Rolf B. Gainer, Ph.D., Diplomate ABDA, is the Chief Executive Office at Brookhaven Hospital and the Vice President of Rehabilitation Institutes of America. Dr. Gainer has been involved in the design and operation of treatment programs since 1977.
The Brain Injury Association of American (BIAA) reports that Defense Secretary Gates continues to defend TRICARE’s stance on cognitive rehabilitation. On August 4, 2008 a group of Senators, led by Senator Evan Bayh (D-IN), wrote a letter to Defense Secretary Gates in an attempt to get him to ensure official TRICARE coverage of cognitive rehabilitation. However, “Secretary Gates continues to defend TRICARE’s lack of coverage of cognitive rehabilitation, maintaining that there is insufficient evidence from properly structured research protocols to establish the general acceptance of cognitive rehabilitation as a proven medical treatment.”
BIAA reports:
Specifically, Secretary Gates states, “The Assistant Secretary of Defense for Health Affairs reports that while the existing evidence is supportive of cognitive rehabilitation, the rigor of the research by which that evidence was produced has not yet met the required standard.” At the same time, Secretary Gates’ letter does acknowledge that “many organizations and reviews have supported cognitive rehabilitation.”
BIAA strongly disagrees with the argument put forth by Secretary Gates that there is insufficient evidence to justify official TRICARE coverage of cognitive rehabilitation. BIAA, along with numerous congressional advocates, will continue to press this issue in the new 111th Congress next year.
Of the 700,000 troops from Operation Desert Storm, about 25% are affected by a complex of multiple symptoms which has now officially been recognized as an illness related to exposure to pyridostigmine bromide, a drug given to U.S. troops to neutralize the effects of nerve gas attacks and exposure to neurotoxic insecticides. Veterans of the First Gulf War who were affected by the complex symptoms, involving neurological problems, immune system disorders and a high rate of cancers have often been denied benefits or given only partial disability due to government's failure to recognize the disease.
At the October 2008 South West Disability Conference, the voice of the veteran's group was heard through the showing of powerful film, "Gulf War Syndrome: Aftermath of a Toxic Battlefield", which was directed by Alison Johnson, the Board Chair of the Chemical Sensitivity Foundation. The film did much to increase my awareness of the cluster of symptoms which cause the disabilities and diseases of this disorder and increase my understanding of far reaching consequences of Gulf War Syndrome.
The Research Advisory Committee on Gulf War Veterans' Illnesses released their findings in a report which identified that "Scientific evidence leaves no question that Gulf War Illness is a real condition with real causes and serious consequences for affected veterans". The symptoms include: memory and concentration problems; persistent headache; unexplained fatigue; widespread pain; chronic digestive difficulties; respiratory symptoms and skin rashes. Elevated rates of brain cancer and ALS (amyotrophic lateral sclerosis) has also been reported among veterans with Gulf War Syndrome. Other causative factors have been named: exposure to low-level nerve agents such as Sarin during destruction of Iraqi weapons stockpiles; close proximity to oil well fires and the effects of multiple vaccinations. The Gulf War Syndrome is associated with diverse biological alterations affecting the brain and nervous systems. The report went on to comment that the illness differs from multi-symptom conditions such as fibromyalgia, but shares some similarities. The committee recommended a $60 million annual budget for new research into Gulf War Syndrome.
This report contradicts earlier studies commissioned by the military and VA which disputed the existence of Gulf War Syndrome as a disease related to toxic exposure and prevented ill veterans from accessing the needed benefits and services. This is an important stride in recognizing a disease caused by toxic exposure, unfortunately for many of the affected veterans it is too late.
Technology Review published an article on a red blood cell booster hormone erythropoietin (EPO), several studies have shown that this hormone can protect against the cell death and even swelling that accompanies traumatic brain injury – at least in animals. Gunnarson, of the Kaarolinksa Institute in Swedend, “found that the drug works by targeting the astroglia (also known as astrocytes), closing down a channel that normally imports water into these cells”.
While some of the neural damage that accompanies traumatic brain injury, such as that resulting from car accidents or explosions, results from the impact of the accident, most of it unfolds over days, weeks and perhaps even months after the injury, triggered by a chemical cascade that triggers inflammation and cell death.
According to the Army Times, “As of October 2007, 186 Soldiers had died in accidents within one year of returning from combat, 168 of them within the first six months after they returned. Sixty percent of the accident fatalities are sergeants or below. The overwhelming majority of the accidents involve high speed, alcohol or both.” Are these deaths due to thrill seeking? Brain injury? PTSD? It appears that the Army thinks the majority of these deaths may be due to the former, regardless the army has recognized they have a problem and are taking steps to fix it.
WAQ or “Warrior Adventure Quest” is designed to help soldiers adjust from their war time lives that were fast paced and packed with adrenaline, by combining high-adventure outdoor recreation with “Battlemind training to help Soldiers re-adjust to a calmer paced lifestyle.”
The high-adventure acts to entice soldiers to participate, and helps them get that adrenaline rush they are craving in a safe, controlled environment. Battlemind on the other hand is an “Army psychological resiliency-building program that helps Soldiers recognize and respond to fear during combat, then mitigate the cumulative effects of a sustained combat environment and become mentally prepared to reintegrate during the redeployment, post-deployment and reset portions of the deployment cycle.”
While the program is still relatively new, the Army is planning to bring the program to 24 garrisons over the next year, and plans to eventually have every BCT participate in WAQ within 90 days of returning from a combat environment.
Does our brain play tricks on us? Michael Gazzaniga, a brain researcher, conducted a study in which hew looked to determine how a lack of control affected how the subjects identified patterns of random stimuli. In short, the study helped us understand that when we lose our sense of control, we search for and establish patterns and relationships which may not exist.In individuals with known brain injuries and those with specific psychiatric diagnoses we call that phenomena "confabulation". Our brains search for meaning to events and, in the absence of being able to formulate an accurate portrayal, we "fill in the blanks".
As we look at individuals who have a brain injury, their deficits in perception may drive their confabulatory response as they interact with the world and attempt to make sense of it. For individuals who are paranoid or obsessive, their troubling perceptions of reality may be better understood as an attempt to regain control. The limits of our ability to perceive what is happening to us, for whatever reason, may be considered "pathological" or "dysfunctional", but, in fact it is just our brain making sense of the world and establishing control and order with the tools that are available to it through our perceptions and interpretations of stimuli.
Salvador Dali, the Surrealist painter, wore various lenses to distort objects and create the visions which served as elements in his paintings. Was he assisting the process of distorting his perceptions to support his creativity or was he engaging in intentional confabulation? Where does creativity end and pathology begin?
Does our brain play tricks on us? Michael Gazzaniga, a brain researcher, conducted a study in which hew looked to determine how a lack of control affected how the subjects identified patterns of random stimuli. In short, the study helped us understand that when we lose our sense of control, we search for and establish patterns and relationships which may not exist.In individuals with known brain injuries and those with specific psychiatric diagnoses we call that phenomena "confabulation". Our brains search for meaning to events and, in the absence of being able to formulate an accurate portrayal, we "fill in the blanks".
As we look at individuals who have a brain injury, their deficits in perception may drive their confabulatory response as they interact with the world and attempt to make sense of it. For individuals who are paranoid or obsessive, their troubling perceptions of reality may be better understood as an attempt to regain control. The limits of our ability to perceive what is happening to us, for whatever reason, may be considered "pathological" or "dysfunctional", but, in fact it is just our brain making sense of the world and establishing control and order with the tools that are available to it through our perceptions and interpretations of stimuli.
Salvador Dali, the Surrealist painter, wore various lenses to distort objects and create the visions which served as elements in his paintings. Was he assisting the process of distorting his perceptions to support his creativity or was he engaging in intentional confabulation? Where does creativity end and pathology begin?
Last week, I had the pleasure of revisiting old friends in Iowa. On one particular morning in Iowa City, I had a chance to catch up with Geoff Lauer, the current executive director of the Brain Injury Association of Iowa. He had brought his daughter along for breakfast (that girl can eat!), who helped brighten the morning with her enthusiasm about the current book she's reading.
After she trotted off to school, Geoff and I chatted about the current state of brain injury care in Iowa. I told him that I felt America needs to begin transferring the awareness that brain injured veterans have helped generate into action for civilians–and primarily among the aging population. It's one of the largest, yet underserved, populations in America. I've met a number of people who have been denied brain injury care because their trauma either instigated, or co-occured with dementia. It's unfair.
In these situations, what typically happens is that the patient is deemed unable to make gains. But my concern is that our measurements–and perhaps even our definition of "gains"–doesn't fit will for the geriatric patients. Life improvement terms like "well-being" and "fulfillment" need to be incorporated into our understanding of aging with brain inury.
Instead of treating brain injury as an episodic event, tomorrow's successful providers are going to offer lifelong services that address satisfaction and quality-of-life concerns. Each of us are rapidly heading into a demographic with high risk for injury–it only makes sense to create and champion the supports that we ourselves may someday need.
I attended the 2008 Toronto ABI Network Conference on November 3 and 4. Each year this conference evolves and deepens in terms of its content and quality. This year the conference was the largest ever, but fortunately remained extremely well organized and scheduled in all respects by the ABI Network Planning Committee and Ms. Charissa Levy, Executive Director. The keynote speakers: Caron Gan, R.N., M.Sc.R.N.; Deidre Dawson, Ph.D.and Donald Meichenbaum, Ph.D. addressed issues of family support, executive functioning and a model of treatment in their excellent presentations about their applied work and research. Constable Carolyn Matthews, the closing speaker, brought the elements of brain injury together in her personal story of injury and recovery.
Personally, I find the ABI Network Conference to be an excellent opportunity to learn and exchange knowledge. I enjoyed sharing my presentations on Social Role Return and Aging with a Brain Injury with the conference participants. Of course, I enjoyed seeing my colleagues in Toronto and being in the downtown area. The ABI Network Conference will convene again in 2010. I look forward to seeing how this conference continues to grow. If you are interested in seeing the 2008 conference materials and handouts visit:
As many as 20 percent of our returning soldiers are diagnosed with traumatic brain injury, and about 40 percent of those are mild cases that are often overlooked because they don’t show up on traditional screening. Thanks to a $1.4 million Defense Department Grant researchers at the Cleveland Clinic and Baylor College of Medicine in Houston “are trying to figure out why so many veterans are suffering from the lingering effects of this injury many months later. The researchers are using brain imaging to try to create a more accurate picture of mild TBI.”
Clinic-Baylor have recently began recruiting 120 subjects and will compare brain injured veterans and civilians using brain images, using the “better studied and understood TBI caused by mechanical forces – such as the sudden jolt of a car accident”.
“Neuroscientists Stephen Rao at the Clinic and Harvey Levin at Baylor know from animal studies that blast causes microscopic changes in the brain. They just don’t know exactly what they’ll see in human brains or what’s causing this kind of damage, which they think will look different from a blunt-force type of TBI.”
Rao and Levin are planning to use two specialized methods of brain imaging to identify where the damage occurred:
One method measures the flow of blood in different areas of the brain in response to activities and tasks - such as remembering a telephone number. These kinds of scans have shown that brain-injured patients have to work harder to perform tasks than do uninjured patients. Rao is not sure if they will see the same patterns in the blast-injured patients.
The other scanning method shows movement of water in the brain at the molecular level, particularly in the part of the brain that contains nerve fibers. For mechanical brain injuries, it frequently shows a lot of damage to nerve fibers when the brain is violently accelerated and nerves shear.
The political fervor in America is nearly palpable. Yesterday, I was walking through the streets of downtown Iowa City, and I overheard a number of conversations, almost all of them political in nature. Today, millions of America will participate in what is expected to be the most significant election in our lifetime.
Now that America is finally engaged in the voting process, we need to start talking about how we can translate that same energy into community involvement. If we think our vote is significant enough to warrant waiting in line for two hours, then how can we turn our back on our friends and neighbors–and particularly those with a brain injury?
There are a number of issues that we can begin to tackle. Insurance carriers are dropping rehabilitation benefits. That's one cause that needs an army. Veterans with brain injury lack long-term supports. There's another. If you want a quick summary of what you need to advocate for, download the Barriers and Recommendations paper at www.nabis.org.
I encourage–no, implore–you to avoid the seduction of political apathy after the election. Your involvement carries tremendous weight in your community, and it becomes a powerful representation for those who can no longer vote.
