Posts Tagged brain injury
Vision and Rehabilitation After Brain Trauma (Part 1)
This is part one of a three-part article published to health.mil.
Vision Problems After Brain Injury
Visual problems following brain trauma are frequent and often complex. It is probably easiest to define the problems based upon how they affect incoming visual information (i.e., the afferent visual pathways) or the outflow of information to the visual organs (i.e., efferent visual pathways). Afferent defects include reduction in visual acuity, visual field, color vision, contrast sensitivity, comfort (usually as it relates to glare), and higher level visual processing, including recording of visual memory and comprehension of visual stimuli. Efferent defects include reduction of the ability to visually pursue a target, focus the lens inside the eye, train the two eyes onto a single target, maintain gaze once a visual target is obtained, and open and close the eyelids. In this three part series, we will describe 1) damage to the afferent visual pathways, 2) damage to the efferent visual pathways, and 3) the role of the neuro-ophthalmologist in visual restoration and rehabilitation.
The Afferent Visual Pathway and How Brain Injury Can Affect It
Light enters the eye through the cornea, the clear window of the eye. The cornea provides the majority of the focusing power of the eye, and is an extremely poor refractive surface, but with a healthy tear film it becomes nearly perfect. Brain injury often causes dry eye thereby reducing visual acuity. Furthermore, brain injury patients often lose an adequate blink response or develop lagophthalmos, the inability to completely close the eye. Dry, unprotected corneas are subject to scarring and infection.
Trauma to the brain often entails injury that can also shake or directly damage the eye along with the rest of the body. Patients suffering a blast injury can experience rapid elevation of pressure in the chest, which is then transmitted by the blood vessels to the retina, the neural tissue lining the inner wall of the eye. This is the tissue which converts light rays into the electrical impulses that are sent to the brain. The retinal blood vessels can rupture from the sudden increase in pressure and cause bleeding within the retina, a condition called Purtscher’s retinopathy. The free blood inside the eye can cause significant scarring and loss of vision.
Direct head trauma can also cause the eye to move too quickly and/or too far relative to the fixed structures in the eye socket. This can cause stretching or shearing of the optic nerve, the nerve that carries visual information to the brain. This traumatic optic neuropathy often can result in permanent visual impairment. Multiple direct head traumas also are a risk factor for problems within the eye itself, such as detachment of the retina from the back of the eye, or formation of a cataract, a clouding of the natural lens.
Trauma to the head invariably is associated with some degree of trauma to the neck, a risk factor for damage to the blood vessels of the neck. Injury to the wall of an artery can cause it to bulge (i.e., form an aneurysm) or separate from its inner lining (i.e., arterial dissection). Either situation can lead to abnormal blood flow to the visual pathways of the brain. Furthermore, either condition can cause the vessels to physically compress portions of the visual pathways, such as the nerves that control the eye muscles or the nerves that bring visual information to the brain. This could result in double vision or in reduction of visual acuity and visual field, respectively.
It has been demonstrated that the world we see is formed into a map upon our brain, specifically onto an area called the visual cortex. This map is organized such that the image of the world is inverted and reversed; the left side of our brain sees what is to the right of where we look and the right side of the brain sees light from the left of where we gaze. Furthermore, visual information emanating from above our visual point of interest is transmitted to the lower portion of the visual cortex while the upper portion of the visual cortex maps the visual world below the object of regard. It is for this reason that damage to the visual cortex causes loss of peripheral vision rather than simply loss of visual clarity.
While we do not know how visual memories are created or stored in our brains, it is known that brain injury slows the acquisition and processing of visual information and impairs the formation of visual memory. Recent research has suggested that these impairments may result from stretching or shearing of nerve fiber bundles after head injury. Sadly, higher level visual processing failure is often particularly difficult for a patient to express. Neuropsychologists have proven to be critically important for the diagnosis of these problems and for guidance in directing rehabilitation efforts.
From Stars and Stripes, March 2010, Health.mil.
- Vision and Rehabilitation After Brain Trauma (Part 2)
- Vision and Rehabilitation After Brain Trauma (Part 3)
- Vision Issues After Brain Injury: BrainLine Talks with Dr. Gregory Goodrich
- Vision Is Our Dominant Sense
- Introduction to Vision and Brain Injury
- What Does a Comprehensive Vision Exam Entail?
- Diagnosing Vision Problems After a Brain Injury
- Scanning Training in Neurological Vision Loss
My brother had a brain injury six years ago and has been through several periods of rehabilitation to where he now jokes he could be a therapist! He can list all the strategies he is supposed to use to get somewhere on time — like his job — he just doesn’t do them or says they don’t help. Can you give me some insight here?
To begin, one has to consider whether being on time to work is meaningful to your brother. If he enjoys his job and recognizes the implications of being late, then chances of helping him figure out how to get there on time are much better.
Assuming this is the case, your brother’s dilemma is not uncommon after a brain injury. Many everyday activities, such as being somewhere on time, actually involve a number of different skills. It’s important to first figure out what skills are involved so you can choose strategies that are likely to work.
Let’s take your example of getting to work on time and list just some of the cognitive skills and steps that play a part and could be causing his problems:
- Attention: What time is it, anyway? Am I on time or running late? Am I doing what I am supposed to be doing right now (or getting distracted by a TV show)?
- Memory: What time do I have to be at work today? What needs to be done before I leave the house?
- Initiation: Do I get started on each step of my routine in a timely manner?
- Planning: Do I have enough time to get ready? Are my clothes ready? Have I planned enough time for transportation?
- Problem-solving: What do I do if I’m running late? What if my transportation falls through? What are my other options? Do I have enough time to go back if I forgot something like my ID badge, lunch, or newspaper?
Breaking down an activity into more specific component skills can often help tease apart where the true difficulty lies. Then a strategy that promotes success (generally, one that builds on his strengths) can be developed by the person with brain injury and if needed, a significant other. If this proves too difficult, some consultation with a cognitive rehabilitationspecialist may be useful as well. And remember, any new strategy often requires a lot of practice to make it a habit, especially after brain injury.
Finally, if your brother does not seem motivated, the discussion needs to be about what is important to him. If getting to work on time is not one of his priorities, what is it that he wants to accomplish?
Continued from Part 1 From The Toronto Acquired Brain Injury Network. My comments are in bold like this. Emotional/Behavioural Changes Impulsivity and disinhibition A person may lose their ability to control their actions or their speech. This problem often goes hand in hand with lack of awareness, and the person may not be aware of […]
DECEMBER 16, 2016
Summary: Findings could lead to new treatments to help regeneration following trauma.
Source: Kobe University.
A research team led by Associate Professor Mitsuharu Endo and Professor Yasuhiro Minami has pinpointed the mechanism underlying astrocyte-mediated restoration of brain tissue after an injury. This could lead to new treatments that encourage regeneration by limiting damage to neurons incurred by reduced blood supply or trauma. The findings were published on October 11 in the online version of GLIA ahead of print release in January 2017.
When the brain is damaged by trauma or ischemia (restriction in blood supply), immune cells such as macrophages and lymphocytes dispose of the damaged neurons with an inflammatory response. However, an excessive inflammatory response can also harm healthy neurons.
Astrocytes are a type of glial cell, and the most numerous cell within the human cerebral cortex. In addition to their supportive role in providing nutrients to neurons, studies have shown that they have various other functions, including the direct or active regulation of neuronal activities.
It has recently become clear that astrocytes also have an important function in the restoration of injured brain tissue. While astrocytes do not normally proliferate in healthy brains, they start to proliferate and increase their numbers around injured areas and minimize inflammation by surrounding the damaged neurons, other astrocytes, and inflammatory cells that have entered the damaged zone. Until now the mechanism that prompts astrocytes to proliferate in response to injury was unclear.
The research team focused on the fact that the astrocytes which proliferate around injured areas acquire characteristics similar to neural stem cells. The receptor tyrosine kinase Ror2, a cell surface protein, is highly expressed in neural stem cells in the developing brain. Normally the Ror2 gene is “switched off” within adult brains, but these findings showed that when the brain was injured, Ror2 was expressed in a certain population of the astrocytes around the injured area.
Ror2 is an important cell-surface protein that regulates the proliferation of neural stem cells, so the researchers proposed that Ror2 was regulating the proliferation of astrocytes around the injured areas. They tested this using model mice for which the Ror2 gene did not express in astrocytes. In these mice, the number of proliferating astrocytes after injury showed a remarkable decrease, and the density of astrocytes around the injury site was reduced. Using cultured astrocytes, the team analyzed the mechanism for activating the Ror2 gene, and ascertained that basic fibroblast growth factor (bFGF) can “switch on” Ror2 in some astrocytes.
This research showed that in injured brains, the astrocytes that show (high) expression of Ror2 induced by bFGF signal are primarily responsible for starting proliferation. bFGF is produced by different cell types, including neurons and astrocytes in the injury zone that have escaped damage. Among the astrocytes that received these bFGF signals around the injury zone, some express Ror2 and some do not. The fact that proliferating astrocytes after brain injury are reduced during aging raises the possibility that the population of astrocytes that can express Ror2 might decrease during aging, which could cause an increase in senile dementia. Researchers are aiming to clarify the mechanism that creates these different cell populations of astrocytes.
By artificially controlling the proliferation of astrocytes, in the future we can potentially minimize damage caused to neurons by brain injuries and establish a new treatment that encourages regeneration of damaged brain areas.
[WEB SITE] Stress Management Following Brain Injury: Strategies for Families and Caregivers – brainline.org
Few illnesses, injuries, or diseases result in the devastating and overwhelming damage which accompanies brain injury. The individual who sustains a brain injury is no longer the same person: he or she may behave differently, think differently and in fact be a different person than before the injury. The differences may be large or small; they are differences nonetheless. And when one member of a family changes, the entire family changes. Learning to live with these changes produces stress for the injured individual and for those who care for that person. The steps outlined below can help lessen the burden and convert stresses into challenges which can be managed and overcome.
1. Identify stress
Sounds easy. We all know when we are stressed. It’s obvious. All your friends and relatives can tell you what is stressing you. We professionals are particularly guilty of telling you what to do and how to do it. Everyone is full of good advice and solutions to your problems. The solutions may range from putting the injured person in an institutional setting to developing some backbone and shouldering responsibility the way you should.
Don’t allow others to identify your stress for you. Stress is cumulative and it is very personal. What might be stressful to one individual is not stressful to another. What is stressful to you at one point in time may not be stressful at another point. Only you can determine what is stressful to you. And you can only do that by experience. Spend time each day analyzing what has stressed you in the past 24 hours.
Avoid making moral judgments about stress. Stress in itself is neither good or bad. It is simply a situation in which your body’s usual, customary, and habitual responses don’t work and you must develop new responses. Your responses are neither good nor bad. You are not a bad person because you become angry at the injured person’s behavior, because you become tired in a very short period of time, because you yell at your kids or another individual, because you don’t want to change sheets or clothes one more time today. Accept your body’s response without making judgments.
- Make a list of each and every thing you do on a daily basis. Be very specific, including even the smallest activity. Include things you do for everyone, not just the injured individual. Then rate each one on a scale of 1 – 10 with 1 being “no stress whatsoever, enjoyable” and 10 being “a root canal without anesthesthia would be much more fun.” Do not show this list to anyone else. Be honest.
2. Reduce or eliminate stressors
Also sounds easy but this is the hardest part. I am always amazed at the number and amount of things people do because they have always done them. Absolutely irrational, meaningless things; things which reduce the time available to enjoy life; things which 24 hours later have no meaning at best, negative meaning at worst.
Do only those things which have meaning to you and to others; do them quickly, efficiently and only once. If you’re dreading doing something for five hours before you have to do it, you have wasted five hours and still have to do it. Whenever possible, live in the present; avoid the future and the past since you have no control over them anyway.
Once you have your list of things you do regularly, decide which of those you rated over 5 truly need to be done. Objectively need to be done. Those things where life would not continue if they weren’t done. Probably they need to be done. I won’t argue with you. I will argue that YOU need to do them. Answer each of the following questions:
- Do they have to be done the way they are usually done? Can the person with the brain injury do them? Can another family member do them? Can a volunteer do them? Can a group of people do them? Can you reduce how often they need to be done? Can they be done at a different time of day? Can they be done in a way that makes them enjoyable (or at least less stressful)?
3. Replace stressful things with pleasant things
It is truly surprising to me to see individuals who successfully reduce or eliminate stressful situations from their life and within a week add a whole new list of activities which are equally stressful. It seems as if they thrive on stress but everyone who lives with the consequences of brain injury knows that it is not true. The problem is that, unless you actively substitute pleasant activities for unpleasant ones, the time will rapidly fill with equally (or perhaps even more) unpleasant activities.
If you have lived with the consequences of brain injury beyond the acute medical stage you know how difficult it is to allow yourself the luxury of enjoyment and relaxation. There never seems to be enough time for you. Simply and solely because you don’t make the time. Every human being is a like a pitcher; you can only serve out what was poured in to you. You cannot continue to give without replacing what you give. If others are not able to give to you, then you must give to yourself. When was the last time you gave yourself a present? A simple, inexpensive present like a walk in the park, dinner with a friend, sleeping late in the morning, maybe even breakfast in bed. Or, even worse, when was the last time you allowed someone else to give you a present of time or assistance?
You may think I have lost touch with reality because you KNOW that other people are not willing to help. You have tried them in the past and they never came through for you. They make empty offers which you know they don’t mean. Besides, many of your friends from before the injury no longer call or visit. You’re alone in this. There is no help. You have tried time and time again. I suggest you try again, making sure you are specific about the kind of help you need, when you need it, what is involved, how often you need it, and, most importantly, what you are willing to do in return. Your family and friends can only give to you if you continue to give to them. They are also pitchers that need to be refilled. When they see you totally stressed out, they assume the same thing will happen to them if they try to help. Try being specific and giving in return. It’s worth the effort.
Another alternative is to try new things in which the entire family can participate. Families sometimes fail to try new activities and stick with the tried-and-true favorites. Try to discover new activities in which the effects of the deficits of the head injured person are minimized. Many injured individuals are able to do things they once did as a child or young adult because those activities rely on old rather than new learning. Experiment with activities which can be enjoyable for everyone and feel less like work for the caregiver.
4. Maximize the capabilities of the person with the brain injury
It is sometimes very difficult to determine just what the injured individual is capable of doing. Therefore, family members may do things for the injured individual that could and should be done independently. Persons who sustain head injuries continue to improve for years, learning new skills or new ways to do things. If the family doesn’t “catch up,” they keep on “doing for” rather than letting go. It often feels easier to do it yourself than to work regularly for a long term goal of independence or at least less dependency. But that strategy doesn’t reduce the stress for the injured individual or for the family.
Many family members have explored or even participated in newly-developed cognitive retraining programs. They usually begin with a detailed analysis of the person’s current capabilities and limitations. From this analysis the treatment program is developed and the progressive steps toward increased independence are outlined. Families can do the same kind of analysis. Start with your stress list. Pick the 5 most stressful situations which require that something be done for or to the injured individual. Evaluate what parts of that task the injured person could do himself/herself. ASK THE INJURED PERSON FOR SUGGESTIONS ON THIS PART OF YOUR TASK. That person may well have very good ideas of how the task could be accomplished more independently. Consider the following ways to accomplish the task:
- Change the time at which the task is done. If fatigue is a problem, for example, switch the task to an earlier time in the day or after a rest period. Schedule more time for completion of the task. Try to set up all necessary materials so the person can do the task independently. Use written instructions, photographs or picture demonstrations to allow the person to complete the task independently.
Basically I am suggesting you experiment to determine what the injured individual can do. You lose nothing by trying and the injured person may well be much more capable than others (or you) think. Give the person a chance. Give yourself a chance to reduce your stress. Allow the injured individual and the family to grow in a more relaxed atmosphere of increasing independence.
Many survivors and family members describe changes in their relationships after the injury. They may not hear much from friends, co-workers, and extended family members. Others notice that their phone calls, emails, and letters are left unanswered. Some survivors find themselves feeling alone even when they spend much of their time with family members or friends. Here are some of the things people say about their relationships after brain injury. Do any of these statements sound like things you have said?
- I can’t relate to other people. It’s easier to be by myself.
- What happened to all the friends who came to visit me in the hospital?
- Other people don’t want to be around me.
- People seem to avoid me.
- My wife threatens to leave me at least twice a week.
- I wonder why no one returns my calls.
- It seems like everyone at work has lost my phone number.
- I haven’t talked to anyone in weeks.
- Nobody cares about me.
- I don’t have any friends.
- Seems like nobody wants to talk to me.
- Nobody has any idea what I am going through. They don’t understand me.
Why people feel lonely even when around family members or friends?
After injury, many survivors describe feeling lonely — even when they are surrounded by other people. This loneliness may arise for many different reasons.
- Difficulty talking to other people or understanding what others are saying are common problems survivors face after injury. Communication problems can make relating to other people and explaining your thoughts and feelings very difficult. These problems can lead to feeling misunderstood and isolated.
- Many survivors feel self-conscious after their injuries. They may worry about being different or less capable than other people. Self-consciousness can make it harder to spend time with other people or seek out new relationships.
- After injury, many survivors worry about what others will think of them and may feel nervous about being around other people. They may be afraid of being hurt or rejected by other people.
- Many survivors notice they are more irritable after their injuries. When irritated, they may say or do things they regret later on. Some survivors try to stay away from those they care about for fear of behaving poorly. Family and friends may also avoid you if they are worried about what you might say or do.
- Fatigue and low energy are common problems after brain injury. Survivors may not have the energy to do things they used to enjoy or to spend time with friends and family. Family and friends may also worry about tiring you out when they invite you to do something.
- Pain and other physical problems often make it harder for survivors to do things they used to enjoy. You may also have trouble leaving the house, traveling, or visiting other people. Injury-related limitations make it harder to nurture and build relationships.
- Many survivors are not able to drive or work after their injury. Lack of transportation and money may make it hard to visit others or do things you enjoy.
- People generally make friends through work or being involved in social or recreational activities. After injury, survivors often stop working and may not be involved in sports, church, and other activities. You may lose contact with friends and co-workers because you don’t see them as much.
- Friends and family may feel uncomfortable because they don’t know what to say, how to act, or how to help. Discomfort may make it harder for them to relate to you or spend time with you. Help them out by letting them know about your positive and negative feelings and what they can do to help you.
Contracture is a loss of motion over time due to abnormal shortening of the soft tissue structures spanning one or more joints. These include skin, ligaments, tendon, muscles and joint capsules. Loss of motion in any of the structures restricts joint mobility leading to pain, stiffness and eventually contracture.
Disuse and Neglect.
Contractures are a common and debilitating problem for individuals who have suffered from neurological or orthopedic injuries. Following a stroke or brain injury, damage to the cerebral cortex and brain stem results in weakness, decreased motor control, sensation, and spasticity.
These clinical findings lead to limited functional movement and learned nonuse. Through disuse, the affected joint becomes less elastic and stiff and eventually contracted….read more…
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Source: What is “contracture”?
[BLOG POST] Quick Points on Wheelchair Safety in Parking Lots – The Transitional Learning Center’s Blog
Following their injuries, many brain injury survivors are left depending upon wheelchairs to meet basic mobility needs. This change in mobility creates new safety considerations that must be taken into account on a daily basis. One of these considerations surrounds strategies for safely navigating a parking lot while in a wheelchair.
Most adults are between 5 and 6.5 feet tall. They are accustomed to being easily visible to drivers distractedly circling a parking lot and through rear windshields as drivers back up vehicles out of parking spaces. When sitting in a wheelchair though, normal adults are often effectively no taller than young children. Even the most conscientious driver can struggle while exiting a parking space to see a pedestrian in a wheelchair. These survivors are also often harder to see by a driver making the turn from one parking lot lane on to another. Due to this change in baseline visibility, survivors in wheelchairs and their families must be more vigilant of vehicle activity and the abilities at every identifiable moment of drivers to see the survivors. They must spend more time looking around to observe vehicle activity, just as they would when in the presence of a small child who may slip the notice of nearby drivers.
Another issue regarding parking lot safety is that survivors in wheelchairs are generally slower than the average person would be while moving across the same parking lot. Since it takes more time to traverse any distance, survivors and their families must add extra time in their calculations as to whether there might be enough time to safely cross in front of an approaching vehicle. If the result of such calculations inspire even the suggestion of doubt, erring on the side of patience is always the best policy. Sometimes, family and friends may need to push the survivors’ wheelchairs to help move quickly enough to safely avoid traffic. Additionally, typical adults generally can step up onto the curb from the parking lot at any location they choose. Survivors in wheelchairs must use curb cut ramps which often means that they have to take a longer route to get onto the curb and consequently spend more time in the path of vehicles. Again, survivors and their families must be aware of this additional urgency when choosing a path across any parking lot.
These are just a few quick points on wheelchair safety in the parking lot. I hope everyone has a safe time in their travels, particularly in parking lots!
Learn about brain injury treatment services at the Transitional Learning Center: http://tlcrehab.org/
The treatment of concussions and traumatic brain injury (TBI) is a clinical challenge. Clinical studies thus far have failed to identify an effective treatment strategy.
According to emerging science and clinical experience, aggressive intake of omega-3 fatty acids (n-3FA) seems to be beneficial to TBI, concussion, and post-concussion syndrome patients.
This research is presented in Concussions, Traumatic Brain Injury, and the Innovative Use of Omega-3s, a review article from the Journal of the American College of Nutrition, official publication of the American College of Nutrition.
Research suggests that early and optimal doses of omega-3 fatty acids (n-3FA) have the potential to improve outcomes from traumatic brain injury.
The article reviews preclinical research and cites three brain injury case studies that resulted from a mining accident, a motor vehicle accident, and a drowning accident.
Each instance showcased evidence of safety and tolerability, wherein the patients who sustained life-threatening brain injuries recovered brain health with the aid of omega-3 fatty acids (n-3FA).
Growing clinical experience by numerous providers is that the brain needs to be saturated with high doses of n-3FA in order for the brain to have the opportunity to heal.
Without an optimal supply of omegas, healing is less likely to happen. It is well recognized that n-3FAs are not a drug and not a cure and every situation is different.
Clinically, some patients respond better than others. However, there is no downside to providing optimal levels of nutrition in order to give a patient the best opportunity to regain as much function as possible following a TBI.