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Better armour, treatment saves more wounded soldiers, but many left in chronic pain

By Sharon Kirkey, Postmedia News April 18, 2012

When the pain hits hard, it feels as if Maj. Mark Campbell’s left foot has been set on fire.

Except, there is no foot. Campbell’s legs were blown off on a midday in June 2008, when a buried improvised explosive device was detonated beneath him during a Taliban ambush in Afghanistan.

His left leg was all but vaporized in the explosion; his right leg barely hung on by a few strands of shredded bone and tissue.

Today, he suffers phantom limb pain where his left leg below the knee used to be — an excruciating kind of torment so severe he needs methadone to manage it. He’s on maximum allowable doses of other pain medications, their list of side-effects long. “But I have no choice,” the 47-year-old father of two says. “It’s that, or I don’t want to live.”

As the nation’s largest military deployment since the Second World War ends, a new and constant companion will follow many wounded soldiers from the battlefield: Chronic, life-altering pain.

Leaders in Canada’s pain community say the unprecedented number of soldiers who survived injuries that in past wars would have killed them will need a high level of care in a country where pain is under-treated, and under-funded. U.S. doctors are reporting that half of Iraq and Afghanistan vets treated at military hospitals are experiencing some form of persistent and significant pain.

“We owe Canadian warriors the best pain care possible,” says Dr. Mary Lynch, director of research at the Pain Management Unit at the Queen Elizabeth II Health Sciences Centre in Halifax.

“But if the military has to rely on the civilian system of complex pain care, it will be grossly inadequate,” she said. Canadian civilians are facing waits of more than a year at specialized pain clinics. Vast areas of the country have no access at all.

A first-ever Canadian pain summit to be held next week in Ottawa will hear how a U.S. army-led task force on pain has led to an overhaul of how wounded soldiers are being treated, from the battlefield through rehabilitation once home. Specialized pain clinics are being set up at civilian and army medical centres across the U.S. that take a holistic approach. A military criticized for over-relying on opioids to manage pain — leading to high rates of addiction among injured soldiers — is now embracing acupuncture, meditation, yoga and other alternative therapies.

“We know that this is something that we need to be aggressively managing,” states Col. Chester (Trip) Buckenmaier III, program director for the U.S. Defense and Veterans Center for Integrative Pain Management.

“We’ve been talking about the ‘rock stars,’ if you will, of the conflict — those soldiers that have obvious injuries from an IED, for example, where there’s a limb missing,” he said.

“But the business of being in the military and the business of being in the war zone is hard, it’s hard on human beings,” Buckenmaier said. “We have these guys now in 40 pounds of body armour. They’re often running around with rucks that are another additional 50 pounds.

Soldiers are returning from war with severe back strain, joint pain and other musculoskeletal injuries, as well as constant headaches from exposure to multiple blasts.

“When a soldier comes back broken, that impacts everybody,” Buckenmaier said. “And until you’ve managed the pain adequately, they can’t focus on anything else. We really become the basest, the most base that we can be as human beings,” he said. “We’re animals. All you can think about is escaping the pain.”

Until the military began offering a combination of therapies, many people did just that by using opioids to excess, “because you could essentially send yourself into oblivion.”

While post-traumatic stress disorder and traumatic brain injury have been called the “signature injuries” of war, Buckenmaier says there is a third: Pain.

No land army in the history of warfare has achieved the level of survival as seen in the war in Afghanistan, he said.

“We have a less than 10 per cent died-of-wounds rate, and I’m pretty sure the Canadian military is enjoying a similar statistic.”

In the Second World War, 30 per cent of wounded troops died.

According to the Canadian Forces Surgeon General report in 2010, if a wounded CF soldier, sailor or airman makes it to the military hospital at the Kandahar Airfield with vital signs, they have a 97 per cent chance of making it back to Canada alive.

Advanced body armour, advanced trauma life support provided by medics on the battlefield and rapid evacuation of the wounded — all are factors behind the improved survival rates.

Still, more than 600 Canadian soldiers have been wounded in action in Afghanistan; more than 1,400 others have sustained non-battle injuries (such as injuries from traffic accidents or the accidental discharge of a weapon).

Many of these injuries will result in pain that is relentless, Lynch says. In addition, research in the U.S. shows that more than half of military personnel suffering physical pain from combat wounds are also plagued by depression, anxiety, panic disorder and other psychological problems — a phenomenon experts have dubbed “post-deployment multi-symptoms disorder,” or PMD.

Blast-related injuries can dominate — wounds from IEDs and landmines and rocket-propelled grenades. The blast force can cause head-to-toe trauma, from “de-gloving injuries” — stripping of skin and soft tissue from bones — avulsion of limbs requiring amputation, shattered pelvic bones, genital amputation, bowel and bladder injuries, hand or finger amputation, punctured lungs and traumatic brain injury.

Soldiers can survive their wounds only to be left with complex regional pain syndrome — “nerve damage that causes pain that is excruciating,” says Lynch, past president of the Canadian Pain Society, co-host of next week’s pain summit. “Even the touch of a cotton ball can be painful, or the sound of a plane overhead or a newspaper rustling in the same room.”

Until Canada pulled out of its combat role in Afghanistan, Lt.-Col. Markus Besemann received casualty and wounded reports regularly.

“Amputees are certainly the most graphic ones,” said Besemann, head of the CF’s rehabilitation program. But other severe injuries involve “multiple orthopedic trauma” — broken bones, shattered pelvis — nerve damage, head trauma, spinal cord injuries and internal organ damage from blasts.

Most military hospitals in Canada were shuttered in the 1990s, their role handed to the civilian sector. Military personnel who need specialized care are treated at civilian hospitals and rehabilitation centres, with followup care provided by their base health clinics. But not all have multi-disciplinary pain programs.

The Canadian Forces has two chronic pain management programs — one in Halifax, the other in Ottawa — that teach patients breathing techniques, mindfulness meditation and other exercises to help manage their pain. The plan, Besemann said, is to expand them to major bases across the country.

Patients are sent to the teams after everything that can be done medically is done, he said.

In addition, doctors specializing in rehabilitation medicine are being hired for bases in Gagetown, Edmonton and Quebec City.

He said soldiers needing complex care could be fast-tracked to civilian pain clinics within a matter of months.

Lynch says the decision on who should take priority should be made on the basis of urgency of need, “and not whether a person is a civilian or in the military.”

“The whole system needs to be fixed,” she said. “There is massive ignorance about the appropriate treatment for chronic pain.”

Pain researchers, doctors and patient groups across Canada want a national pain strategy that would see more investment in training doctors — civilian and military — in pain and more specialized pain clinics.

But for soldiers, there are other challenges in seeking care: The “tough-it-out” mentality embedded within the military can make soldiers fearful that their careers will end if they report that they’re in pain.

“I guess it’s inbred in their training to suck it up,” Besemann says. “They often come back and tell me that: I was basically taught as an infanteer I have to just suck it up and get on with it.”

Many delay seeking care until their pain becomes chronic, he said.

“People are desperately wanting to maintain their careers, and so they’ll push through pain. . . . And those are significant challenges, trying to convince people, ‘Look, you need to come to us earlier, rather than later.’ ”

Pain isn’t a threat to a career, he said, “so long as the condition they have is treatable.”

Yet a recent Postmedia News series on Canada’s combat mission in Afghanistan told how the number of soldiers being “medically released” jumped from a low of about 675 a year in 2002 to almost 1,200 a year in 2006.

Many of these were forced out, their injuries from Afghanistan leaving them unable to fulfil the military’s requirement that all personnel be physically able to go into combat. Then-chief of defence staff Rick Hillier would later promise to exempt any soldier wounded in Afghanistan from that requirement — a promise some have complained is inconsistently applied.

Campbell, of Edmonton, says for serving soldiers with pain, “the career is on the line, and every soldier knows it.” For those with back pain, knee pain, shoulder pain: “You walk it off, you suck it up, and you do what you’ve got to do.”

The difference for him is that, “I’m done.”

“I’m never going to be an infantry officer again. I’m finished. My career is over,” he says. “What’s holding me back from saying: ‘Hell, I hurt. I want it fixed.’ ”

It took two tourniquets on each leg to stop his severed femoral arteries from bleeding him out. He was lucid — and in “indescribable agony” — the entire time it took soldiers to run with him on a carpet stretcher, through irrigation ditches and with gunshots and grenades exploding around them, to a secure area where an evacuation helicopter could safely land.

Campbell spent two months at Edmonton’s Glenrose Rehabilitation Hospital — a rehab centre that a 2008 Senate committee report on national security and defence said stands out in Canada “like a 2009 Lamborghini on a car lot dotted with too many 1970 Ladas.”

After Campbell was discharged home, the phantom pain was so severe he couldn’t sleep most nights. His military psychiatrist referred him to a University of Alberta Hospital specialized pain clinic, where his doctor suggested methadone.

“Campbell remembers thinking: “The pain is so bad that I need a heroin treatment for it?”

The drug, he says, has been a “life changer.”

It allows him to sleep; it helps keep him from thinking about the pain.

For Campbell, the road to rehabilitation has been long. “You don’t ever fully recover from wounds like mine,” he says.

His pain, he says, is exacerbated by the struggle for fair compensation from the government of Canada.

“One moment you’re in combat, then the next thing you know you’re in a hospital bed, and you’ve got no legs,” he said. “The last thing you remember was that whole horrible incident you hope was just a nightmare.

“Except once the drugs wear off, you realize, ‘this isn’t a nightmare. This is real.’

“And the nightmare never really lets up.”

With files from Lee Berthiaume, Postmedia News

skirkey@postmedia.com

Neuroscientist’s book gives tips, exercises for training your brain to boost emotional connections

By HEIDI STEVENS, McClatchy News, June 18, 2012

“Life’s slings and arrows” is Harvard-educated neuroscientist Richard J. Davidson’s phrase for the events we spend our days ducking, sometimes unsuccessfully.

Losing out on that promotion. Getting dumped. Navigating a cocktail party of boors (or bores). The stuff that conspires to keep us in a foul mood, despite our best intentions.

And Davidson argues that our response to such events — and even to full-on tragedies, such as the death of a loved one — is as much a part of our identity as our fingerprints.

“Each of us is a colour-wheel combination of the resilience, outlook, social intuition, self-awareness, context and attention dimensions of emotional style,” he writes in his book, The Emotional Life of Your Brain, “a unique blend that describes how you perceive the world and react to it, how you engage with others and how you navigate the obstacle course of life.”

Unlike our fingerprints, though, our emotional style can be altered. “We have the power,” Davidson contends, “to live our lives and train our brains in ways that will shift where we fall on each of the six dimensions of emotional style.”

That may sound more like your yoga instructor than a guy who has spent the past three decades studying brain chemistry. But study brain chemistry he does, which makes his findings all the more compelling. (And he did spend three months during graduate school in India and Sri Lanka studying meditation, therefore he’s entitled to sound a little like a yogi.)

So, the six dimensions. Davidson, a professor of psychology and psychiatry at the University of Wisconsin-Madison, identifies them as such, based on activity he has identified in specific brain circuits:

Resilience: How slowly or quickly you recover from adversity.

Outlook: How long you are able to sustain positive emotion.

Social intuition: How adept you are at picking up social signals from the people around you.

Self-awareness: How well you perceive bodily feelings that reflect emotions.

Sensitivity to context: How good you are at regulating your emotional responses to take into account the social context you find yourself in.

Sleeplessness eroding public health, say docs

By Charlie Fidelman, Postmedia News May 4, 2012

MONTREAL — Emergency room doctors helped implement seatbelt use, lung specialists led the charge to reduce cigarette smoking. Now, a group of sleep specialists meeting in Montreal is agitating for a sleep policy.

That’s right. A good night sleep is so important for physical and mental well-being that its lack poses a grave risk to public health, experts say.

If science has yet to unravel the mystery of why we need to sleep, the toll of inadequate slumber is well-documented in studies linking bad sleep to obesity, cancer, cardiovascular diseases and metabolic disorders. Lack of sleep weakens the immune system.

Look at the numbers: 25 per cent of adults don’t get enough sleep or have chronic insomnia, said psychologist Reut Gruber, director of the attention, behaviour and sleep lab at the Douglas Mental Health University Institute in Montreal.

But the worst group for sleeplessness is adolescents: up to 80 per cent of Canadian students come to school extremely sleep-deprived, while the portrait of school age children “isn’t pretty . . . 43 per cent are going to bed at a very, very late time.”

Robust evidence on sleep deprivation and health consequences led most medical schools in North America, including Montreal’s McGill University, to abolish 24-hour shifts for medical residents. Not only do sleepless nights impede students’ ability to learn, they can lead to medical errors that put patients at risk.

Fatigue is cumulative, and crashing on weekends to play catch-up doesn’t work, said Gruber, who is bringing together about 40 sleep scientists from across Canada and the United States to discuss how to translate sleep medicine research, specifically pediatric sleep, into educational and public policies and lifestyle changes.

Some people suffer from sleep apnea or other medical problems that interfere with slumber, but for many, the chief culprit is the mistaken belief that sleep is a waste of time.

“Sleep feels like it’s something we can give up when we have other competing priorities,” said Gruber, who is chair of the pediatric interest group, Canadian Sleep Society. “Our choices are going to affect many things that are important to us.”

In fact, sleep should be a high health priority, along with eating well and exercising, she said.

Children, for example, need at least nine hours of sleep, Gruber said. Among other functions, sleep allows the brain to do its “executive actions”, consolidating learning and memory, something that is imperative for academic performance, she said.

Working guidelines on good sleep hygiene would mean, for example, that sports and cultural activities would not be scheduled late on school nights

“I’m very excited to hear presentations from the (Quebec) institute of public health on this topic. It’s a great step forward,” Gruber said. “My request to each presenter was to identify barriers to integrating pediatric sleep into public health and the education systems.

“We have the knowledge. We have the evidence. Why can’t we integrate it and overcome the barriers?”

cfidelman@montrealgazette.com

Five common myths about sleep.

1. Sleep is a time when your body and brain shut down for rest and relaxation.

False. Our bodies and brains actually do a lot of work while we sleep, which helps us to refuel and to stay healthy and happy. Sleep also plays an important role in memory and learning; as we sleep, we consolidate all the information we learned during the day.

2.  Sleep is less important than some of our other important basic needs, such as eating.

False. Even cutting our sleep by one hour one night has a serious impact on our health, mood, and behaviour the following day. Furthermore, a single night of partial sleep deprivation is enough to impair our immune functioning, which heightens our risk for acquiring a virus or illness.

3.  Adolescents need less sleep than younger children.

False. While it is true that adolescents tend to get less sleep than younger children and may have a harder time falling asleep, getting an adequate amount of sleep is still just as important for their development and well-being as it is for younger people.

4.  Sleeping in on weekends compensates for lack of sleep throughout the week.

False. Having a consistent bedtime and wake time throughout the week is important to ensure we maintain healthy sleep habits. Waking up early throughout the week and then sleeping in on the weekends creates an irregular sleeping schedule and confuses our bodies. If we do not get enough sleep one night, a better way to compensate for this is a short nap in the afternoon.

5.  Alcohol and other sedatives help us to sleep.

False. While alcohol may help us to fall asleep easily and quickly, it actually disrupts our sleep and prevents us from achieving a deep, restful sleep. Sleeping pills can be problematic. If we use them regularly and then stop, it becomes difficult to fall asleep without their use, thus starting a vicious cycle of dependence.

Source: Douglas Mental Health University Institute

Read more: http://www.montrealgazette.com/health/Sleeplessness+eroding+public+health+docs/6562402/story.html#ixzz1yAuI87FB

Could poor mental health be driving Canada’s obesity epidemic?

By Sharon Kirkey, Postmedia News June 18, 2012

Canada is losing the war against obesity because we’re ignoring one of its major drivers, doctors say: the state of our mental well-being.

Some say obesity and mental health are so intricately entwined, they should be considered a “double epidemic.”

Depression, anxiety, sleep disorders, attention deficit disorders, post traumatic stress, addictions — all can cause changes in appetite, energy and metabolism that can prime people to gain weight. What’s more, antidepressants, mood stabilizers and newer generation anti-psychotics — drugs Canadians are being prescribed in record numbers — can themselves cause rapid and dramatic weight gain.

No one is suggesting that everyone with a weight problem has a mental illness.

But missing in the relentless drumbeat to “eat less, move more” is any public discussion about the role common mental health problems are playing in the obesity dilemma, observors say.

“We absolutely have not looked at this issue at all,” says Dr. Valerie Taylor, chief psychiatrist at Toronto’s Women’s College Hospital.

“This is probably one of the number one reasons that we’re not getting anywhere in terms of battling the obesity epidemic.”

The relationship works both ways.

Fat tissue isn’t inert. It’s biologically active. It produces cortisol, a stress hormone, as well as inflammatory chemicals, both of which have been linked to mental illness. Cortisol is neuro-toxic. It can act on the brain in vulnerable people — putting them at increased risk for depression.

Conversely, people with depression produce excess cortisol. And one of the effects of cortisol on the body, Taylor and her colleagues recently reported in the Canadian Journal of Psychiatry, is a propensity to accumulate fat around the abdomen.

The interplay between obesity and mental health is complex, but “we have not had a public discourse on how tightly these two epidemics are linked,” says Dr. Arya Sharma, professor of medicine and chair in obesity research and management at the University of Alberta.

Nowhere in the recent report from Canada’s mental health commission is there a mention of obesity, he says. “And vice versa. With all the talk about healthy weights, there’s a lot of focus on diet and exercise, but I don’t see any focus on improving the mental health of our kids and our adults. And that is a huge part of what is really driving the obesity epidemic.”

Studies have found that 66 per cent of those seeking bariatric, or weight loss surgery have had a history of at least one mental health disorder. Attention deficit disorder occurs in an estimated one in four. “These people really struggle with being able to eat healthy — they make impulsive choices, they can never make it to the gym, or they get to the gym, they’ve forgotten half their stuff,” Taylor says. “If you get that illness under control they can be successful in losing weight.”

Currently, 62 per cent of the nation’s adult population is either overweight or obese, a trend that’s tracking at an even faster pace among children and adolescents. Today, there are more overweight than “normal” weight Canadians, and the heaviest weight classes are growing the fastest.

In many cases, the weight gain happens so insidiously, people can’t put their finger on exactly how it happened.

Humans have been hard-wired through evolution to eat as much, and as often, as we can, and the food industry, critics say, has done a formidable job creating extraordinarily seductive foods loaded in sugar and fat. Some of the world’s leading addiction researchers believe today’s highly processed foods interact with the brain in ways similar to cocaine or heroin.

It takes significant impulse control to resist the smorgasbord before us, “because your brain wants all of those things and can’t get enough,” says Sharma, who will be among the featured speakers at a three-day conference on obesity and mental health in Toronto later this month sponsored by the Canadian Obesity Network, the International Association for the Study of Obesity and the Centre for Addiction and Mental Health.

“Even the slightest problem with impulse control and decision-making is going to expose you, and make you much more likely to gain weight,” Sharma said.

“I can’t think of a single mental health problem which would not, in some form or fashion, contribute to weight gain, or make weight management extremely difficult for someone who has the genetics to put on weight.”

Mood affects metabolism and changes the way the body responds to certain foods, he said.

Depression or bipolar disorder can cause changes in appetite, energy and motivation. Depression and anxiety cause play havoc with sleep, and the link between sleep problems and weight has never been stronger.

In a normal, sleep-wake cycle, leptin — the satiety or “I’m full hormone” that tells the brain to reduce food intake — increases, while ghrelin, which triggers appetite, decreases. That’s so that people don’t feel hungry when they’re sleeping.

But when sleep is disrupted, the opposite occurs, Taylor’s team wrote, so that people are not only awake, but they’re also hungry.

Taylor says the links are also strong between adult obesity and abuse in childhood — emotional abuse, physical abuse and neglect. “Sexual abuse is probably the biggest one,” she says. “Often times children incorrectly blame themselves for causing the abuse, so they want to change the way they look.”

Psychiatric drugs — among the most commonly prescribed pills nationwide — are adding to the problem. Antipsychotics — medications that are now even being used for insomnia — can trigger “hedonic hyperphagia” — eating in pursuit of reward, rather than to ease hunger.

“With some drugs, they can put on massive amounts of weight,” says Rohan Ganguli, professor of psychiatry and Canada Research Chair at the University of Toronto. One of his patients gained more than 100 pounds over the course of a year.

The drugs are often necessary. “But we have to mitigate risk,” Taylor said. “We need to be aware of these side effects and prescribe correctly.”

Food soothes anxiety and stress. It becomes a coping mechanism. Certain foods like carbohydrates can boost serotonin, which affects mood. For brief periods of time, we feel relaxed and comforted. But it doesn’t last, and so people get into a cycle, Taylor says, “where they’re constantly using food to feel better.

“We have to teach people how to stop doing that.”

Taylor says she can’t think of a more stigmatized group than those who have both obesity and mental illness. “Lots of times people don’t come forward and say they have a psychiatric illness going on when they’re looking for obesity treatment. Family doctors don’t ask about it.

“We need to raise awareness. This is a complicated illness. It’s not a blame thing. There are associations and things occurring that people aren’t aware of,” Taylor says.

“You have to care about the whole person, and not just one symptom.”

skirkey@postmedia.comTwitter.com/sharon_kirkey

Read more: http://www.canada.com/health/Could+poor+mental+health+driving+Canada+obesity+epidemic/6796355/story.html#ixzz1yAqVcU7L

New motorcycle helmet law rides into B.C.

By Ted Laturnus, June 14, 2012, The Georgia Straight

After almost 30 years, the B.C. beanie is history. As of June 1, there are new rules governing motorcycle helmets in British Columbia, and so-called novelty helmets—in particular, the B.C. beanie—are out.

Offering about as much protection to riders’ heads as a Tupperware bowl, the low-cost beanies managed to slip through the cracks in the late 1980s when—among other things—the existing helmet laws were challenged in court by various groups, one of which claimed that being obliged to wear a motorcycle helmet infringed on their right to wear religious headgear. Since then, law enforcement has essentially overlooked the beanie, despite common knowledge that it’s not legal and does almost nothing to prevent head trauma in the event of an accident.

The statistics are hard to argue with. According to the B.C. Ministry of Justice, helmet laws—and proper headgear—have been found to reduce accident fatalities by as much as 37 percent. Since motorcyclists are eight times more likely to be killed and some 40 percent more likely to be injured in a vehicle collision than other road users, wearing proper headgear is a bit of a no-brainer. If you ride regularly and wear a beanie or a skid lid, the only reason you haven’t been injured is sheer luck. Even a relatively low-speed collision can have dire consequences if all you have on your head is a one-centimetre-thick piece of fibreglass.

Unbelievably, some riders in B.C. have even found store-bought beanies to be too large, whittling down their “helmets” to skullcaps the size of a yarmulke. Other riders claim that a full-sized helmet with a front visor and proper padding limits their peripheral vision and deadens road noise so they can’t hear what’s going on around them. Interestingly, authorities in Italy also recently banned the use of inadequate helmets on scooters and motorcycles.

So what constitutes a proper helmet? First of all, it must meet industry standards established by the U.S. Department of Transport, which Canada adopted years ago, or those established by the Snell Memorial Foundation. This latter group is a nonprofit research foundation whose purpose is to define what constitutes proper head protection “through scientific and medical research, standards development, helmet testing and public education”. It was founded after the death of amateur racing driver Pete Snell in 1957, and is recognized by virtually every sanctioned motorsport body in North America, including the American Motorcyclist Association, the National Hot Rod Association, NASCAR, the Sports Car Club of America, and others.

Although several high-profile accidents have brought the helmet issue to the fore, law-enforcement personnel in B.C. have chafed over the beanie loophole for years. Says Jamie Graham, former Vancouver chief of police and chair of the B.C. Association of Chiefs of Police traffic safety committee, in a news release, “We have seen the harm that inadequate safety equipment and poor choices cause. You have to be responsible for your actions, dress appropriately, pay attention and focus on driving.”

What happens if you defy the law and ride around with a beanie now? The first fine is $138, and if you can’t produce a legal helmet, that’s another $276, thank you.

Some other motorcycle safety regulations were brought forward by the B.C. government at the same time the beanie law was introduced. As of June, passengers riding on the rear pillion have to be able to “place their feet on foot pegs or floorboards”. If you have kids who can’t reach the rear pegs, they can’t ride. Ontario has had this law on the books for the past couple of years, and it makes sense all around.

As well, the size of the font on motorcycle licence plates has been increased slightly—some 0.95 centimetres—to “improve visibility and enforcement for police”.

Perhaps the best news to come out of the B.C. government’s announcements is that it intends to move forward with a graduated licensing program for new riders that may include restrictions on power and bike size. The U.K. has had this kind of system in place for years, and Ontario also has a type of graduated licensing program that restricts where and when you can ride but says nothing about the size or power level of the bike.

Most of these new regulations are for the good, but it’ll be interesting to see if another legal challenge is mounted against the new helmet laws.

Concussions 101

Turning rehab into a game

Simple blood test detects concussion

A Canadian doctor has found a promising way to detect concussions using a simple blood test that can tell within the first hour after a blow to the head how severe the injury may be.

In what could soon become the world’s first blood test for the brain, Dr. Linda Papa, a Montreal native leading a U.S. National Institutes of Health-funded research project at American trauma centres, has shown certain proteins released by the brain after a head injury can be detected in blood.

Every year, at least 1.7 mil-lion people in the U.S. sustain a traumatic brain injury, or TBI, Papa and her co-authors write in the Journal of Trauma.

“More than 1.4 million of these are treated and released from emergency departments across the country.”

Concussions, or mild traumatic brain injury, can be difficult to diagnose. Even CT scans can miss subtle, micro bleeds in the brain that, if not picked up, can lead to “second impact syndrome” – potentially fatal brain swelling – if the person suffers another head injury before recovering from the first.

“Some of these patients actually go home and they don’t feel quite right,” said Papa, an emergency physician and director of research for Orlando Regional Medical Center in Orlando, Fla. “They’re forgetful. They have trouble concentrating. They become very anxious, and they don’t know why. Everybody tells them, ‘You’re fine. Your CT scan was fine.’ And so they’re not offered therapy.'”

Concern is also growing around unnecessary exposure to radiation from repeated scans of the head. The study found high levels of this protein was associated with having an abnormal CT scan.

Earlier studies in rats found a number of proteins are released in the brain after traumatic brain injury.

After a head trauma, the barrier around the brain also gets damaged, and the proteins leach out into the blood.

The new study enrolled 295 people – 96 of whom had a mild or moderate concussion. They were compared to two “control” groups: normal adult volunteers without any injuries whatsoever, and “non-head injured” patients treated in emergency after a car crash or with a broken bone, but no head trauma.

Some earlier proteins studied in brain injuries have also been found in bones. “So if a patient has multiple trauma with a broken leg and head injury, we can’t tell if the protein is coming from the broken leg, or the brain,” Papa said.

Her team found two proteins were higher only in the blood of patients with a brain injury. “Patients who walked off the street had almost no levels of marker in their blood – we detected almost nothing,” she said.

They took it to the next level by comparing the blood tests to CT scans. The more severe the brain lesions, the higher the protein levels in blood. Papa said the proteins are detect-able in blood within an hour of injury; up to four hours later, they’re still elevated. The study also found that these protein levels were higher in patients who needed urgent surgery.

“The key is, could these proteins tell us in advance how severe the head injury is, and is this patient going to require some kind of neurosurgery?” “There’s really no approved blood test for the brain as we know it right now,” Papa said. “When people come in with heart attacks, you do a blood test to see if there’s heart dam-age.” There are blood tests for the kidneys, liver and thyroid.

More research is needed to validate the findings. But Papa believes a blood test for concussions will be available in emergency departments within five years.

Sex, age may affect athletes’ concussion recovery

BY AMY NORTON, REUTERS MAY 18, 2012

 

Female and high school athletes may need more time to recover from a concussion than their male or college counterparts, according to a U.S. study that comes amid rising concern about concussions in young athletes.

Researchers, whose report appeared in the American Journal of Sports Medicine, found that of 222 young athletes who suffered a concussion, female athletes tended to have more symptoms than males. They also scored lower on tests of “visual memory” – the ability to recall information about something they’d seen.

Meanwhile, high school athletes fared worse on memory tests than college players, and typically took longer to improve.

For parents, coaches and athletes, the key message is to have patience with concussion recovery, said lead researcher Tracey Covassin, an assistant professor at Michigan State University in East Lansing.

“It’s going to take time for your child to fully recover, so don’t rush them back into the sport,” she said, adding that extra time may be in order for female athletes and high schoolers.

The study covered 222 high school and college athletes who suffered a concussion over two years, including players in football, soccer and volleyball.

Covassin’s team gave them standard tests of memory and other mental skills, as well as balance, over their first two weeks after they suffered concussions.

Overall, female athletes complained of more symptoms than their male counterparts – an average of 14 symptoms, versus 10. Concussion symptoms include problems like headache, dizziness, nausea, ringing in the ear, fatigue and confusion.

Female athletes also had lower scores on visual memory tests, though male and female players alike gradually improved over the two weeks.

High school athletes, meanwhile, performed worse on memory tests than their college counterparts and improved more slowly. After one week they were still lagging behind older athletes.

And among male athletes, high schoolers also had more problems when researchers tested their balancing skills.

Younger athletes likely need more recovery time because the teenage brain is still developing, Covassin said. It’s also smaller, which means it can be more easily “knocked around” within the skull if a young athlete takes a hit.

It’s not clear why female athletes may fare worse, but there is research suggesting that differences in brain structure are at work.

And young athletes seem to be sustaining more concussions than in the past. A study found that in 2008, there were five concussions for every 10,000 U.S. high school athletes who hit the playing field. That was up from just one per 10,000 a decade earlier.

There are more people playing contact sports, and young athletes are training more aggressively at an early age. Doctors are also becoming more vigilant about diagnosing concussions, experts said.

Potential remedy to relieve PTSD? Puppy love

By Jamie Hall, Postmedia News April 26, 2012

EDMONTON — There are mornings when it’s only the persistent nudging of Halo’s cold, wet nose that convinces Richard Yuill to get out of bed.

The post-traumatic stress disorder with which he has struggled since his tour of duty in Bosnia sometimes comes with crushing depression that makes it difficult for him to face the day.

Seven-month-old black lab puppies care little about such things, though, especially when they have empty tummies and full bladders.

“He’s pretty hard to ignore,” smiles Yuill, gently stroking the puppy’s smooth forehead.

Halo — he’s named after a Canadian military operation in Haiti — is part of Bravo K9, a program of Hope Heels. The non-profit organization initially was established to help people with mental-health issues but has expanded to include current members of the Canadian Forces or veterans who have symptoms of operational stress injury or post-traumatic stress disorder, known as PTSD.

It’s a unique twist on animal-assisted therapy. Instead of being provided with a service dog that already has been trained, participants are given the job of doing it themselves, with help of a professional dog trainer and a registered psychologist. The goal is to teach people skills that help them work beyond the bounds of their disabilities, and in the process, contribute to their own healing.

For Yuill, it’s not just about getting out of bed in the morning — it’s being able to leave the house by himself and to do things that most people take for granted: grocery shopping, banking, dropping off the dry-cleaning.

A member of the Canadian military from 1990 to 2002, he was diagnosed with PTSD shortly after his release. In 2000, he was part of a peacekeeping unit given the task of “de-mining” the Bosnian countryside. Although the hostilities of the bloody civil war involving the Serbs, Croats and Muslims had ceased, the danger had not, and areas of the country were still littered with mines left from the conflict.

An ammunition technician, Yuill knew well the maiming — and killing — capabilities of such mines. During his five-month tour of duty, a young girl from a nearby town was killed after she stepped on one of the mines near their camp. Other things happened, too, some involving his own unit, that contributed to his PTSD and left him battling debilitating bouts of depression, anxiety and anger upon his return.

He experienced major trust issues. Being around large groups of people, even at family gatherings, triggered severe panic attacks. And, until recently, the idea of leaving the house without the company of the handful of people he does trust — his partner Terri-Lynn, her daughter, his sons — was nearly unthinkable.

“Anywhere there are lots of people — banks, grocery stores — I feel trapped, totally surrounded,” says Yuill. “I can barely resist the urge to run.”

Many veterans with PTSD suffer from agoraphobia and need a safe person to go out with, says Kristine Aanderson, the executive director of Hope Heels and a registered psychologist.

“We can train them to use their dog as that safe person, so that they always have a buddy with them,” she says. “Someone to ‘watch their back’ when they’re out and feel vulnerable.”

Today, Yuill and his faithful pooch venture out for leisurely strolls around the neighbourhood that get longer with each passing day. In time, he hopes to take Halo with him to run errands, a goal that seems more attainable than it did a few months ago.

When he came to live with Yuill, Halo was a 10-week-old puppy, with all the attendant demands and needs of a newborn. In canine years, he’s now a teenager. And while he occasionally exhibits the attitude that age suggests, his seal-brown eyes and unwavering loyalty have won his master’s heart and trust.

“We’ve developed a very tight bond,” says Yuill with a smile. “I mean, who can you trust more than an animal; dogs, especially. They don’t judge you, and the love they offer is unconditional.”

jhall@edmontonjournal.com