Posts Tagged concussion

[FACTSHEET] Concussion Recovery

What is a concussion?

A concussion is a mild traumatic brain injury (TBI) caused by a blow to the head which causes the head and brain to move rapidly back and forth. This can happen due to a car or bike crash, a fall, an assault, or a sports injury. In most cases, there are no lasting symptoms or ill effects from a concussion. During recovery, brain function and blood flow may be slightly changed and therefore it is best not to take part in rigorous activities (e.g., contact sports) that might lead to a second concussion for a few days to a week.

Recovering from concussion

Most concussion symptoms resolve within hours to days or a few months. Recovery is usually faster when a person gets some rest for a short period of time (e.g., a couple of days) and gradually returns to their activities and responsibilities over a week or so. Complete rest is not recommended, and instead, light exercise and mental activity may actually improve recovery. A small number of people may take longer to recover and need specific treatments. They could include specific support at work or school for a short period of time such as days or a few weeks while they recover.

Common symptoms of concussion

People with concussions may have temporary symptoms for a brief period of time that include a combination of headaches, poor concentration, fatigue, memory problems, dizziness, and nausea. People may feel irritable and have changes in mood or sleep. They may also have trouble thinking clearly, short-term disorientation, blurry or double vision, and be sensitive to bright light or noise.

Course of recovery

The common symptoms of concussion listed above are part of the recovery process; they are not signs of permanent damage or complications. These symptoms are normal, like the itch of stitches that are healing. Most people with a concussion who have symptoms recover in hours or a week to a few months. If you are older than 40, it may take a bit longer to get back to normal. Symptoms usually go away without treatment.

What can I do about my symptoms?

Some people who have had a concussion find it hard to do daily activities or their job during recovery. They may also find it hard to get along with everyone at home, or to relax. Pace yourself and be sure to get the rest you need. If your symptoms get worse, or if you have new symptoms, it may be a sign that you are pushing yourself too hard. Slow down and take care of yourself. For most people, after the injury, it is best to relax for a few hours or days and then slowly increase activity over the course of a week. Remember that symptoms are a normal part of recovery; they will usually go away on their own.

Many of the symptoms of concussion may also be due to stress, anxiety or pain. Many people have some of these symptoms once in a while even without having a concussion. Some of your symptoms may be similar to the symptoms of everyday stress that all people experience. A pulled muscle or a bruised leg needs time to heal; your brain does as well. You may have some trouble with work or school at first. This may be stressful, but it is normal. Trying to do your regular work right after a concussion is like trying to play baseball or swim with a pulled muscle. If you have concerns about your recovery, talk to your doctor. Most children and athletes with sports-related concussions need a doctor’s release in order to return to play.

Concussion and outcomes

As noted above, there should be no long-term difficulties after a concussion and healing occurs relatively quickly. You may have heard of a disease called chronic traumatic encephalopathy, or CTE. A disease thought to be caused by repeated brain injury, CTE is poorly understood at this time. Most studies of CTE have used elite athletes with a long history of physical trauma. Based on existing evidence, experts think that one or two concussions do not lead to long-term conditions such as CTE, dementia, or Parkinson’s disease.

Where can I go for support?

Most people find it helpful to get support from their friends and family after a concussion. They also look to health care providers like doctors, nurses, and psychologists who specialize in brain injury when possible for advice and support during recovery. But this is not always enough. Since you or your family member had a concussion, you may want to talk to other people who have been through similar experiences. Many support groups exist for people who have had a TBI and their loved ones. You can get more information from the sources below.

A free concussion recovery guide can be found at https://www.rimrehab.org/docs/librariesproviderdmcrim/default-document-library/tbi-recovery-guide-full-document-ada.pdf?sfvrsn=ad02e63e_0.

The Brain Injury Association of America can be contacted at 1-800-444-6443 or www.biausa.org. The Brain Injury Alliance can also be contacted at https://usbia.org/.

Authorship

The factsheet was developed by Robin Hanks, Ph.D, Kathy Bell, M.D., Laura Dreer, Ph.D. in collaboration with the Model Systems Knowledge Translation Center.

Source: This content is based on research and/or professional consensus. This content has been reviewed and approved by experts from the Traumatic Brain Injury Model Systems (TBIMS) Program, funded by the National Institute on Disability, Independent Living, and Rehabilitation Research, as well as experts from the Polytrauma Rehabilitation Centers (PRCs), funded by the U.S. Department of Veterans Affairs.

Disclaimer: This information is not meant to replace the advice of a medical professional. You should consult your health care provider regarding specific medical concerns or treatment. The contents of this factsheet were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DP0082). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this factsheet do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the federal government.

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[Booklet] Recovering from Mild Traumatic Brain Injury/Concussion – PDF File

Guide for Patients and Their Families

This booklet provides a few answers to questions commonly asked by patients and family members following a mild traumatic brain injury (TBI) which is also called a concussion. It describes some of the problems that people may experience after a mild TBI and offers some tips on coping with these problems. As you read this booklet, keep in mind that everyone recovers a little bit differently. Everyone improves after a mild TBI, and most people recover completely in time. We hope that you find this booklet helpful.[…]

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[Abstract] Gait Performance in People with Symptomatic, Chronic Mild Traumatic Brain Injury

Abstract

There is a dearth of knowledge about how symptom severity affects gait in the chronic (>3 months) mild traumatic brain injury (mTBI) population despite up to 53% of people reporting persisting symptoms after mTBI. The aim of this investigation was to determine whether gait is affected in a symptomatic, chronic mTBI group and to assess the relationship between gait performance and symptom severity on the Neurobehavioral Symptom Inventory (NSI). Gait was assessed under single- and dual-task conditions using five inertial sensors in 57 control subjects and 65 persons with chronic mTBI (1.0 year from mTBI). The single- and dual-task gait domains of Pace, Rhythm, Variability, and Turning were calculated from individual gait characteristics. Dual-task cost (DTC) was calculated for each domain. The mTBI group walked (domain z-score mean difference, single-task = 0.70; dual-task = 0.71) and turned (z-score mean difference, single-task = 0.69; dual-task = 0.70) slower (p < 0.001) under both gait conditions, with less rhythm under dual-task gait (z-score difference = 0.21; p = 0.001). DTC was not different between groups. Higher NSI somatic subscore was related to higher single- and dual-task gait variability as well as slower dual-task pace and turning (p < 0.01). Persons with chronic mTBI and persistent symptoms exhibited altered gait, particularly under dual-task, and worse gait performance related to greater symptom severity. Future gait research in chronic mTBI should assess the possible underlying physiological mechanisms for persistent symptoms and gait deficits.

Source: https://www.liebertpub.com/doi/abs/10.1089/neu.2020.6986

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[WEB SITE] Brain Injury News – CNS

RESEARCH UPDATES, INDUSTRY NEWS, SURVIVOR STORIES

The world of advancements in brain injury knowledge and treatment is a rich composite of the progress being made by scores of dedicated people. The articles and reports below reflect current research, industry analysis, and stories of recovery. Innovations in patient care and the evolution of best practices in rehabilitation are among the subjects addressed by thought leaders, universities, and institutes noted here.

Categories:  Survivor  Stories  Traumatic Brain Injury  Concussion  Stroke  Aneurysm  Coma

NEWS & EVENTS ARCHIVES

via Brain Injury News

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[WEB PAGE] True or False? Seven Common Myths About Brain Injury

Brain Injury Association of America Blue Logo

 

By Kellie Pokrifka, Member, Brain Injury Association of America Advisory Council

There is so much misinformation regarding brain injury floating around on the internet. Research in this field is progressing every day, and we frequently disprove old theories. It can be difficult to keep up with the latest research, so let’s take a few minutes to dispel some of the most common myths regarding brain injury.

Myth: You can always see brain injury on CT and MRI scans.

CT and MRI scans are looking for brain bleeds, skull fractures, and other acute trauma. Not all brain injuries, and especially not concussions, will appear on these scans. A clear CT or MRI does not eliminate the possibility that you have a brain injury.

Myth: Two years after brain injury, no further recovery can be made.

Many people assert that recovery from brain injury is only possible within the first year or two. We now know that is incorrect. Following the first nine months of recovery, time is no longer an indicator of recovery. What matters after this point is finding the proper therapies for your symptoms. Doing the right activities 50 years post-injury has the same chance of recovery as receiving proper treatment nine months out. Improvements in your recovery are always possible.

Myth: Concussions are not serious.

Concussion is a form of mild traumatic brain injury (TBI). “Getting your bell rung” or “seeing stars” are never things to ignore – they are signs of brain injury. Concussions are described as “mild” brain injury because they not usually life-threatening, but this does not mean they are not serious. While many people will fully recover after two weeks, a percentage of patients will have lifelong symptoms following a concussion.

Myth: Individuals with brain injury don’t think about suicide.

Unfortunately, suicide is not an uncommon occurrence after brain injury. Nearly one in five brain injury survivors admit to suicidal ideation, plans, or attempts in the five-year period following injury. In the general population, that statistic goes down to one in twenty-five. Extreme life changes and organic changes in the brain after TBI can increase the chances of suicide. Because of this increased risk, it is important for medical teams and loved ones to address this subject. Being open and honest about this tough conversation can save a life and help connect your loved one with proper resources. If you need help, you can call the suicide hotline at 1-800-273-8255.

Myth: Only athletes get concussions.

Concussions are not only a problem for athletes; concussions, like other TBIs, can happen anywhere, at any time, and to anyone. TBI is a common result of motor vehicle accidents, falls (particularly in elderly and child populations), military action or blast exposure, intimate partner violence, abuse, gunshot wounds, and other physical trauma.

Myth: If someone has sustained a concussion, you should wake them up every hour for the next day.

There is no need to keep someone awake for 24 hours after a concussion. Sleep is critical for brain injury recovery. If the person has been cleared by a professional for brain bleeds and acute trauma, restful sleep is safe and is crucial for recovery.

Myth: You should not be exposed to any stimulation that may trigger symptoms until you are completely recovered.

It used to be common practice to protect patients with brain injury by placing them in silent, dark rooms for weeks or months until symptoms subsided. However, the “rest and wait” approach is no longer an appropriate recovery plan and can actually worsen symptoms. Many experts even suggest light, controlled exercise within 72 hours of sustaining a concussion. As always, consult your doctor before making any changes to your recovery plan.

References

  1. “Brain Scans for Head Injuries.” Choosing Wisely, American Medical Society for Sports Medicine, 2018, www.choosingwisely.org/patient-resources/brain-scans-for-head-injuries/.
  2. Horn, Gordon & Lewis, Frank. (2013). Analysis of Post-Hospital Neurological Rehabilitation Outcomes. Journal of Head Trauma Rehabilitation. 28. E53-E54.
  3. Leddy, John J et al. “Exercise is Medicine for Concussion.” Current sports medicine reports vol. 17,8 (2018): 262-270. doi:10.1249/JSR.0000000000000505
  4. “Misconceptions about Sleep and Concussions.” ReThink Concussions, UPMC Life Changing Medicine, 2015, rethinkconcussions.upmc.com/concussion-sleep-myth.
  5. Schwartz-Lifshitz, Maya et al. “Can we really prevent suicide?” Current psychiatry reports vol. 14,6 (2012): 624-33. doi:10.1007/s11920-012-0318-3.
  6. Sports Medicine. “Concussion and Loss of Consciousness.” UPMC HealthBeat, 29 Aug. 2018, share.upmc.com/2015/04/concussion-and-loss-of-consciousness/.

This article originally appeared in Volume 14, Issue 1 of THE Challenge! published in 2020.

via True or False? Seven Common Myths About Brain Injury

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[NEWS] Telemedicine may be as effective as in-person visit for people with many neurologic disorders

For people with many neurologic disorders, seeing the neurologist by video may be as effective as an in-person visit, according to a review of the evidence conducted by the American Academy of Neurology (AAN). The evidence review examined all available studies on use of telemedicine for several neurologic conditions – stroke being one of the conditions that is well-validated and highly utilizes telemedicine – and is published in the December 4, 2019, online issue of Neurology®, the medical journal of the AAN. The results indicate that a diagnosis from a neurologist by video for certain neurologic conditions is likely to be as accurate as an in-person visit.

Telemedicine is the use of video conferencing or other technology for doctor visits from another location. The patient could be at home or at a local doctor’s office.

Telemedicine can be especially helpful for people with epilepsy, who may not be able to drive to appointments, people with neurologic disorders like multiple sclerosis and movement disorders, who may have mobility issues that make getting to a clinic difficult, and, of course, for people in rural areas who may not be able to see a neurologist based hours away without making that trip. Another effective use may be for evaluating people with possible concussions, where telemedicine could be used on-site to make an immediate diagnosis. For sports injuries, it could be used to make a decision on whether the athlete is ready to return to the field.”

Jaime Hatcher-Martin, MD, PhD, lead author who was with Emory University in Atlanta while serving on the American Academy of Neurology’s Telemedicine Work Group, is now with the company SOC Telemed and is a member of the American Academy of Neurology

For the evidence review, the researchers analyzed 101 studies on telemedicine use in the areas of concussion and traumatic brain injury, dementia, epilepsy, headache, multiple sclerosis, movement disorders, neuromuscular conditions and general neurology. Hatcher-Martin noted that evidence for the use of telemedicine for stroke has been well-established.

Overall, studies found that patients and their caregivers were just as satisfied with virtual doctor visits as they were with in-person visits. Some studies show that using telemedicine is as effective as in-person visits to make accurate diagnoses and in some cases may show improved health outcomes. However, few randomized, controlled studies have been conducted on telemedicine for neurology, outside of stroke. In many areas, little research has been done.

“This is just the beginning of evaluating the benefits of telemedicine in neurology,” said senior author Raghav Govindarajan, MD, of the University of Missouri, who served as a chair on the American Academy of Neurology’s Telemedicine Work Group and is a Fellow of the American Academy of Neurology.

“We need to conduct further studies to better understand when virtual appointments are a good option for a patient. Keep in mind that telemedicine may not eliminate the need for people to meet with a neurologist in person. Rather, it is another tool that can help increase people’s access to care and also help lessen the burden of travel and costs for patients, providers and caregivers.”

via Telemedicine may be as effective as in-person visit for people with many neurologic disorders

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[WEB PAGE] Types and Levels of Brain Injury

Types of Brain Injury

All brain injuries are unique.  The brain can receive several different types of injuries depending on the type of force and amount of force that impacts the head. The type of injury the brain receives may affect just one functional area of the brain, various areas, or all areas of the brain.

Traumatic Brain Injury  •  Acquired Brain Injury • Levels of Brain Injury

 


Traumatic Brain Injury

Concussion

Even a concussion can cause substantial difficulties or impairments that can last a lifetime. Whiplash can result in the same difficulties as head injury. Such impairments can be helped by rehabilitation, however many individuals are released from treatment without referrals to brain injury rehabilitation, or guidance of any sort.

  • A concussion can be caused by direct blows to the head, gunshot wounds, violent shaking of the head, or force from a whiplash type injury.
  • Both closed and open head injuries can produce a concussion. A concussion is the most common type of traumatic brain injury.
  • A concussion is caused when the brain receives trauma from an impact or a sudden momentum or movement change. The blood vessels in the brain may stretch and cranial nerves may be damaged.
  • A person may or may not experience a brief loss of consciousness.
  • A person may remain conscious, but feel dazed.
  • A concussion may or may not show up on a diagnostic imaging test, such as a CAT Scan.
  • Skull fracture, brain bleeding, or swelling may or may not be present. Therefore, concussion is sometimes defined by exclusion and is considered a complex neurobehavioral syndrome.
  • A concussion can cause diffuse axonal type injury resulting in temporary or permanent damage.
  • A blood clot in the brain can occur occasionally and be fatal.
  • It may take a few months to a few years for a concussion to heal.

Contusion

  • A contusion can be the result of a direct impact to the head.
  • A contusion is a bruise (bleeding) on the brain.
  • Large contusions may need to be surgically removed.

Coup-Contrecoup

  • Coup-Contrecoup Injury describes contusions that are both at the site of the impact and on the complete opposite side of the brain.
  • This occurs when the force impacting the head is not only great enough to cause a contusion at the site of impact, but also is able to move the brain and cause it to slam into the opposite side of the skull, which causes the additional contusion.

Diffuse Axonal

  • A Diffuse Axonal Injury can be caused by shaking or strong rotation of the head, as with Shaken Baby Syndrome, or by rotational forces, such as with a car accident.
  • Injury occurs because the unmoving brain lags behind the movement of the skull, causing brain structures to tear.
  • There is extensive tearing of nerve tissue throughout the brain. This can cause brain chemicals to be released, causing additional injury.
  • The tearing of the nerve tissue disrupts the brain’s regular communication and chemical processes.
  • This disturbance in the brain can produce temporary or permanent widespread brain damage, coma, or death.
  • A person with a diffuse axonal injury could present a variety of functional impairments depending on where the shearing (tears) occurred in the brain.

Penetration

Penetrating injury to the brain occurs from the impact of a bullet, knife or other sharp object that forces hair, skin, bones and fragments from the object into the brain.

  • Objects traveling at a low rate of speed through the skull and brain can ricochet within the skull, which widens the area of damage.
  • A “through-and-through” injury occurs if an object enters the skull, goes through the brain, and exits the skull. Through-and-through traumatic brain injuries include the effects of penetration injuries, plus additional shearing, stretching and rupture of brain tissue. (Brumback R. (1996). Oklahoma Notes: Neurology and Clinical Neuroscience. (2nd Ed.). New York: Springer.)
  • The devastating traumatic brain injuries caused by bullet wounds result in a 91% firearm-related death rate overall. (Center for Disease Control. [Online August 22, 2002: http://www.cdc.gov/ncipc/didop/tbi.htm#rate,]).
  • Firearms are the single largest cause of death from traumatic brain injury.
  • (Center for Disease Control. [Online August 22, 2002: http://www.cdc.gov/ncipc/didop/tbi.htm#rate,]).

Acquired Brain Injury

Acquired Brain Injury, (ABI), results from damage to the brain caused by strokes, tumors, anoxia, hypoxia, toxins, degenerative diseases, near drowning and/or other conditions not necessarily caused by an external force.

Anoxia

Anoxic Brain Injury occurs when the brain does not receive any oxygen. Cells in the brain need oxygen to survive and function.

Types of Anoxic Brain Injury

  • Anoxic Anoxia- Brain injury from no oxygen supplied to the brain
  • Anemic Anoxia- Brain injury from blood that does not carry enough oxygen
  • Toxic Anoxia- Brain injury from toxins or metabolites that block oxygen in the blood from being used Zasler, N. Brain Injury Source, Volume 3, Issue 3, Ask the Doctor

Hypoxic

A Hypoxic Brain Injury results when the brain receives some, but not enough oxygen.

Types of Hypoxic Brain Injury

  • Hypoxic Ischemic Brain Injury, also called Stagnant Hypoxia or Ischemic Insult- Brain injury occurs because of a lack of blood flow to the brain because of a critical reduction in blood flow or blood pressure.

Resources:

Brain Injury Association of America, Causes of Brain Injury. www.biausa.org

Zasler, N. Brain Injury Source, Volume 3, Issue 3, Ask the Doctor

 


Levels of Brain Injury Brain Injury

Mild Traumatic Brain Injury (Glasgow Coma Scale score 13-15)

Mild traumatic brain injury occurs when:

  • Loss of consciousness is very brief, usually a few seconds or minutes
  • Loss of consciousness does not have to occur—the person may be dazed or confused
  • Testing or scans of the brain may appear normal
  • A mild traumatic brain injury is diagnosed only when there is a change in the mental status at the time of injury—the person is dazed, confused, or loses consciousness. The change in mental status indicates that the person’s brain functioning has been altered, this is called a concussion

Moderate Traumatic Brain Injury (Glasgow Coma Scale core 9-12)

Most brain injuries result from moderate and minor head injuries. Such injuries usually result from a non-penetrating blow to the head, and/or a violent shaking of the head. As luck would have it many individuals sustain such head injuries without any apparent consequences. However, for many others, such injuries result in lifelong disabling impairments.

A moderate traumatic brain injury occurs when:

  • A loss of consciousness lasts from a few minutes to a few hours
  • Confusion lasts from days to weeks
  • Physical, cognitive, and/or behavioral impairments last for months or are permanent.

Persons with moderate traumatic brain injury generally can make a good recovery with treatment or successfully learn to compensate for their deficits.

Severe Brain Injury

Severe head injuries usually result from crushing blows or penetrating wounds to the head. Such injuries crush, rip and shear delicate brain tissue. This is the most life threatening, and the most intractable type of brain injury.

Typically, heroic measures are required in treatment of such injuries. Frequently, severe head trauma results in an open head injury, one in which the skull has been crushed or seriously fractured. Treatment of open head injuries usually requires prolonged hospitalization and extensive rehabilitation. Typically, rehabilitation is incomplete and for most part there is no return to pre-injury status. Closed head injuries can also result in severe brain injury.

TBI can cause a wide range of functional short- or long-term changes affecting thinking, sensation, language, or emotions.

TBI can also cause epilepsy and increase the risk for conditions such as Alzheimer’s disease, Parkinson’s disease, and other brain disorders that become more prevalent with age.1

Repeated mild TBIs occurring over an extended period of time (i.e., months, years) can result in cumulative neurological and cognitive deficits. Repeated mild TBIs occurring within a short period of time (i.e., hours, days, or weeks) can be catastrophic or fatal.

Resources:

National Institute of Neurological Disorders and Stroke. Traumatic brain injury: hope through research. Bethesda (MD): National Institutes of Health; 2002 Feb. NIH Publication No.: 02-158.

Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Atlanta (GA): Centers for Disease Control and Prevention; 2003.

Brain Injury Association of America, Causes of Brain Injury. www.biausa.org

via Types and Levels of Brain Injury – Brain Injury Alliance of Utah

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[WEB PAGE] Treatment of Traumatic Brain Injury With Hyperbaric Oxygen Therapy

Hyperbaric oxygen therapy (HBOT) is defined as the use of oxygen at higher than atmospheric pressure for the treatment of underlying disease processes and the diseases they produce. Modern HBOT in which 100% O2 is breathed in a pressurized chamber dates back to the 1930s, when it was first used for treatment of decompression illness in divers. There are currently 13 FDA-approved uses for HBOT, including decompression illness, gas gangrene, air embolism, osteomyelitis, radiation necrosis, and the most recent addition—diabetic ulcers.

Just as practicing physicians routinely identify off-label uses for medications, over the years HBOT physicians have identified many other conditions that respond to HBOT. A number of chronic neurological conditions including traumatic brain injury (TBI) have been shown to respond particularly well. There is published literature supporting HBOT’s efficacy for TBI, including human trials and animal research, but due to the impossibility of arranging sham pressure there are no rigorous double-blind placebo-controlled trials.1 As a result, HBOT is not FDA-approved for TBI, and insurance will generally not pay for it.

HBOT can dramatically and permanently improve symptoms of chronic TBI months or even many years after the original head injury. This assertion is generally met with skepticism within the medical establishment because we have been taught for generations that any post-concussion symptoms persisting more than 6 months or so after a head injury are due to permanent brain damage that cannot be repaired. Therefore, treatment has been limited to symptom management and rehabilitative services, and any claim suggesting that fundamental healing is possible is suspect. The combination of entrenched skepticism and lack of insurance coverage has made it very difficult for patients to access treatment.

Another source of skepticism has been the large number of disparate conditions that are claimed to be helped by HBOT. A brief review of the mechanisms through which HBOT triggers healing responses, with particular reference to the modern understanding of the pathophysiology of TBI, provides a theoretical framework to explain these claims.

Physiological effects of HBOT

About 97% of the total oxygen in blood is tightly bound to hemoglobin when breathing room air (21% O2) at sea level (1 atmosphere, or 1 ATM; 3% of the oxygen is dissolved in blood serum. This amounts to about 0.3 mL of oxygen dissolved in 100 mL of serum. By the time oxygen diffuses out of the circulatory system and ultimately reaches the mitochondria, there is just a trace amount present. HBOT’s primary mechanism is to temporarily hyper-oxygenate body tissues. HBOT delivered at 1.3 ATM increases dissolved oxygen in serum by a factor of 7. HBOT delivered in hard chambers at 2.5 to 3.0 ATM increases dissolved oxygen by a factor of 15 or more. Oxygen levels in body tissues outside the circulatory system will be increased commensurately.

If a hyper-oxygenated state is maintained for long periods it will cause significant oxidative damage, but when it is “pulsed” for an hour it triggers a variety of healing processes without overwhelming the body’s anti-oxidant system. The currently known mechanisms include a powerful anti-inflammatory effect, reduction of edema, increased blood perfusion, angiogenesis, stimulation of the immune system, stimulation of endogenous antioxidant systems, mobilization of stem cells from bone marrow, axonal regrowth, and modulation of the expression of thousands of genes involved in the inflammatory response and various healing responses.2,3

[…]

Continue —>  Treatment of Traumatic Brain Injury With Hyperbaric Oxygen Therapy | Psychiatric Times

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[REVIEW ARTICLE] Blood Biomarkers for Traumatic Brain Injury: A Quantitative Assessment of Diagnostic and Prognostic Accuracy – Full Text

Blood biomarkers have been explored for their potential to provide objective measures in the assessment of traumatic brain injury (TBI). However, it is not clear which biomarkers are best for diagnosis and prognosis in different severities of TBI. Here, we compare existing studies on the discriminative abilities of serum biomarkers for four commonly studied clinical situations: detecting concussion, predicting intracranial damage after mild TBI (mTBI), predicting delayed recovery after mTBI, and predicting adverse outcome after severe TBI (sTBI). We conducted a literature search of publications on biomarkers in TBI published up until July 2018. Operating characteristics were pooled for each biomarker for comparison. For detecting concussion, 4 biomarker panels and creatine kinase B type had excellent discriminative ability. For detecting intracranial injury and the need for a head CT scan after mTBI, 2 biomarker panels, and hyperphosphorylated tau had excellent operating characteristics. For predicting delayed recovery after mTBI, top candidates included calpain-derived αII-spectrin N-terminal fragment, tau A, neurofilament light, and ghrelin. For predicting adverse outcome following sTBI, no biomarker had excellent performance, but several had good performance, including markers of coagulation and inflammation, structural proteins in the brain, and proteins involved in homeostasis. The highest-performing biomarkers in each of these categories may provide insight into the pathophysiologies underlying mild and severe TBI. With further study, these biomarkers have the potential to be used alongside clinical and radiological data to improve TBI diagnostics, prognostics, and evidence-based medical management.

Introduction

Traumatic brain injury (TBI) is a common cause of disability and mortality in the US (1) and worldwide (2). Pathological responses to TBI in the CNS include structural and metabolic changes, as well as excitotoxicity, neuroinflammation, and cell death (34). Fluid biomarkers that may track these injury and inflammatory processes have been explored for their potential to provide objective measures in TBI assessment. However, at present there are limited clinical guidelines available regarding the use of biomarkers in both the diagnosis of TBI and outcome prediction following TBI. To inform future guideline formulation, it is critical to distinguish between different clinical situations for biomarker use in TBI, such as detection of concussion, prediction of positive and negative head computed tomography (CT) findings, and prediction of outcome for different TBI severities. This allows for comparisons to determine which biomarkers may be used most appropriately to characterize different aspects of TBI.

The identification of TBI severity has become a contentious issue. Currently, inclusion in TBI clinical trials is primarily based on the Glasgow Coma Scale (GCS), which stratifies patients into categories of mild, moderate, and severe TBI. The GCS assesses consciousness and provides prognostic information, but it does not inform the underlying pathologies that may be targeted for therapy (56). Furthermore, brain damage and persistent neurological symptoms can occur across the spectrum of TBI severity, limiting the use of GCS-determined injury severity to inform clinical management. Biomarkers in TBI have the potential to provide objective and quantitative information regarding the pathophysiologic mechanisms underlying observed neurological deficits. Such information may be more appropriate for guiding management than initial assessments of severity alone. Since the existing literature primarily focuses on applications of biomarkers in either suspected concussion, mild TBI (mTBI), or severe TBI (sTBI), we will discuss biomarker usage in these contexts.

Concussion is a clinical syndrome involving alteration in mental function induced by head rotational acceleration. This may be due to direct impact or unrestrained rapid head movements, such as in automotive crashes. Although there are over 30 official definitions of concussion, none include the underlying pathology. Missing from the literature have been objective measures to not only identify the underlying pathology associated with the given clinical symptoms, but also to indicate prognosis in long-term survival. Indeed, current practices in forming an opinion of concussion involve symptom reports, neurocognitive testing, and balance testing, all of which have elements of subjectivity and questionable reliability (7). While such information generally reflects functional status, it does not identify any underlying processes that may have prognostic or therapeutic consequences. Furthermore, because patients with concussion typically present with negative head CT findings, there is a potential role for blood-based biomarkers to provide objective information regarding the presence of concussion, based on an underlying pathology. This information could inform management decisions regarding resumption of activities for both athletes and non-athletes alike.

Blood-based biomarkers have utility far beyond a simple detection of concussion by elucidating specific aspects of the injury that could drive individual patient management. For example, biomarkers may aid in determining whether a mTBI patient presenting to the emergency department requires a CT scan to identify intracranial pathology. The clinical outcome for a missed epidural hematoma in which the patient is either discharged or admitted for routine observation is catastrophic; 25% are left severely impaired or dead (8). The Canadian CT Head Rule (9) and related clinical decision instruments achieve high sensitivities in predicting the need for CT scans in mild TBI cases. However, they do this at specificities of only 30–50% (10). Adding a blood biomarker to clinical evaluation may be useful to improve specificity without sacrificing sensitivity, as recently suggested (11). In addition, given concern about radiation exposure from head CT scans in concussion cases, particularly in pediatric populations, identification of patients who would be best assessed with neuroimaging is crucial. Thus, the use of both sensitive and specific biomarkers may serve as cost-effective tools to aid in acute assessment, especially in the absence of risk factors for intracranial injury (12). S-100B, an astroglial protein, has been the most extensively studied biomarker for TBI thus far and has been incorporated into some clinical guidelines for CT scans (1314). However, S-100B is not CNS-specific (1516) and has shown inconsistent predictive capacity in the outcome of mild TBI (1718). Given that several other promising biomarkers have also been investigated in this context, it is important to evaluate and compare the discriminative abilities of S-100B with other candidate blood-based biomarkers for future use.

Blood biomarkers also have the potential to help predict unfavorable outcomes across the spectrum of TBI severity. Outcome predication is difficult; in mTBI, existing prognostic models performed poorly in an external validation study (19). Identifying biomarkers that best predict delayed recovery or persistent neurological symptoms following mTBI would help with the direction of resources toward patients who may benefit most from additional rehabilitation or prolonged observation. In sTBI, poorer outcome has often been associated with a low GCS score (20). However, factors such as intoxication or endotracheal intubation may make it difficult to assess GCS reliably in the acute setting (2122). The addition of laboratory parameters to head CT and admission characteristics have improved prognostic models (23). Thus, prognostic biomarkers in sTBI could help determine whether patients are likely to benefit from intensive treatment. Several candidate biomarkers that correlate with various pathologies of mild and severe TBI have been studied (24), but their relative prognostic abilities remain unclear.

Existing reviews on biomarkers in TBI have provided valuable insight into the pathologic correlates of biomarkers, as well as how biomarkers may be used for diagnosis and prognosis (2531). However, there has been no previous quantitative comparison of the literature regarding biomarkers’ discriminative abilities in specific clinical situations. Here, we compare existing studies on the discriminative abilities of serum biomarkers for four commonly studied clinical situations: detecting concussion, predicting intracranial damage after mTBI, predicting delayed recovery after mTBI, and predicting adverse outcome after sTBI.[…]

 

Continue —-> Frontiers | Blood Biomarkers for Traumatic Brain Injury: A Quantitative Assessment of Diagnostic and Prognostic Accuracy | Neurology

Figure 2. Anatomical locations of potential TBI biomarkers. The biomarkers included in this schematic all rated as “good” (AUC=0.800.89) or better for any of the four clinical situations studied (detecting concussion, predicting intracranial damage after concussion, predicting delayed recovery after concussion, and predicting adverse outcome after severe TBI). Biomarkers with a pooled AUC <0.8 are not shown. 1Also found in adipose tissue; 2synthesized in cells of stomach and pancreas; may regulate HPA axis; 3found mostly in pons; 4also found extracellularly; 5lectin pathway of the complement system; 6also found in endothelial cells. BBB, blood brain barrier. ECM, Extracellular matrix. Image licensed under Creative Commons Attribution-ShareAlike 4.0 International license. https://creativecommons.org/licenses/by-sa/4.0/deed.en. See Supplementary Material for image credits and licensing.

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