although the heterogeneity of stimulation protocols did not allow definitive conclusions to be drawn.37

Post-stroke depression is a relevant complication of cerebrovascular diseases.38 The role of rTMS in the management of major depressive disorders is well documented,39,40 and currently, rTMS is internationally approved and indicated for the treatment of major depression in adults with antidepressant medication resistance, and in those with a recurrent course of illness, or in cases of moderate-to-severe disease severity.39 In major depression disorders, according to the IFCN guidelines, there is a clear antidepressant effect of HF-rTMS over the left DLPFC, a probable antidepressant effect of LF-rTMS on the right DLPFC, and probably no differential antidepressant effect between right LF-rTMS and left HF-rTMS. Moreover, there is currently no recommendation for bilateral stimulation combining HF-rTMS of the left DLPFC and LF-rTMS of the right DLPFC. The mentioned guidelines also state that the antidepressant effect when stimulating DLPFC is probably additive, and possibly potentiating, to the efficacy of antidepressant drugs.10 However, no specific recommendation currently addresses the use of rTMS in post-stroke depression. Recently, rTMS has been proposed as a treatment option for the late-life depression associated with chronic subcortical ischemic vascular disease, the so called ‘vascular depression’.4144 Three studies tested rTMS efficacy in vascular depression (one was a follow-up study with citalopram). Although presenting positive findings, further trials should refine clinical and diagnostic criteria to assess its impact on antidepressant efficacy.45

Approximately 25–30% of stroke patients develop an immediate or delayed cognitive impairment or an overt picture of vascular dementia.46 There is evidence of an overall positive effect on cognitive function for both LF-rTMS47 and HF-rTMS,48 supported by studies on experimental models of vascular dementia.4952 Nonetheless, the few trials examining the effect on stroke-related cognitive deficit produced mixed results.5356 In particular, two studies found no effect on cognition when stimulating the left DLPFC at 1 Hz and 10 Hz,53,54 whereas a pilot study found a positive effect on the Stroop interference test with HF-rTMS over the left DLPFC in patients with vascular cognitive impairment without dementia.55 However, this finding was not replicated in a follow-up study.56 To summarize, rTMS can induce beneficial effects on specific cognitive domains, although data are limited and their clinical significance needs to be further validated. Major challenges exist in terms of appropriate patient selection and optimization of the stimulation protocols.57

Central post-stroke pain (CPSP) is the pain resulting from an ischemic lesion of the central nervous system.58 It represents a relatively common complication after a stroke, although it is often under-recognized and, therefore, undertreated.59 According to the IFCN guidelines for the use of rTMS in the treatment of neuropathic pain, there is a definite analgesic effect of HF-rTMS of contralateral M1 to the pain side, and LF-rTMS of contralateral M1 to the pain side is probably ineffective. In addition, there is currently no recommendation for cortical targets other than contralateral M1 to the pain side.10 Notably, rTMS might be effective in drug-resistant CPSP patients.58 A recent systematic review that included nine HF-rTMS studies suggested an effect on CPSP relief, but also underlined the insufficient quality of the studies considered.60

Study objective

In this article, we aim to provide an up-to-date overview of the most recent evidence on the efficacy of rTMS in the rehabilitation of stroke patients. Although several studies have been published, a conclusive statement supporting a systematic use of rTMS in the multifaceted clinical aspects of stroke rehabilitation is still lacking.

[…]

 

Continue —> Repetitive transcranial magnetic stimulation in stroke rehabilitation: review of the current evidence and pitfalls – Francesco Fisicaro, Giuseppe Lanza, Alfio Antonio Grasso, Giovanni Pennisi, Rita Bella, Walter Paulus, Manuela Pennisi, 2019

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[Abstract] Functional Balance and Postural Control Improvements in Patients with Stroke after Non-Invasive Brain Stimulation: A Meta-Analysis

Highlights

  • NIBS improved deficits in functional balance and postural control post stroke.
  • The treatment effects on postural imbalance were significant following rTMS.
  • The improvements after rTMS appeared in acute, subacute, and chronic patients.
  • A higher number of rTMS sessions significantly increased the treatment effects.

Abstract

Objectives

The postural imbalance post stroke limits individual’s walking abilities as well as increase the risk of falling. We investigated the short-term treatment effects of non-invasive brain stimulation (NIBS) on functional balance and postural control in patients with stroke.

Data Sources

We started the search via PubMed and ISI’s Web of Science on March 1, 2019 and concluded the search on April 30, 2019.

Study Selection

The meta-analysis included studies that used either repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) for the recovery of functional balance and postural control post stroke. All included studies used either randomized control trial or crossover designs with a sham control group.

Data Extraction

Three researchers independently performed data extraction and assessing methodological quality and publication bias. We calculated overall and individual effect sizes using random effects meta-analysis models.

Data Synthesis

The random effects meta-analysis model on the 18 qualified studies identified the significant positive effects relating to NIBS in terms of functional balance and postural control post stroke. The moderator variable analyses revealed that these treatment effects were only significant in rTMS across acute/subacute and chronic stroke patients whereas tDCS did not show any significant therapeutic effects. The meta-regression analysis showed that a higher number of rTMS sessions was significantly associated with more improvements in functional balance and postural control post stroke.

Conclusions

Our systematic review and meta-analysis confirmed that NIBS may be an effective option for restoring functional balance and postural control for patients with stroke.

via Functional Balance and Postural Control Improvements in Patients with Stroke after Non-Invasive Brain Stimulation: A Meta-Analysis – Archives of Physical Medicine and Rehabilitation

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[WEB SITE] Bring Back Handwriting: It’s Good for Your Brain

People are losing the brain benefits of writing by hand as the practice becomes less common

Illustration: Kieran Blakey

NNot so long ago, putting pen to paper was a fundamental feature of daily life. Journaling and diary-keeping were commonplace, and people exchanged handwritten letters with friends, loved ones, and business associates.

While longhand communication is more time-consuming and onerous, there’s evidence that people may in some cases lose out when they abandon handwriting for keyboard-generated text.

Psychologists have long understood that personal, emotion-focused writing can help people recognize and come to terms with their feelings. Since the 1980s, studies have found that “the writing cure,” which normally involves writing about one’s feelings every day for 15 to 30 minutes, can lead to measurable physical and mental health benefits. These benefits include everything from lower stress and fewer depression symptoms to improved immune function. And there’s evidence that handwriting may better facilitate this form of therapy than typing.

A commonly cited 1999 study in the Journal of Traumatic Stress found that writing about a stressful life experience by hand, as opposed to typing about it, led to higher levels of self-disclosure and translated to greater therapeutic benefits. It’s possible that these findings may not hold up among people today, many of whom grew up with computers and are more accustomed to expressing themselves via typed text. But experts who study handwriting say there’s reason to believe something is lost when people abandon the pen for the keyboard.

Psychologists have long understood that personal, emotion-focused writing can help people recognize and come to terms with their feelings.

“When we write a letter of the alphabet, we form it component stroke by component stroke, and that process of production involves pathways in the brain that go near or through parts that manage emotion,” says Virginia Berninger, a professor emerita of education at the University of Washington. Hitting a fully formed letter on a keyboard is a very different sort of task — one that doesn’t involve these same brain pathways. “It’s possible that there’s not the same connection to the emotional part of the brain” when people type, as opposed to writing in longhand, Berninger says.

Writing by hand may also improve a person’s memory for new information. A 2017 study in the journal Frontiers in Psychology found that brain regions associated with learning are more active when people completed a task by hand, as opposed to on a keyboard. The authors of that study say writing by hand may promote “deep encoding” of new information in ways that keyboard writing does not. And other researchers have argued that writing by hand promotes learning and cognitive development in ways keyboard writing can’t match.

The fact that handwriting is a slower process than typing may be another perk, at least in some contexts. A 2014 study in the journal Psychological Science found that students who took notes in longhand tested higher on measures of learning and comprehension than students who took notes on laptops.

“The primary advantage of longhand notes was that it slowed people down,” says Daniel Oppenheimer, co-author of the study and a professor of psychology at Carnegie Mellon University. While the students who typed could take down what they heard word for word, “people who took longhand notes could not write fast enough to take verbatim notes — instead they were forced to rephrase the content in their own words,” Oppenheimer says. “To do that, people had to think deeply about the material and actually understand the arguments. This helped them learn the material better.”

Slowing down and writing by hand may come with other advantages. Oppenheimer says that because typing is fast, it tends to cause people to employ a less diverse group of words. Writing longhand allows people more time to come up with the most appropriate word, which may facilitate better self-expression. He says there’s also speculation that longhand note-taking can help people in certain situations form closer connections. One example: “A doctor who takes notes on a patient’s symptoms by longhand may build more rapport with patients than doctors who are typing into a computer,” he says. Also, a lot Berninger’s NIH-funded work found that learning to write first in print and then in cursive helps young people develop critical reading and thinking skills.

Finally, there’s a mountain of research that suggests online forms of communication are more toxic than offline dialogue. Most of the researchers who study online communication speculate that a lack of face-to-face interaction and a sense of invisibility are to blame for the nasty and brutish quality of many online interactions. But the impersonal nature of keyboard-generated text may also, in some small way, be contributing to the observed toxicity. When a person writes by hand, they have to invest more time and energy than they would with a keyboard. And handwriting, unlike typed text, is unique to each individual. This is why people usually value a handwritten note more highly than an email or text, Berninger says. If words weren’t quite so easy to produce, it’s possible that people would treat them — and maybe each other — with a little more care.

via Bring Back Handwriting: It’s Good for Your Brain – Elemental

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[WEB SITE] Nootropics: Types, safety, and risks of smart drugs

Last reviewed 

Nootropics, or “smart drugs,” are a class of substances that can boost brain performance. They are sometimes called cognition enhancers or memory enhancing substances.

Prescription nootropics are medications that have stimulant effects. They can counteract the symptoms of medical conditions such as attention deficit hyperactivity disorder (ADHD), narcolepsy, or Alzheimer’s disease.

Nonprescription substances that can enhance brain performance or focus — such as caffeine and creatine — are also considered nootropics. They do not treat diseases but may have some effects on thinking, memory, or other mental functions.

This article looks at prescription and nonprescription smart drugs, including their uses, side effects, and safety warnings.

Prescription nootropics

a woman taking nootropics at her desk.

A person may take a nootropic to treat ADHD, narcolepsy, or dementia.

Prescription nootropics include:

  • modafinil (Provigil), a stimulant that addresses the sudden drowsiness of narcolepsy
  • Adderall, which contains amphetamines to treat ADHD
  • methylphenidate (Ritalin), a stimulant that can manage symptoms of narcolepsy and ADHD
  • memantine (Axura), which treats symptoms of Alzheimer’s disease

While these can be effective in treating specific medical conditions, a person should not take them without a prescription.

Like any prescription medications, they carry risks of side effects and interactions, and a person should only take them under a doctor’s care.

Common side effects of prescription nootropics include:

Some evidence suggests that people who use prescription nootropics to improve brain function have a higher risk of impulsive behaviors, such as risky sexual practices.

Healthcare providers should work closely with people taking prescription nootropics to manage any side effects and monitor their condition.

Over-the-counter nootropics

The term “nootropic” can also refer to natural or synthetic supplements that boost mental performance. The following sections discuss nootropics that do not require a prescription.

Caffeine

Many people consume beverages that contain caffeine, such as coffee or tea, because of their stimulant effects. Studies suggest that caffeine is safe for most people in moderate amounts.

Having a regular cup of coffee or tea may be a good way to boost mental focus. However, extreme amounts of caffeine may not be safe.

The Food and Drug Administration (FDA) recommend that people consume no more than 400 milligrams (mg) of caffeine a day. This is the amount in 4–5 cups of coffee.

Caffeine pills and powders can contain extremely high amounts of the stimulant. Taking them can lead to a caffeine overdose and even death, in rare cases.

Women who are pregnant or may become pregnant may need to limit or avoid caffeine intake. Studies have found that consuming 4 or more servings of caffeine a day is linked to a higher risk of pregnancy loss.

L-theanine

L-theanine is an amino acid that occurs in black and green teas. People can also take l-theanine supplements.

A 2016 review reported that l-theanine may increase alpha waves in the brain. Alpha waves may contribute to a relaxed yet alert mental state.

L-theanine may work well when paired with caffeine. Some evidence suggests that this combination helps boost cognitive performance and alertness. Anyone looking to consume l-theanine in tea should keep the FDA’s caffeine guidelines in mind.

There are no dosage guidelines for l-theanine, but many supplements recommend taking 100–400 mg per day.

Omega-3 fatty acids

person at desk holding omega 3 supplements in palm

Studies have shown that omega-3 fatty acids are important to fight against brain aging.

These polyunsaturated fats are found in fatty fish and fish oil supplements. This type of fat is important for brain health, and a person must get it from their diet.

Omega-3s help build membranes around the body’s cells, including the neurons. These fats are important for repairing and renewing brain cells.

A 2015 review found that omega-3 fatty acids protect against brain aging. Other research has concluded that omega-3s are important for brain and nervous system function.

However, a large analysis found “no benefit for cognitive function with omega‐3 [polyunsaturated fatty acids] supplementation among cognitively healthy older people.” The authors recommend further long term studies.

A person can get omega-3 supplements in various forms, including fish oil, krill oil, and algal oil.

These supplements carry a low risk of side effects when a person takes them as directed, but they may interact with medications that affect blood clotting. Ask a doctor before taking them.

Racetams

Racetams are synthetic compounds that can affect neurotransmitters in the brain. Some nootropic racetams include:

  • piracetam
  • pramiracetam
  • phenylpiracetam
  • aniracetam

A study conducted in rats suggests that piracetam may have neuroprotective effects.

One review states that “Some of the studies suggested there may be some benefit from piracetam, but, overall, the evidence is not consistent or positive enough to support its use for dementia or cognitive impairment.” Confirming this will require more research.

There is no set dosage for racetams, so a person should follow instructions and consult a healthcare provider. Overall, studies have no found adverse effects of taking racetams as directed.

Ginkgo biloba

Ginkgo biloba is a tree native to China, Japan, and Korea. Its leaves are available as an herbal supplement.

2016 study found that gingko biloba is “potentially beneficial” for improving brain function, but confirming this will require more research.

Ginkgo biloba may help with dementia symptoms, according to one review, which reported the effects occurring in people who took more than 200 mg per day for at least 5 months.

However, the review’s authors note that more research is needed. Also, with prescription nootropics available, ginkgo biloba may not be the most safe or effective option.

Panax ginseng

Panax ginseng is a perennial shrub that grows in China and parts of Siberia. People use its roots for medicinal purposes.

People should not confuse Panax ginseng with other types of ginseng, such as Siberian or American varieties. These are different plants with different uses.

2018 review reports that Panax ginseng may help prevent certain brain diseases, including Alzheimer’s disease, Parkinson’s disease, and Huntington’s disease. It also may help with brain recovery after a stroke.

Panax ginseng interacts with many medications, so consult a doctor before taking it. A typical dosage for mental function is 100–600 mg once or twice a day.

Rhodiola

Some evidence suggests that Rhodiola rosea L., also known as rhodiola or roseroot, can help with cognitive ability.

One review reported that rhodiola may have neuroprotective effects and may help treat neurodegenerative diseases.

Another review found that rhodiola helped regulate neurotransmitters in the brain, having a positive effect on mood.

Rhodiola capsules have varying strengths. Usually, a person takes a capsule once or twice daily.

Creatine

Creatine is an amino acid, which is a building block of protein. This supplement is popular among athletes because it may help improve exercise performance. It may also have some effects on mental ability.

A 2018 review found that taking creatine appears to help with short term memory and reasoning. Whether it helps the brain in other ways is unclear.

The International Society of Sports Nutrition report that creatine supplementation of up to 30 grams per day is safe for healthy people to take for 5 years.

Another 2018 review notes that there has been limited research into whether this supplement is safe and effective for adolescent athletes.

Do nootropics work?

Some small studies show that some nootropic supplements can affect the brain. But there is a lack of evidence from large, controlled studies to show that some of these supplements consistently work and are completely safe.

Because of the lack of research, experts cannot say with certainty that over-the-counter nootropics improve thinking or brain function — or that everyone can safely use them.

For example, one report on cognitive enhancers found that there is not enough evidence to indicate that they are safe and effective for healthy people. The researchers also point to ethical concerns.

However, there is evidence that omega-3 fatty acids can benefit the brain and overall health. In addition, caffeine can improve mental focus in the short term.

Notes on the safety of nootropics

doctor and patient in office discussing adrenal cancer

A person should talk to a doctor about any interactions supplements may have with existing medications.

Also, some supplements may not contain what their labels say. A study of rhodiola products, for example, found that some contain contaminants or other ingredients not listed on the label.

For this reason, it is important to only purchase supplements from reputable companies that undergo independent testing.

BUYING NOOTROPICSA prescription is necessary for some nootropics, such as Provigil and Adderall. Over-the-counter nootropics are available in some supermarkets and drug stores, or people can choose between brands online:

Not all of these supplements are recommended by healthcare providers and some may interact with medications. Always speak to a doctor before trying a supplement.

Summary

Many doctors agree that the best way to boost brain function is to get adequate sleep, exercise regularly, eat a healthy diet, and manage stress.

For people who want to boost their cognitive function, nootropic supplements may help, in some cases. Anyone interested in trying a nootropic should consult a healthcare professional about the best options.

 

via Nootropics: Types, safety, and risks of smart drugs

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