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BORN OF BULLETS, DASHBOARDS AND TACKLES:
Shattered cognitive processing // Fragmented psychological function // Inappropriate emotional reactions // It’s not just an event, it’s a disease.

TBI: The Injured Brain

By Lauren Ware // Photographs by Shannon Taggart // Summer 2011
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TBI

Shannon Taggart

We walk around each day with our brain, a three-pound organ with the consistency of custard, sloshing about inside a sealed chamber of cerebrospinal fluid. It’s protected, though only just, by a tough outer membrane, the dura mater, and by the skull, a layer of bone a quarter-inch thick. With every movement we make—sitting, rising, running, stumbling—the brain moves within the fluid, accelerating, shifting and twisting in response to external forces. But the brain is unlike other organs. It controls thought as well as physical function—it’s the seat of personality and identity. So when its integrity is violated, we may emerge, in almost every sense, as someone else.

Trauma sometimes comes as a penetrating injury—as it did in the form of the nine-millimeter bullet that last winter tore through the brain of U.S. Representative Gabrielle Giffords, entering the front of her head and exiting the rear. Other times, there may be a closed head injury—for example, from striking a car dashboard during an accident, as happened to Todd Lamkin of Holliston, Mass., who was driving home from a holiday party in 2003 when his car slammed into a tree. Brain tissue will bruise when it smashes against the skull, and blood vessels may hemorrhage. In the days, weeks and months that follow, there can be a cascade of secondary damage, with brain swelling (edema), increased intracranial pressure (which can cause high blood pressure), infection, epilepsy, low blood pressure (which can starve the brain of oxygen) and hematoma (a swelling of clotted blood), as well as cardiac and lung changes.

Public awareness of brain injuries was surging even before Giffords was shot. Concussions in sports have become a hot topic because of the growing realization that such head injuries, once considered relatively minor, can have lifelong implications for any athlete, whether playing in a youth soccer league or on a professional baseball team. And, in fact, some kind of traumatic brain injury, or TBI, happens to an estimated 1.7 million people in the United States each year, according to the Centers for Disease Control and Prevention. The top two causes for civilians are falls and motor vehicle accidents. During the military conflicts in Iraq and Afghanistan, blast-related injuries—from artillery, improvised explosive devices, rocket-propelled grenades and mines—have become common, affecting as many as one in five of those serving in war zones. That has led the Department of Defense to ramp up spending on TBI research, while Congress has increased funding at the National Institutes of Health and for TBI rehabilitation programs.

Though scientists have been studying traumatic brain injury for decades, there is still not a single therapeutic approach that has been proven to speed recovery or change TBI outcomes, says Joseph Giacino, director of Rehabilitation Neuropsychology at Spaulding Rehabilitation Hospital in Boston. That’s not to say people don’t get better—many do. Rather, in most cases, the reason for improvement remains a mystery.

Still, there’s progress across many fronts. Physicians and researchers are studying exactly what happens in the brain when it is injured, both in the immediate minutes, hours and days after the traumatic event and in the months and years following injury. They now recognize that TBI is not just an event, it’s a disease—and its symptoms continue for much longer than previously believed. Diagnosis presents its own unique challenges, so scientists are working toward identifying specific markers in the blood associated with brain injury. Clinical studies are gauging the effectiveness of several drug regimens that, anecdotally at least, have seemed to speed recovery for some patients. Meanwhile, cognitive rehabilitation is evolving, utilizing new insights into how the brain recovers to design individualized treatment programs that focus on the whole person and address both emotional difficulties and physical symptoms.

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Brain Injury: Signs of Trouble

Gauging the severity of brain trauma could become simpler if scientists can find molecular tip-offs.

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1. “Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 2003 Through 2008,” by Keith D. Cicerone et al., Archives of Physical Medicine and Rehabilitation, April 2011. This meta-analysis considers studies on cognitive rehabilitation and makes clinical recommendations, including interventions for attention, memory, social communication skills and executive function.

2. “Blood-Based Diagnostics of Traumatic Brain Injuries,” by Stefania Mondello et al., Expert Review of Molecular Diagnostics, January 2011. A thorough look at an emerging approach to detecting and monitoring traumatic brain injury.

3. “Effects of Methylphenidate on Attention Deficits After Traumatic Brain Injury: A Multidimensional, Randomized, Controlled Trial,” by John Whyte et al., American Journal of Physical Medicine & Rehabilitation, June 2004. The first study to show that methylphenidate has positive effects on attention and processing speed for individuals with traumatic brain injuries.

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