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SCIENTISTS VERIFY TREATMENT FOR OLD BRAIN INJURIES

Could Help The Almost 400,000 Brain Injured Service Members And Veterans
Returning From Iraq.

Today, the prestigious peer-reviewed journal, Brain Research, published an article that verifies rats with an old traumatic brain injury can be healed with a protocol perfected by treating humans since 1978.  Traumatic brain injury is a condition that denies oxygen to certain parts of the brain which causes inflammation, cell death, and loss of use.  Intermittent treatments with pure oxygen, called Hyperbaric Oxygen Therapy (HBOT) saturate these oxygen-deprived tissues with up to 10X the amount of oxygen we breathe.  HBOT has now been shown to restore function and heal these old brain injuries.  It is approved for other kinds of wound care.

Lead author of the study, Paul G. Harch, M.D., Hyperbaric Medicine Fellowship director at Louisiana State University School of Medicine, New Orleans, who teaches other doctors how to use pressurized oxygen as a drug, stated, “We have now demonstrated that rats can be treated for chronic traumatic brain injuries just like we’ve treated humans for their brain injuries for the past 21 years.”  This treatment originally developed to treat injured divers, carbon monoxide poisoned patients, and wound patients has now been used by hundreds of doctors around the world to treat thousands of patients with different types of chronic brain injury.  In 2002 and 2004, Dr. Harch presented some of his case experience to Congress, Walter Reed Brain Injury Center, Bethesda Naval Hospital, and the National Institutes of Health.  Since traumatic brain injury is the signature injury in the Iraq and Afghanistan Wars, the military has indicated as many as 300,000 soldiers may have suffered some traumatic brain injury.  This animal research now verifies and underpins the human experience.

With this study, the American Association for Health Freedom (AAHF), in conjunction with the International Hyperbaric Medical Association, is announcing the Brain Injury Rescue and Rehabilitation Project (BIRR), coordinated across the nation with clinics willing to treat our brain injured service members with hyperbaric oxygen. 

A recent study released by the military states between 154,000 and 392,000 service members and veterans returning from Iraq have suffered at least mild brain injury, and 30% of service members treated at Walter Reed have mild, moderate, or severe traumatic brain injury.  Brenna Hill, Executive Director of AAHF stated, “To date U.S. military medicine has not implemented hyperbaric oxygen as standard of care, though some high ranking officers have been able to receive treatment.  This latest study should show that it is time that hyperbaric oxygen was available for all who have sacrificed for our country.” Together, AAHF and IHMA is requesting $10 million from Congress to coordinate and conduct treatment for 400 veterans. This is a sufficient group for this randomized and controlled trial to verify or refute the findings of the civilian physicians who have treated many patients and have expertise in this treatment. 

Consciousness in the Raw
The brain stem may orchestrate the basics of awareness

Recommended Reading: What You Should Know in Emergency Situations (pdf)
Scientific American Brain Issue (pdf 2.2 megs)

Recommended Reading: "The Brain That Changes Itself"  by Norman Doidge, MD.

The Brain That Changes Itself  by Norman Doidge, MD

(inside cover)

THE BRAIN CAN CHANGE ITSELF.  It is a plastic, living organ that can actually change its own structure and function, even into old age.  Arguably the most important breakthrough in neuroscience since scientists fist sketched out the brain’s basic anatomy, this revolutionary discovery, called neuroplasticity, promises to overthrow the centuries-old notion that the adult brain is a fixed and unchanging.  The brain is not, as was thought, like a machine or “hardwired” like a computer.  Neuroplasticity not only gives hope to those with mental limitations, or what was thought to be incurable brain damage, but expands our understanding of the healthy brain and the resilience of human nature.  Norman Doidge, MD, a psychiatrist and researcher, set out to investigate neuroplasticity and met both the brilliant scientists championing it and the people whose lives they’ve transformed.

The result is this book, a riveting collection of case histories detailing the astonishing progress of people whose conditions had long been dismissed as hopeless.  We see a woman born with half a brain that rewired itself to work as a whole, a woman labeled retarded who cured her deficits with brain exercises and now cures those of others, blind people learning to see, learning disorders cured, IQ’s raised, aging brains rejuvenated, painful phantom limbs erased, stroke patients recovering their faculties, children with cerebral palsy learning to move more gracefully, entrenched depression and anxiety disappearing, and lifelong character traits altered.

Doige takes us onto terrain that might seem fantastic.  We learn that our thoughts can switch our genes on and off, altering our brain anatomy.  Scientists have developed machines that can follow these physical changes in order to read people’s thoughts, allowing the paralyzed to control  computers and electronics just by thinking.

We learn  how people of average intelligence can, with brain exercises, improve their cognition and perception in order to become savant calculators, develop muscle strength, or learn to play a musical instrument, simply by imagining doing so.

Using personal stories form the heart of this neuroplasticity revolution, Dr. Doidge explores the profound implications of the changing brain for understanding the mysteries of love, sexual attraction, taste, culture, and education in an immensely moving, inspiring book that will permanently alter the way we look at human possibility and human nature.

Norman Doidge, MD, is a psychiatrist, psychoanalyst, and researcher on the faculty at the Columbia University Center for Psychoanalytic Training and Research in New York and the University of Toronto’s department of psychiatry, as well as an author, essayist, and poet.  He is a four-time recipient of Canada’s National Magazine Gold Award.  He divides his time between Toronto and New York.

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Neuro-Optometry Rehabilitation
The cerebellum contains more then 50 percent of the brains neurons!  The brain consumes 20 percent of the body’s oxygen.  Blood rushes to the cerebellum when a person prepares to perform a task.  Oxygen molecules pass from the blood, reaching the neurons with the help of glial cells that out number neurons 10 to 1.

The cerebellum of course, has a regulatory effect on eye movement.  The eyes have two types of functions, A. Image delivery from central visional function, and B. Peripheral or ambient vision.  The Lateral Geniculate Body connects the optic nerve with the occipital cortex, but it also relays visual information to parts of the brain other then the visual cortex.

The Lateral Geniculate Body feeds information into the Superior Brachium to the Superior Colliculus, which influences sensory motor pathways through the Spinotectal Tract.  It is the peripheral or ambient visual process that links up with the sensory motor pathway at the level of the Mid Brain.The matching information that occurs between the ambient visual process, kinesthetic, proprioceptive, vestibular and tactile systems sets up a special framework that becomes the basis of higher sensory interpretation. A limitation to the visual process will alter the effects on the motor systems and vice versa. An infant is more dependent on ambient vision and as motor development becomes organized the focal process of vision develops in an attempt to refine motor function.

So it is very important that patients who have motor impairments seek out specialists in Neuro-Optometry Rehabilitation. Ambient vision, not focusing, is the critical issue related to disorders of posture, balance and movement.

For more information and where to find a specialist in your area can be had by contacting: 
Neuro-Optometrist Rehabilitation Association (NORA)
C/O: Carolyn Carmen Merrifield, OD
5616 S.W. Green
Oaks Bluff, Arlington, TX 76017.

Vestibular System
“As we move and interact with gravity sensory receptors in the ear are activated, and impulses appraising the central nervous system about the positioning of the head in space are directed to various parts of the brain and down the spinal cord. It is believed that sensory impulses from the eyes, ears, muscles and joints must be matched to the vestibular input before such information can be reprocessed efficiently. If this is true, what we see, hear and feel makes sense only if the vestibular system is functioning adequately.” Pyter, J. Johnson, R. 1981

The vestibular system is the first sensory system to develop. It is visible at two months gestation and fully formed by the fifth month of gestation. It is one system that feeds input to the reticular activating part of the central nervous system, responsible for awareness it is sometimes referred to as the “wake up the brain system” allowing us to focus our attention. Electric stimulation of the Median Nerve also is used to wake up coma patients by stimulating the reticular system.

Aphasia

Very few people know that there are visual and vestibular projections to tongue motor neurons.

A study accepted in 1993 and published in Brain Research bulletin Vol. 33 pp. 7-16, 1994 was about conveyance of visual input on the hypoglossal nerve modulated by the Vestibular System demonstrating visual input played a part in control of tongue posture in rabbits.

We have noticed improved speech in patients who were involved in our vestibular stimulation program for improving static and dynamic balance problems.

The first sensory system to fully develop is the vestibular system at 5 months after conception. The primary structures of the vestibular system are located in the inner ear. There are three semicircular canals in each ear that are filled with fluid and hair cells. When the head moves the fluid moves which stimulates the hair cells. This information is then sent to the eyes for adjustments so vision is not blurred. It is sent to the muscles for maintaining balance. It is also sent to the reticular activating system in the brain stem to increase alertness.

To treat deficits in the vestibular system you must stimulate it by movement of the head in space. Spinning is a very effective way of stimulating the vestibular system. Spinning should be done 1-2 times everyday. You begin with 5 spins in each direction. When you stop spinning the eyes will move side to side very quickly. This is called nystagmus. You must wait for the nystagmus to stop before spinning in the other direction. If there is a significant increase in nystagmus or an excessively long recovery period, or if the person breaks out in a cold sweat, becomes nauseous, or has a marked increase in heart rate, decrease the number of spins and progress at a slower rate. Continue to spin daily until nystagmus is no longer noted.

Vestibular stimulation, when combined with balance and gait activities, as instructed by your therapist, should help you see progress in coordination, alertness and agility.

Eight Safety Tips When Lifting Heavy Objects
1) Stand close to the load and center yourself over it with your feet shoulder width apart
2) Tighten your abdominal muscles
3) Keeping your back straight, bend your knees and squat down to the floor
4) Get a good grasp on the load with both hands
5) Keeping the load close to your body use your leg muscles to stand up lifting the load off the floor
6) Your back should remain straight throughout lifting, using only the muscles in the legs to lift the load
7) Do not twist your body when moving the load. Instead take small steps with your feet turning until your are in the correct position
8) Again bend at the knees using only your leg muscles and place the load in the appropriate spot

ELECTRICAL STIMULATION
Author: Carrie Sussman, PT
 
Note: This paper on electrical stimulation for wound healing has been excerpted from: Chapter 16, Sussman, C and Byl, N, Electrical Stimulation for Wound Healing, Wound Care Collaborative Practice Manual for Physical Therapists and Nurses, Sussman, C. And Bates-Jensen, BM, Aspen Publishers 1998.
DEFINITIONS:
Electrical stimulation is defined as the use of an electrical current to transfer energy to a wound. The type of electricity that is transferred is controlled by the electrical source. ( AHCPR 94). Capacitatively coupled electrical stimulation involves the transfer of electric current through an applied surface electrode pad that is in wet (electrolytic) contact ( capacitatively coupled) with the external skin surface and /or wound bed. When capacitatively coupled electrical stimulation is used, two electrodes are required to complete the electric circuit. Electrodes are usually placed over wet conductive medium, in the wound bed and on the skin a distance away from the wound.
When discussing electrical stimulation, it is important to distinguish the waveform used for the protocol. Although there are many waveforms available on electrotherapy equipment, the one that has the most thorough and consistent evaluation in vitro, in animal studies and in controlled clinical trials is monophasic twin peaked high voltage pulsed current ( HVPC).The pulse width varies with a range from 20-200 microseconds. The HVPC devices also allow for selection of polarity and variation in pulse rates both of which seem to be important in wound healing. It is a very safe current because it's very short pulse duration prevents significant changes in both tissue pH and temperature. Therefore, the most tested and safe type of stimulation is the one recommended.
Other types of waveforms and have been tested in clinical trials but will not be discussed here due to limited space. They are discussed in the full chapter.
THEORY AND SCIENCE OF THE THERAPY
Acceptance of electrical stimulation for wound healing by the medical community has been a long and complex task. In 1994, the Agency for Health Care Policy and Research (AHCPR) panel issued Treatment of Pressure Ulcers, Clinical Practice Guideline, Number 15. The panel of pressure ulcer care experts used an explicit science-based methodology and expert clinical judgment to develop statements regarding pressure ulcer treatment. Extensive literature searches, critical review and synthesis were used followed by peer and field review to evaluate the validity, reliability and utility of the guideline in clinical practice. AHCPR panel issued a statement about use of electrical stimulation as an adjunctive therapy for pressure ulcers: " Consider a course of treatment with electrotherapy for Stage III and IV pressure ulcers that have proved unresponsive to conventional therapy. Electrical stimulation may also be useful for recalcitrant Stage II ulcers. Strength of Evidence = B." The panel found that data from 5 clinical trials involving 147 patients to support the effectiveness of this therapy for pressure ulcers.
(Note: The complete chapter contains a review of some of the significant areas and observations of research used to develop protocols and support treatment of non-conforming wound healing with electrical stimulation. This an excerpt of that section.)
Bioelectric System
The body has its own bioelectric system. This system influences wound healing by attracting the cells of repair, changing cell membrane permeability ,enhancing cellular secretion through cell membranes and orientating cell structures. A current termed the "current of injury" is generated between the skin and inner tissues when there is a break in the skin. The current will continue until the skin defect is repaired. Healing of the injured tissue is arrested or will be incomplete if these currents no longer flow while the wound is open. A moist wound environment is required for the bioelectric system to function. A rationale for applying electrical stimulation is that it mimics the natural current of injury and will jump start or accelerate the wound healing process.

Research Wisdom:
Keeping a wound moist with normal ( 0.9% ) saline ( sodium chloride ) maintains the optimal bioelectric charge because it is like the electrolytic concentration of wound fluid. Dressings such as amorphous hydrogels and occlusive dressings help promote the body's "current of injury" by keeping the wound moist.
Research Wisdom: Moist wounds promote the "current of injury "

Debridement and Thrombosis
Debridement is helped if the tissue is solubilized such as with enzymatic debriding agents. ES using negative current has been shown to solubilize clotted blood. Necrotic tissue is made up of coalesced blood elements. The negative pole has been used to begin treatment in all controlled clinical studies and most of the wounds have necrotic tissue. This research would lend support to that part of protocol. The positive electrode has been found to induce clumping of leukocytes and forming of thrombosis in the small vassals this was reversed with the negative electrode. (Gentzkow 91) This may explain a clinical observation that hematoma or hemorrhaging at the wound margin or on granulation tissue are dissolved and reabsorbed following application of HVPC with the negative pole. Hemorrhagic material goes on to necrosis if not dissolved and reabsorbed quickly.
Clinical Wisdom:
Clinical experience has repeatedly shown that treatment with the inflammation protocol, using negative polarity, promotes rapid absorption of hemorrhagic material, usually within 48 hours. (Sussman)
Clinical Wisdom: Absorption of Hemorrhagic Material

Clinical Wound Healing Studies
Early studies using direct current stimulation reported long treatment times of 20-40 hours per weeks. Four controlled clinical studies and three uncontrolled studies with HVPC report a mean healing time of 9.5 weeks with 45-60 minute treatment 5-7x/wk.
Summary of Scientific Rationale for Application
Electrical stimulation affects the biological phases of wound healing in the following ways:
Inflammation phase
• Initiates the wound repair process by its effect on the current of injury
• Increases blood flow
• Promotes phagocytosis
• Enhances tissue oxygenation
• Reduces edema perhaps from reduced microvascular leakage
• Attracts and stimulates fibroblasts and epithelial cells
• Stimulates DNA synthesis
• Controls infection ( Note: HVPC proven bacteriocidal at higher intensities than use in clinic and may not be tolerated by patient)
• Solubilizes blood products including necrotic tissue
Proliferation phase
• Stimulates fibroblasts and epithelial cells
• Stimulates DNA and protein synthesis
• Increases ATP generation
• Improves membrane transport
• Produces better collagen matrix organization,
• Stimulates wound contraction
Epithelialization phase
• Stimulates epidermal cell reproduction and migration
• Produces a smoother, thinner scar

INDICATIONS FOR THE THERAPY
Use and application of the modality is not pathology dependent.
Types of wounds for which there is indication to use HVPC include:
• Pressure Ulcers Stage I through IV
• Diabetic ulcers due to pressure, insensitivity and dysvascularity
• Venous Ulcers
• Traumatic Wounds
• Surgical Wounds
• Ischemic Ulcers
• Vasculitic Ulcers
• Donor Sites
• Wound Flaps
• Burn wounds

PROCEDURE
The protocols change as the wound healing phase changes. Assessment and diagnosis of the wound healing phase determines the treatment protocol. The set up and protocols used by Sussman are the same regardless of wound pathogenesis.

Research Wisdom:
Research compared direct application of HVPC to the wound, using the whirlpool to conduct the current and whirlpool alone. Application of HVPC directly to the wound had best outcomes. Safety is also a concern because electrical leads can become tangled in the turbine of the whirlpool and HVPC stimulators have been known to fall into the water.
Research Wisdom - Best method for effective and safe HVPC treatment

Protocol for treatment:
Wound Healing Phase Diagnosis: Inflammation phase
Expected outcomes:
• Wound progresses to the Proliferation phase
Change in Wound Healing Phase Diagnosis: Proliferation phase
Stimulator settings:
• Polarity - negative
• Pulse rate - 100 - 128 pps
• Intensity - 100-150 volts
• Duration - 60 minutes
• Frequency 5-7 x per week, once daily
Wound Healing Phase Diagnosis: Proliferation phase
Expected Outcomes:
• Wound progresses to Contraction and Epithelization phase.

Change in Wound Healing Phase Diagnosis: Epithelialization phase
Stimulator settings:
• Polarity - alternate every three days ie 3 days negative followed by 3 days positive
• Pulse rate - 64 PPS
• Intensity - 100-150 volts
• Duration - 60 minutes
• Frequency 5-7 x per week, once daily
Wound Healing Phase Diagnosis: Epithelialization phase
Expected Outcomes:
• Wound progresses to Remodeling phase

Change in Wound Healing Phase Diagnosis: Remodeling
Research Wisdom:
A saline based amorphous hydrogel, which has the ability to conduct electric current has been tested and the conductivity is comparable to saline. Whether the healing of the wound is improved when this product is used for conducting current and then left in the wound has not been tested. In the meantime, such a product may have the added advantage of being used as the wound dressing to keep the wound moist after the electrical stimulation treatment is completed.
Research Wisdom: Use of Amorphous Hydrogel for Conduction

Setting Up the Patient
1. Have supplies ready before undressing the wound.
2. Position patient for ease of access by staff and comfort of both.
3. Remove the dressing and place in an infectious waste bag.
4. Cleanse wound thoroughly to remove slough, exudate and any petrolatum products
5. Sharp debride necrotic tissue, if required, before HVPC treatment
6. Open gauze pads and fluff, then soak in normal saline solution, squeeze out excess liquid. An alternative is to use an amorphous hydrogel impregnated gauze. Hydrogel sheets can also be used to conduct current under the electrodes
7. Fill the wound cavity with gauze including any undermined/tunneled spaces. Pack gently.
8. Place an electrode over the gauze packing cover with dry gauze pad and hold in place with bandage tape.
9. Connect an alligator clip to the foil.
10. Connect to stimulator lead
11. Dispersive electrode placement:
• Usually placed proximal to the wound
• Place over soft tissues, avoid bony prominences
• Place a washcloth, wetted with water and wrung out, under the dispersive electrode
• Place against skin and hold in good contact at all edges with a nylon elasticized strap.
• If placed on the back, the weight of the body plus the strap can be used to achieve good contact at the edges
• Dispersive pad should be larger than the sum of the areas of the active electrodes and wound packing.
• The greater the separation between the active and dispersive electrode the deeper the current path. Use for deep and undermined wounds
• Dispersive and active electrodes can be close together but should not touch. Current flow will be shallow> Use for shallow, partial thickness wounds
Clinical wisdom:
All petrolatum products including enzymatic debriding agents such as collagenase, Santyl , and fibrinolysin, Elase , which are petrolatum-based products, must be removed before treatment or current will not be conducted into the wound tissues.
Clinical Wisdom: Remove Petrolatum Before Stimulation

Aftercare
After the electrical stimulation treatment is complete, slip the electrode out from between the wet and dry gauze. The wound can be left undisturbed. If saline soaked gauze is the conductive medium, it should be changed before it dries or be covered with an occlusive dressing. If hydrogel impregnated gauze is the conductor, change BID. If additional topical treatments are required such as enzymatic debriding agents or antibiotics, then the packing will need to be removed, topical agent applied and redressed.
Research wisdom:
Frequent dressing changes are being discouraged because it disturbs the wound healing environment by removing important substances in wound exudate and cooling the wound. It takes three hours for a chilled wound to re-warm and slows leukocytic and mitotic activity
Research Wisdom: Avoid Wound Chilling

PRECAUTIONS
Signs of adverse effects were evaluated in the various clinical trials and none were found except some skin irritation or tingling under the electrodes in a few cases. Patients with severe peripheral vascular occlusive disease (PVD), may experience some increased pain, usually described as throbbing, in the leg after electrical stimulation.
Research Wisdom:
An alternative protocol with reported healing, by Kaada, calls for placing the active electrode on the web space of the hand between thumb and first finger instead of over the ulcer. This may be more comfortable for the patient with PVD.
Research Wisdom:
An Alternative protocol with reported healing of lower extremity ulcers , by Kaada, calls for placing the active electrode on the web space between the thumb and first finger instead of over or around the ulcer. This may be more comfortable for the patient with PVD.
Research Wisdom: Kaada Protocol for Wound Healing

CONTRAINDICATIONS
Contraindications for treatment with electrical stimulation include:
1. Placement of electrodes tangential to the heart
2. Presence of a cardiac pacemaker
3. Placement of electrodes along regions of the phrenic nerve
4. Presence of malignancy
5. Placement of electrodes over the carotid sinus
6. Placement of electrodes over the laryngeal musculature
7. Placement of electrodes over topical substances containing metal ions
8. E.I. povidone iodine and mercurochrome, unless thoroughly cleaned.
9. Placement of electrodes over osteomyelitis
Note: This paper on electrical stimulation for wound healing has been excerpted from: Chapter 16, Sussman, C and Byl, N, Electrical Stimulation for Wound Healing, Wound Care Collaborative Practice Manual for Physical Therapists and Nurses, Sussman, C. And Bates-Jensen, BM, Aspen Publishers 1998.

Medicare Reimbursement:
Medicare has been enjoined by the court to pay for electrical stimulation for wound healing if the treatment is medically necessary and appropriate and if it is effective.  Individual Medicare carriers and contractors have the option to cover this service based on policies for reimbursement prior to July 14, 1997.  Contact the American Physical Therapy Association, Government Affairs office at 1-800-999-APTA for more details about this coverage policy.

Reference sources:
The Role of Physical Therapy in Wound Care, C. Sussman, B.S. PT Chronic Wound Care: A Source book for Health Care Professionals , Krasner, Diane,RN, MS, CETN 1990 Health Management Publications
Wound Healing: Alternatives in Management, Kloth, McCulloch. , Feedar 2nd Ed. 1994
F.A. Davis. Clinical Wound Management, Gogia, P 1995 SLACK Inc.
AHCPR TREATMENT GUIDELINE FOR PRESSURE ULCERS U.S. Government Printing Office 1994 - Copyright 1995 - 2006