The Handiest Girlie Of All

Parkinson’s Drug May Help With Brain Injuries, Report Finds

Dr John Whyte Of Moss Rehabilitation Research Institute helped lead the study

Daily doses of a drug used to treat Parkinson’s disease significantly improved function in severely brain-injured people thought to be beyond the reach of treatment, scientists reported on Wednesday, providing the first rigorous evidence to date that any therapy reliably helps such patients.

 

The improvements were modest, experts said, and hardly amounted to a cure, or a quick means of “waking up” someone who has long been unresponsive. But the progress was meaningful, experts said, and, if replicated, would give rehabilitation doctors something they have never had: a standard treatment for injuries that are not at all standard or predictable in the ways they affect the brain.

Some 50,000 to 100,000 Americans live in states of partial consciousness, and perhaps 15,000 in an unresponsive “vegetative” condition. According to the Department of Defense, more than 6,000 veterans have had severe brain injuries since 2000 and would potentially benefit from this therapy. The new report, appearing in The New England Journal of Medicine, gives doctors a solid basis to address such injuries, if not yet a predictable outcome.

“This study puts the traumatic brain injury field on the first step of the ladder to developing scientific treatments. We’ve been trying to get there for a long time,” said Dr. Ramon Diaz-Arrastia, director of clinical research at the Center for Neuroscience and Regenerative Medicine at the Uniformed Services University of the Health Sciences in Rockville, Md., who was not involved in the research. “And there’s no reason to doubt that this therapy would also be effective in people with less severe brain injuries” than in the study.

“Hope is critical and false hope is cruel for families dealing with this,” said Susan Connors, president and chief executive of the Brain Injury Association of America, in Vienna, Va. The new findings, she added, are “a little piece of hope, the real kind.”

Doctors have long experimented with the Parkinson’s drug — amantadine hydrochloride — as well as many others to treat severe brain injuries, with mixed and uncertain results. Previous studies of amantadine suggested some benefit, but the numbers were small and experts were unsure of the findings.

The new experiment put those doubts to rest, by testing the drug against a placebo in two large groups of patients.

A consortium of researchers from 11 clinics enrolled 184 patients who recently had a traumatic brain injury from a car accident or from blows to the head. Some were in a vegetative state, breathing, their eyes open when awake, but unresponsive to commands or prompts. Others were in what is known as a minimally conscious state, able to track objects and follow commands once in a while, but not predictably.

The research team, led by Joseph T. Giacino of the J. F. K. Johnson Rehabilitation Institute in Edison, N.J., and Dr. John Whyte of the Moss Rehabilitation Research Institute, in Elkins Park, Pa., divided the patients into two groups, carefully matched for the severity of their injuries. Members of one group got two doses of amantadine a day, given through their feeding tubes. Members of the other group received placebo pills.

The study was “blinded,” meaning that the therapists providing the usual daily care — moving limbs, stimulating the senses and giving medical support — did not know who was on the drug and who was not.

After four weeks, the researchers analyzed the patients’ progress, using a standard scale that rates abilities in such areas as coordination and communication. The scale ranges from zero, for no disability, to 29, for a state of total unresponsiveness, and is scored regularly at bedside.

 

Almost all of the patients improved somewhat during the four weeks. This was expected; their injuries were recent, and in the first year after a traumatic brain injury most people recover some function, even if they do not always regain full awareness later on, scientists say.

But the group receiving amantadine showed more improvement, by two points on the disability scale. Two points is not a dramatic difference, but it occurred in just a month, a short period of time in terms of recovery.

“The main finding is that on every single behavioral domain measured, we had a higher incidence of recovery in the amantadine group than in the placebo group,” said Dr. Giacino, who is now at Harvard’s Spaulding Rehabilitation Hospital.

When doctors took patients off the drug, the rate of recovery slowed down. “In the next two weeks, the placebo group caught up,” said Dr. Whyte. “So we know that the drug accelerates recovery, but we can’t say whether it alters the trajectory entirely.”

The patients on the drug showed no adverse effects, Dr. Whyte said.

Among other effects, amantadine increases the activity of dopamine, a chemical messenger that is highly active in the frontal areas of the brain behind the forehead. Those areas control attention and help plan and execute deliberate actions and responses, and are at least partly damaged or offline in people with severe brain injuries.

Some experts said that the study, financed by the National Institute on Disability and Rehabilitation Research, could be a turning point in the understanding and treatment of people with severe traumatic brain injuries. The centers that conducted the study were located around the world, in Germany, Canada and Denmark, as well as Indianapolis and Jackson, Miss. The collaboration produced a positive result.

Having a standard therapy may give family members, doctors and policymakers leverage to get treatment covered by insurers. Many thousands of people with such severe injuries lie trapped in partial states of consciousness, in nursing homes and living rooms, with no access to rehabilitation.

“I see this as a tipping point for the entire field,” said Dr. Nicholas Schiff, a neuroscientist at Weill Cornell Medical College in New York, who was not involved in the study. “If this drug works, then other things will too, in various combinations, and we can begin to develop a medical model for treatment.”

 

NYT

Related articles

• Flu drug Amantadine may boost recovery from severe brain injuries (cbsnews.com)
• Amantadine Speeds Recovery From Severe Traumatic Brain Injury - ABC News (abcnews.go.com)
• Parkinson's Disease Drug May Help Brain Injuries, Report Says (nytimes.com)
• Amantadine: Flu / Parkinson's Drug In Treatment For Traumatic Brain Injury (medicalnewstoday.com)
• Incoming! Traumatic Brain Injury Month (rjwh617dotcom.wordpress.com)
• Stem Cells Safe for Young Traumatic Brain Injury (repairstemcell.wordpress.com)

One Soldier’s Progress Against Traumatic Brain Injury

Sgt. Victor Medina, who suffered a brain injury from a roadside blast in Iraq, walks down the hall while tossing a tennis ball from hand to hand working on dynamic hand-eye coordination at Mentis Neuro Rehabilitation Center in El Paso, Texas

When Army Sgt. Victor Medina returned home from Iraq in the summer of 2009, his life was a shambles. His tour had been cut short after he suffered a concussion during a roadside blast. Though his injury wasn't visible, he struggled with balance and noticed that his ability to read, think and even talk had changed for the worse.

But in the spring of 2011, Medina became one of the first patients at the National Intrepid Center of Excellence, the military's $65 million, state-of-the-art treatment center for brain-injured soldiers.

During his three weeks at the Bethesda, Md., center, the staff developed a rehabilitation program designed specifically for Medina. His recovery has progressed rapidly ever since, he and his wife, Roxana Delgado, told ProPublica and NPR.

Medina has continued to work from El Paso, Texas, by videoconference with a speech therapist based at the center, and he said his stutter is improving. After his injury, he had struggled to read more than a paragraph; now he says he can read and absorb two pages in one sitting. Medina also was ordered to stop driving after his injury, but he told ProPublica and NPR that he has regained his ability to do that, too.

"It's like night and day," Delgado said of his improvement.

The couple believes that Medina benefited dramatically from media attention. In June 2010, ProPublica and NPR published stories about the couple's struggle to get medical treatment for Medina at Fort Bliss, Texas, where he was stationed at the time. The Army's vice chief of staff, Gen. Peter Chiarelli, denounced the reports at a hearing before the Senate Armed Services Committee as a "disservice ... to everyone." But a year later, Chiarelli flew the couple to Washington so they could talk privately to top commanders about their battles at Fort Bliss, and how to improve treatment for troops with TBI.

Last year, Medina became one of NICOE's first patients. He received more than 100 hours of personalized treatment from neurologists, psychologists, physical therapists and others at the center, a NICOE spokesman said. Medina also had access to some of the center's virtual-reality equipment, which is used to simulate ordinary civilian activities like crossing the street and driving a car. Delgado and Medina have become advocates for victims of traumatic brain injury, or TBI, the signature injury of the Iraq and Afghanistan conflicts. Last week, Delgado was invited to attend President Barack Obama's Stateof the Union speech as a guest of Rep. Silvestre Reyes, D-Texas, whose district includes part of Fort Bliss.

 

In an interview with ProPublica and NPR before the speech, Delgado said the invitation was "very empowering because it tells me that leadership and people in Congress are paying attention to traumatic brain injuries," she said.

But not every soldier with a brain injury has been as fortunate as Medina.

Delgado told ProPublica and NPR that she frequently receives calls from military wives who've had a hard time getting their husbands enrolled at NICOE, which has treated only about 200 soldiers since it opened in October 2011, center spokesman Joshua Stueve told ProPublica and NPR.

By comparison, recent estimates show that nearly 230,000 soldiers have been diagnosed with traumatic brain injuries, Stueve said. "We aren't going to make a huge dent in that population," said Stueve. Most of the center's $35 million budget is spent on research, not clinical care, he noted.

To get into the program, a service member must be referred by a physician at his or her local military hospital, agree to live with other soldiers in a group house near the facility, and plan to continue military service after treatment.

Brain-injured troops who don't plan on staying in the military have to rely on U.S. Veterans Affairs Department hospitals for treatment once they get out. But VA hospitals don't have the same resources or equipment as NICOE.

Stueve said troops at NICOE benefit from being treated by an "inverted system" in which a soldier has the opportunity to work with perhaps 10 doctors at once, instead of being at a hospital where there might be just one doctor for every 10 patients. The advantage, he said, is that a patient isn't shuffled to separate referrals from multiple specialists over the course of treatment.

Stueve said the center "doesn't keep data" on how many soldiers are rejected, and handles only 20 patients at a time for about four weeks of concentrated treatment.

"The real story here is patient experience," Stueve said. "The service members, when they come here, they feel like they are in control, and they play a huge part in their own treatment."

Delgado agrees but said she knows "that's not the case for all service members, because some are denied a chance to go to NICOE. This should be the standard of care for everybody."

The Pentagon plans to expand the NICOE system to other bases, Stueve said, but that effort could be stymied by pending defense budget cuts. The defense department is drafting a plan to cut $259 billion from its budget over the next five years.

The military is already having problems with its budgets for TBI and post-traumatic stress disorder. In a recent report to Congress, the Government Accountability Office said the defense department can't provide reliable data on how it spent $2.7 billion allocated to treat soldiers with brain injuries and psychological health problems.

 

PRIMARY BLAST INJURY

Traumatic brain injuries have been called the "signature wound" of the wars in Iraq and Afghanistan. While improvements in armor and battlefield medicine mean more soldiers are surviving bomb blasts that would have killed them in previous wars, the explosions are leaving some of them with permanent wounds. Mild traumatic brain injuries are difficult to detect as they leave behind no obvious signs of trauma. While many soldiers recover fully from the injury, others are left with persistent mental and physical problems 

An explosion generates a blast wave traveling faster than sound and creating a surge of high pressure followed by a vacuum. Studies show that the blast wave shoots through armor and soldiers' skulls and brains, even if it doesn't draw blood. While the exact mechanisms by which it damages the brain's cells and circuits are still being studied, the blast wave's pressure has been shown to compress the torso, impacting blood vessels, which send damaging energy pulses into the brain. The pressure can also be transferred partially through the skull, interacting with the bra

in.

SECONDARY BLAST INJURY

Shrapnel and debris propelled by the blast can strike a soldier's head, causing either a closed-head injury through blunt force or a penetrating head injury that damages brain tissue.

TERTIARY BLAST INJURY

The kinetic energy generated and released by an explosion can accelerate a soldier's body through the air and into the ground or nearby solid object. Once the body stops, the brain continues to move in the direction of the force, hitting the interior of the skull and then bouncing back into the opposite side, causing a coup-contrecoup injury.

 

ProPublica

 

Giffords May Get Better Brain-Injury Care Than Most of Her Constituents

In the minutes, hours and weeks after U.S. Rep. Gabrielle Giffords was shot at a meeting with her constituents in Tucson, Ariz., the public witnessed some of the very best brain-injury care in the country. In the year following the shooting, Giffords herself has championed the rights of others -- whether injured by gunfire or car crashes -- to get the same care she continues to receive. Holding town hall meetings and panel discussions, she has argued that everyone should get the full spectrum of treatments: from the intensive trauma care that saved her life to the rehabilitation therapies that are, albeit slowly, helping her return to living it.

We've covered in detail the military's track record of refusing treatments such as cognitive rehabilitation therapy for thousands of soldiers and veterans with traumatic brain injuries, or TBIs. But "despite how much people have criticized military care," said Geoff Manley, a professor of neurological surgery at the University of California, San Francisco, "it's a hundred times better than what goes on in the civilian sector."

The average American has a paucity of services to choose from, according to Manley, who describes the current lack of standards in treating traumatic brain injuries a "travesty." The problem is twofold: a lack of research into the best course of treatment for TBI, and a lack of access to the treatments that are available.

Brain injuries come in many different types and severity. This year, the estimated National Institutes of Health funding for research on traumatic brain injuries is $85 million. But Manley said treatment for a single patient with a severe injury can cost $2 million to $4 million. Last year alone, the estimated total cost of TBI was $76.3 billion, according to a report by Lisa McGuire of the federal Centers for Disease Control and Prevention. The mismatch between the enormous annual cost of TBI to the general population and the amount of money going into research is striking, said Manley.

Despite the need for more research, Giffords' story shows the potential of the treatments now available. But according to Susan Connors, the president of the Brain Injury Association of America, what treatment you receive depends heavily on your state, insurance plan (or lack of one), hospital and the people advocating for you.

In some states, like Texas, laws mandate rehabilitation for people who suffer brain injuries. Other states, like Michigan, have mandatory auto insurance policies that cover all medical costs if you have an accident (collisions are one of the leading causes of traumatic brain injuries). According to Connors, both state laws give patients comprehensive access to the whole continuum of care.

Other states, like Georgia, have created special programs or "trust funds" for people who suffer brain injuries. An added fee on traffic-related fines (usually about 50 cents to $1) is deposited in an account set aside for individuals who can't afford to pay for care. In Florida, the fee also applies to drunk boaters.

Your care also depends heavily on the kind of insurance you have, if any. Many types, from standard health insurance like Blue Cross Blue Shield to workers' compensation to auto insurance, provide some coverage for TBI, but plans vary widely even within each category. Most plans cover the intensive care immediately after the injury, such as the brain surgery that saved Giffords' life. But few cover the longer-term rehabilitation therapies that are so critical to regaining mental and physical functions. (One plan that generally doesn't offer much coverage even for immediate care is "mini-medical" insurance, which often doesn't pay for major injuries caused by accidents or usually requires the patient to pay a large proportion of the bill.)

According to Connors, Giffords received superb treatment because she had great coverage from her federal workers' compensation, which is available not only to Congressional representatives but to roughly three million federal employees.

Dr. Steve Flanagan, chairman of Rusk Rehabilitation at NYU Langone Medical Center, said comprehensive rehabilitation must address any problems in physical abilities (muscle strength, balance, reflexes), cognitive abilities (memory, problem-solving, attention) and emotional aspects (anxiety, depression, irritability). Because some of these problems continue for years after an injury, they often require lifelong follow-up treatments and regular monitoring.

Even if your insurance policy theoretically covers such long-term treatments, whether it actually ends up paying for the care can be utterly arbitrary, Flanagan said. The advocacy skills of you, your family members and your provider also make a difference. According to Connors, the more vocal, the better. When it comes to injury coverage, Connors said, "the squeaky wheel gets the grease, whether it's UnitedHealthcare, Medicare or TriCare."

Finally, your hospital matters. "There are only a handful of places you'd want to be for your acute care or your rehab," Manley said, namely facilities with specialized trauma and rehabilitation units. The TIRR Memorial Hermann in Houston, where Giffords went for her rehab, is renowned for treatment of traumatic brain injuries. U.S. News & World Report lists another 18 of the top-ranked hospitals for rehabilitation.

ProPublica

When Injuries to the Brain Tear at Hearts

BEFORE AND AFTER Hugh and Rosemary Rawlins have put their lives back together since his 2002 brain injury, but their struggle has included her diagnosis of post-traumatic stress syndrome. 

 

At a crowded vigil on Sunday night in Tucson, Representative Gabrielle Giffords held her husband’s hand as she stepped up to the lectern to recite the Pledge of Allegiance..

It had been one year since a shooting at a Tucson supermarket killed six people, injured 12 others and left her with a severe brain injury. Ms. Giffords’s appearance was greeted by an enthusiastic crowd that applauded her remarkable progress toward recovery.

The man next to her, fighting tears, offered his own remarks. “For the past year, we’ve had new realities to live with,” said her husband, the astronaut Mark E. Kelly. “The reality and pain of letting go of the past.”

Captain Kelly was speaking of the survivors of the shooting. But his words echoed the sentiments of many brain injury survivors and their spouses as they grapple with interpersonal challenges that take much longer than a year to overcome.

Until recently, there had been little evidence-based research on how to rebuild marriages after such a tragedy. Indeed, doctors frequently warn uninjured spouses that the marriage may well be over, that the personality changes that can result from brain injury may do irreparable harm to the relationship.

Captain Kelly and Ms. Giffords largely have kept private their own experiences in this regard, and they declined to be interviewed for this article. Still, therapists are beginning to understand the obstacles that couples like them face, and what they are learning may lead to new counseling techniques to help restore the social links that give lives meaning.

Contrary to conventional wisdom, many relationships do survive after a spouse suffers a brain injury. Some studies find divorce rates well below the national average among these couples. A 2007 investigation found that the divorce rate was around 17 percent in couples followed for as long as 90 months after a spouse sustained a brain injury.

That is not to say these couples are always happy.

“Two or three years later, they want a whole lot more than simply to be alive,” said an author of the 2007 study, Jeffrey S. Kreutzer, a psychologist at Virginia Commonwealth University in Richmond. “While people may technically be married, the quality of their relationship has been seriously diminished.”

Dr. Kreutzer and other psychologists at V.C.U. are among the few therapists in the country trying to develop marriage counseling techniques tailored to couples dealing with brain injuries. Traditional marriage counselors often hope to restore people and their relationships to their original luster. For Dr. Kreutzer and his team, recovery often means teaching uninjured spouses to forge a relationship with a profoundly changed person — and helping injured spouses to accept that they are changed people.

The research is still in early stages, and in many ways the therapeutic toolbox is not much different from that of regular marriage counseling: Couples coping with a brain injury are taught to communicate better, to focus on positive developments and things they like about each other, and to set aside time to inject a little romance and fun into a life that can be consumed by doctors’ appointments and paperwork.

But other traditional techniques can backfire with these couples, the researchers have learned. For example, said Emilie Godwin, another V.C.U. psychologist, encouraging partners to remember what sparked their love in the first place can mean “highlighting the things that have probably been lost.”

“You’re asking people to just look forward, to not look back at all,” she said. “To try to recreate a relationship.”

The Stranger in the Living Room

About a month after surgery to remove a brain tumor in 2006, Terry Curtis turned to his wife, Vicky, and offered her a divorce.

“I told her she was free to leave,” he said. “I’m not the person you married.”

Mr. Curtis knew he had become cold, impulsive and incapable of focusing his attention. But it would be 18 months before doctors explained to the couple that complications from surgery had caused a brain injury.

Mrs. Curtis, 60, was once drawn to her husband’s “sparkle,” she said. After the injury, he “flat-lined” emotionally, and he suffers from depression, anxiety and a lack of motivation.

Her husband sometimes makes erratic decisions, she added, like the time he decided to take a do-it-yourself approach to the plumbing at their home in Coralville, Iowa. “Not a good picture when I got home,” Mrs. Curtis said. “And you can yell at him like a little kid, but he didn’t know any better.”

Once a software programming analyst, Mr. Curtis, 57, has “a lot fewer interests” than he did before the injury, and he estimates he has lost 90 percent of his friends.

“It’s a new you,” he said, “and they just can’t cope with that.”

Brain injury can be isolating, psychologists say, as the mental symptoms may last well beyond the obvious injuries. Strangers and friends often do not understand the root of a survivor’s socially inappropriate behavior.

Even relatives well versed in the changes wrought by brain injury constantly struggle not to take outbursts or remarks personally, therapists said.

“The word that describes it is just ‘lonely,’ ” said Mrs. Curtis of her role as caregiver. “My life is sitting in the living room quiet while my husband just sleeps.”

Guilt is the tie binding many people to a dependent stranger inhabiting their spouse’s body after a brain injury, Dr. Kreutzer said. But guilt is not unique to the caregiver who might fantasize about getting away. Studies show that few of the injured can work and that about half suffer from major depression; many feel inadequate because of their inability to provide financial and emotional support.

But Mrs. Curtis said she was staying with her husband not out of guilt or an obligation to take care of him — though she couldn’t say she had never contemplated leaving.

“If I was that unhappy, I would make the arrangements for him to be taken care of and get out,” she said.

Counseling has helped Mrs. Curtis, who works in administration at the University of Iowa, to manage her expectations, both for Mr. Curtis’s recovery and her own responses.

“We’ll have a whole day where he’s just fine, and it’s just like the old Terry,” she said last month. “And then he’ll say something out of whack, and I’ll say, ‘Oh, yeah, it’s 2011.’ ”

Psychologists say this type of halting progress adds to what they call “ambiguous loss.” Every day, reminders of the damage appear and disappear, and often couples struggle with grief that is never fully resolved and must constantly be reassessed.

Though the Curtises have not quite let go of the “old Terry,” their relationship is not identical to what they had before his injury. It has become a “combination,” Mrs. Curtis said.

Said Dr. Godwin: “People hold on to hope that just as when they survived the crash and they had this miraculous recovery, that they will overcome these challenges that other people may not in this miraculous way. That’s not going to happen.”

 

A Qualified Miracle

But some couples do manage to put their lives, and relationships, back together in the years after a traumatic brain injury. In 2002, while Hugh Rawlins was in an induced coma, half his skull removed to allow his brain to swell, doctors told his wife, Rosemary, that he might be angry, even abusive to their 14-year-old twin daughters — when and if he learned to talk again.

Mr. Rawlins had been struck by a car while riding his bike near his home in Glen Allen, Va. As he entered rehab, doctors warned that the couple might soon face bankruptcy and divorce.

But after years of halting rehabilitation and a devastating, failed attempt to return to his old job, Mr. Rawlins is a financial executive at a midsize engineering company. An avid surfer before the accident, he rides the waves off North Carolina’s Outer Banks, where the couple spends almost every weekend.

He never became the aggressive misanthrope doctors warned about. And he’s back on the bike.

But each positive step in Mr. Rawlins’s recovery has posed difficult challenges for his wife. Fearful, she hid the car keys as he learned to drive again. His determination to ride his bike sent her into therapy.

“All of a sudden I was in this position of always telling what you can do, what you can’t do — it’s horrible,” said Mrs. Rawlins, who documented her family’s ordeal in “Learning by Accident,” a self-published memoir.

Mr. Rawlins may have suffered a traumatic brain injury, but it was Mrs. Rawlins who, like many others caregivers, ultimately received a diagnosis of post-traumatic stress disorder.

Despite progress toward stable relationships, many couples stay trapped in a pattern in which the uninjured spouse does everything for the survivor, even when it’s no longer necessary, researchers have found. “No one likes to have their freedom stolen from them,” said Dr. Godwin.

Before they entered counseling, fights over Mr. Rawlins’s limits sometimes ended in a silent stalemate.

“There’s always a bit of the rebellion in me, and she’d pull me back just as a mother would or a father would to their teenager,” said Mr. Rawlins, now 55. “Sometimes she was right, and sometimes I could do it.”

The accident rocked the couple out of their “midlife doldrums,” Mrs. Rawlins said. As Dr. Kreutzer tells his patients, some post-injury changes can be positive. Mrs. Rawlins was thrilled to find her once wry and stoic husband is much less emotionally inhibited.

“The touchy-feely stuff, that shows more in me now,” he acknowledged.

More and more, Mrs. Rawlins believes that her husband is back to his “old self.”

She’s just no longer sure she remembers who that was.

NEW YORK TIMES

Related articles

• Gabrielle Giffords mourns dead 1 year after attack (sfgate.com)
• Januar 2012: Wyoming Brain Injury Resources (braininjuryresourcecenter.wordpress.com)
• Jan 8, 2012: Journal of Head Trauma Rehabilitation Announces Collaboration with Center for Outcomes Measurement in Brain Injury (braininjuryresourcecenter.wordpress.com)
• Helping Survivors of Traumatic Brain Injury Live Fuller, More Independent Lives (mooresutekia.wordpress.com)