The Personal Legacy Of Brain Injury
Friday, March 25, 2005
A 63-year-old warehouse worker, knocked out when a heavy box fell on his head, suffered no bleeding or bruising but did have a concussion. Months later, his family complained that his personality had changed. He was easily irritated and said nasty things to his grandchildren. They didn't trust him alone with the kids.
A physical therapist, banged on the head when a suitcase fell from an overhead bin during a flight, became a different person after the injury. She needed notes to remember what she wanted to do and had a hard time putting her thoughts into words. Focusing on anything for a long time exhausted her, and she had to take frequent breaks while driving or balancing a checkbook. She was unable to return to work.
A teacher hit her head on the dashboard after being rammed from behind while her car was stopped at a red light. Emergency room doctors said she had a mild concussion and sent her home. But months later, she found it impossible to organize everything she had to do. The stress of work and home life was overwhelming. She began having panic attacks.
Outwardly, these people appeared normal. They seemed to have recovered from personal injury – brain injury, that had jolted and jarred their brains, sometimes sending it ricocheting within the skull. Yet unseen by standard emergency-room tests like MRIs and CT scans, brain cells and the blood vessels that supply them had been torn and sheered, crushed and displaced.
The result was a change in some of the brain's complex and subtle functions, processes that affect personality, mood, memory, social interaction and the ability to work and learn. Those close to them noticed a new mental rigidity, inattention, swinging moods and shifting energy levels.
"These injuries [to the brain] are invisible to the casual observer, maybe even a family member or co-worker," said Dr. Gerald Tramontano, who labels the constellation of symptoms "invisible syndrome." "The family expects them to get better, be normal. But they have to struggle to get through the day."
The effects of invisible syndrome vary from person to person, depending in part on which lobe of the brain has been hurt and how severely. Sometimes, symptoms appear months after outward injuries have healed.
Tramontano, a neuropsychologist and clinical director of the NeuroRehab Institute in Mount Arlington, believes the problem is under-diagnosed and under-treated.
It's not just professional hockey players, football players and boxers who suffer from post-concussion syndrome, he says. Ordinary people - injured in car accidents, falls or recreational activities - also suffer. Doctors need to be more aware of this possibility and the availability of diagnostic procedures and effective treatment, he said.
More than a million people a year suffer concussions or other mild traumatic brain injuries, according to the federal Centers for Disease Control. The signs and symptoms - headache, nausea, blurred vision, temporary amnesia and, in some cases, loss of consciousness - are well known.
But not all victims go to the hospital, and there is little follow-up of how they fare weeks or months later. The CDC has recommended more research and monitoring of the effects of traumatic brain injury to identify the scope of the problem.
Tramontano estimates that 15 to 30 percent of those who receive concussions experience long-term effects, depending upon whether the injury resulted from a hit or quick acceleration and deceleration, as in a car accident. He says those most at risk have had previous head injuries or concussions, previous neurological or psychiatric diagnoses or even a family history of the same.
But doctors often miss the diagnosis of post-concussion syndrome, Tramontano said, because it is not as recognizable as a broken bone or tumor. The patient may be as smart as ever, in fact. But he or she may have become "socially disabled" - impulsive, disinhibited, likely to say things out of context or inappropriately, unable to start a relationship or maintain one.
This can often be the basis for damage awards in a lawsuit, said Tramontano, whose NeuroRehab Institute includes a "forensic division," whose experts testify in court.
The physical therapist, who has been in treatment for four years, said, "It's like being behind a glass wall that nobody can see. It's just isolating. I don't mean lonely. You've got things going on, and people don't get it. They can't see it. It's not like you have a cast on your arm. It's invisible."
She has lost several friends. "My self-esteem is just pffft," she said. "I used to be one person, and now I'm not. My brain was who I was. Now in conversation, if I have three things to say, I get one out and forget the other two."
She's reached a point where she doesn't apologize anymore. "What am I going to do? You can't tell every store clerk that you had a head injury when you're struggling to make change."
Michael Kinney was in a coma for three months after a car accident when he was 25. "I'm a shadow of the guy I used to be," said the 34-year-old Branchville resident. "It's pretty much the same thing as a grieving process. You lose the person that used to be there."
A graphic artist before the accident, he now is colorblind to three colors. He once was a 6-foot-4 "moose,'' by his own account, who could bench press 400 pounds. Now he lives at home with his parents, walks with a limp and works part-time as a maintenance worker with his father. He can no longer drive.
"It kind of humbles you," said his mother, Cheryl Kinney. "Things can be replaced, but people can't. But God has brought back the person that Mike used to be, very kind and giving, with a wonderful sense of humor."
Tests, such as MRIs or CT scans, reveal damage to the brain tissue, made up of brain cells, support cells and blood vessels. They show brain swelling or bleeding. Neuropsychiatric and cognitive tests, in which the examiner asks a series of questions or instructs the patient to do certain things, identify the types of brain functions that have been affected by the injury.
The effects of post-concussion syndrome can also be seen through "brain-mapping," using the results of tests such as a QEEG, for quantitative EEG (electroencephalogram). The mapping opens a window into the physiology of the brain, particularly the cortex.
Think of the brain as an electrical system, with neurons creating voltages to send signals to each other. These voltages also enter the membranes surrounding the brain, continue up through the skull and then appear on the scalp where they are measured in microvolts. By placing 24 electrodes on the scalp using a standardized pattern, the electrical activity in various parts of the brain can be measured and recorded. This is then compared with graphs or databases of electrical activity in a "normal" or uninjured brain.
The comparison reveals what lobes of the brain are stuck in abnormal, slow, wave patterns or disconnected waves. Frontal lobe damage, for example, can cause personality changes that make a person "flat," or inactive. The patient may lose his drive and act like "a bump on a log."
Another area of the frontal lobes, when injured, can cause a person to lose his inhibitions or act impulsively. Injury to the orbital frontal cortex, for example, typically results in a loss of social awareness or the ability to "read" another's reaction and respond appropriately.
Of course, brain mapping and neuropsychological testing can also be used to show the opposite of a problem: If brain activity is normal, then the patient may be a "malingerer" whose disability claim, for example, is not valid.
Once the location of a problem is identified, specific treatment and coping strategies can be planned. Neurocognitive rehab, neurofeedback, medication, psychotherapy and behavior strategies and technologies can be used to improve day-to-day life.
Through neurofeedback, a type of biofeedback, patients can actually develop an awareness of the type of electrical activity their brain is generating and suppress the slow waves. Over time, this helps to improve focus and concentration.
Kinney, who's been in neuro-rehab for almost 10 years, describes it as a kind of video game or concentration game. Electrodes are hooked up to his head, and through concentration, he tries to move a bar up a screen or expand the size of a circle. Although initially he found this very difficult, he has mastered it.
Drugs used to treat attention-deficit disorder or Parkinson's disease have also been used to treat brain injuries with some success, controlling impulsive behavior or boosting the patient's drive. Tailored "homework assignments" that require patients to summarize a television program or a short reading help them relearn how to organize their thoughts.
Another tool is a pocket personal computer, which can beep as a reminder to do something and list all a patient's activities. "This is awesome for head injury patients," said Tramontano. "This becomes their frontal lobe."
All of these techniques can be used together to help the patient.
