BRAIN INJURIES

Brain injuries are one of the top five causes of death in the United States. Over half of the deaths involving brain injuries come from motor vehicle accidents (MVA's). Strokes are probably second to MVA's in deaths involving brain injury. Other sources of brain injury include falls, sports injuries, and various medical conditions. Besides death, brain injuries can range from mild to severe. Postconcussive syndrome often accompanies minor head injuries. Symptoms of concussion may include headache, dizziness, irritability, fatigue, anxiety, difficulty with attention/concentration, memory problems, and insomnia or other sleep disturbances. These symptoms may last up to three months or longer. More severe brain injury can lead to speech problems, paralysis or partial paralysis in one or more limbs, and even coma.

Although many mild head injuries resolve on their own, it is still very important to follow symptoms closely at least the first month post injury. If symptoms to not improve or get worse, it is important to follow up with someone experienced in head injuries. Follow up CT scans or MRI's often may detect problems weeks after a minor head injury that were not there immediately after the accident. Many people, including some health professionals, believe that, if there are no external signs of injury that there is no internal brain injuries. This often leads to the "walk and drop" cases that collapse after they have been discharged from the emergency room.

Coma is an altered state of consciousness that results from more severe brain trauma. The patient is generally considered unconscious and unresponsive to outside stimuli.  Persistent vegetative state (PVS) is a term that is often applied to coma patients and those with severe brain damage who are generally unresponsive to their environment for at least four weeks. During coma or PVS, a patient may retain autonomic nervous system function (general body functions) and may even show signs of sleep and wake EEG patterns. Patients with severe brain injuries should be assessed for neurological (anatomical and physiological status) and neurocognitive function

 The Glascow Coma Scale is used to assess severity of head traumas in emergency settings. Three areas are assessed: Eye Opening, Motor Response, and Verbal Response. Eye scores range from 1-4. motor responses from 1-6, and verbal scores from 1-5. Thus, a total score of 3 would be the most severe and 15 would be a completely normal score. From a brain rehabilitation perspective, the Rancho Los Amigos Scale of Cognitive Function is generally used. Scoring on this scale ranges from Level I-Level VIII. Levels I-III fall within the coma range whereas, Level IV may be best described as a transitory level of consciousness between coma and wakefulness. It is characterized by confused, agitated behavior. Levels V-VI involved confusion and may still require some level of hospitalization or assisted care. At Level VII, patients may be discharged home with home health care or assisted living facility as their behavior becomes more automatic and appropriate. Level VII is essentially normal cognitive function. It is not uncommon for patients to have residual cognitive impairments at level VIII or to exhibit a noticeable personality change from their premorbid condition.

Assessmentgenerally involves a multi-disciplinary approach. The ER physician is often the first to provide a thorough medical assessment. From there, other specialists such as neurologists, neurosurgeons, and neuropsychologists may become involved in the assessment and further treatment of the patient. Later, once medically stable, a physiatrist usually becomes the primary physician during the course of rehabilitation. Other injuries are treated along with the head injury and appropriate specialists are called in to assess and treat other injuries. One of the most exciting new methods of assessing and treating coma involves neurosensory feedback coma stimulation. The assessment phase involves the use of multi-modal evoked potentials (MEPs), cognitive EEG assessment, and neurocognitive assessment. The MEPs assess the patients ability to hear, respond to visual stimuli,  and experience sensory input to the brain. From this information, it is possible to tell where to apply stimulation, how to apply it, and if the patient responds to certain types of stimuli. Traditional stimulation involves talking and other forms of stimulation to patients. While this is of value, there is no way of knowing if the patient can hear or is responding to certain stimuli or level of stimulation. It may be possible to adjust the intensity of stimulation to the right level or use the most effective forms of stimulation using the MEP and EEG information gathered from the assessment.

Once the assessment of brain injury is completed, a treatment program is developed which may involve neurosensory feedback coma stimulation and/or neurocognitive rehabilitation. As discussed in the neurofeedback section, a cognitive EEG is performed and then rehabilitation is then initiated based on the findings of the assessment. Treatment of brain injury involves three major components: 1) Biochemical therapy to include neuronutrients and orthomolecular medicines. (2) Neurocognitiverehabilitation to include Brain Fitness exercises, and (3) neurofeedback. Nerves have a limited ability to heal and repair damage (neuroplasticity). When these neural "circuits" are damaged, it is imperative that the body has all the building blocks (neuronutrients), and substances needed by the brain (orthomolecular medicines) to be able to repair and heal injured nerves. The exercises and neurofeedback forces these circuits to work which places a demand on the brain to heal itself. The combination of building blocks and exercise ensures that the brain achieves maximal possible recovery.