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How Technology is Assisting and Aiding Patients with Traumatic Brain Injuries (TBI)

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futurehealth.org Headlined to H3 10/10/14

 
Abstract:
To understand how the brain works and functions is no easy task.  It is by far the most complex part of the human body.  The human brain is responsible for body movement, balance, our senses, hearing and seeing; behavior, intelligence, it is more than just the center of human nervous system.  Each half, or hemisphere of our brains are mirrors of each other and control different and unique functions. Yet, the left half of our brain controls our right side and vice versa.  The left hemisphere is responsible for math and logic and the right hemisphere is responsible for memory, reasoning, problem solving, attention and social communication.  Our brains are also responsible for our cognition: how we think, learn and know. 

Blast injuries from Improvised Explosive Devices (IEDS) and other forms of blasts and explosions have caused closed head injuries and trauma to over 178,000 service men and women serving in our wars in Iraq and Afghanistan.  These injuries are called Traumatic Brain Injuries (TBI) and they range from Mild TBI (mTBI) to moderate and severe TBI.  A TBI is a "form of acquired brain injury, occurs when a sudden trauma causes damage to the brain. TBI can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue."  The future of treatments and aids to patients suffering from TBI, and to include a possible cure for TBI lay in assistive and interactive technology.  The types of technology that are currently being employed range from video games that aid and assist not only the cognitive development, but their motor-skills improvement.  Researchers are working on the next generation of Brain Machine Interface and Brain Computer Interface technology that can manipulate the same side of the brain to control the same side of the body.  These are only a few of the technology that will be discussed in this article.

Introduction: The Brain
To understand how the brain works and functions is no easy task.  It is by far the most complex part of the human body.  The human brain is responsible for body movement, balance, our senses of: smell, taste, touch, hearing and seeing; behavior, intelligence, it is more than just the center of human nervous system.  The brain is all of those things and more.  It has been studied by scientist for centuries, and yet there is still so much more to learn and understand.  Your brain controls speech, language, words, math, logic, memory, reasoning, problem-solving, attention, social communication, breathing, motor-skills, sleeping, reproductive skills, along with respiration, digestion and your heart rate.  As you can see, the brain is responsible for virtually every single thing about your body that happens either consciously or unconsciously.  Without our brains, we could not stand, walk, talk, breathe, eat, sleep or think. 
The brain can be divided into two hemispheres; the left hemisphere and the right hemisphere.  Each half, or hemisphere of the brain is responsible for different functions.  According to the National Institutes of Neurological Disorders and Strokes (NINDS) of the National Institutes of Health (NIH) "the two cerebral hemispheres communicate with each other through a thick tract of nerve fibers that lies at the base of this fissure.  Although the two hemispheres seem to be mirror images of each other, they are different."  Now, you may be thinking that the left half of the brain controls the left side of your body.  It is in fact, the opposite.  The left hemisphere of the brain is responsible for the right side of the body, and vice versa.  The left hemisphere of the brain is primarily responsible for speech, language and words.  The left hemisphere tends to primarily be analytical in that it analyzes information that the right side collects. The left side of the brain is also primarily responsible for math and logic.  The right half of the brain, according to the American Speech-Language-Hearing Association (ASLHA) controls the left half of the body and is responsible for memory, reasoning, problem solving, attention and social communication.  The right hemisphere is visual in nature, meaning it sees or visualizes information and puts it together.  If the right hemisphere of the brain sees a car, the left hemisphere sees a Silver Chevrolet Malibu.
Cognition:
So aside from the brain controlling our movements, breathing, sleeping, and eating, it also controls how we think, learn and speak.  Thinking and learning are part of cognition.  Cognition means "to know".  To think, learn and know involves our brain.  To pick up a book involves the frontal lobe of the brain which controls motor skills.  To read the words on the page of a book involves the occipital lobe of the brain that controls vision.  According to Gregory Kellett, a cognitive neuroscience researcher with SFSU and UCSF, he states "cognition encompasses everything from knowing/remembering what pizza is (and that you like it)" to realizing that you are hungry and making plans to have it delivered."  Kellett goes on to assert that "knowledge can be thought of as memories formed from the manipulation and assimilation of raw input" and that "using knowledge to direct and adapt action towards goals is the foundation of the cognitive process."  It's not just important to know or realize that our brains are responsible for seeing things or understanding the words on the page of a book, but to correlate what we have read and tie those into our past memories or visual images within our minds.
Our Memory:  Short term and long term
    Now that we have discussed the brain and how it works, and the thinking, learning, and knowing aspect of cognition, it's essential to discuss our memory; more specifically, our short-term and long-term memory.  The hippocampus is primarily responsible for your memory.  The NINDS relates the hippocampus of your inner brain as a "memory indexer -- sending memories out to the appropriate part of the cerebral hemisphere for long-term storage and retrieving them when necessary." Your short-term memory, is just that, short-term.  It lasts just long enough for you to complete a task.  Your short-term memory lasts between a few seconds to a few minutes.  Your long-term-memory lasts longer and is able to recall information stored days, weeks, months or even decades ago.  It is viewed as relatively permanent storage.  You can choose to remember 867-5309 by repeating the phone number over and over again to move it from short-term memory into long-term memory, or you can possibly forget the telephone number after you dial it.  That is difference between short-term and long-term memory and how your memory, or the lack of it works.
Blast Injuries:
    Now, imagine that you are Soldier serving in Afghanistan or Iraq.  You are serving as a gunner in a four truck convoy.  You are in the last truck, standing up, through the gun-turret of the truck when an Improvised Explosive Device (IED) detonates right in front of your vehicle.  The first thing that hits you from the explosion is the blast, or shock wave.  The blast from the explosion affects your brain due to the overpressure that is created when the IED detonates.  To put this in perspective, at 2 pounds per square inch (psi), overpressure can create wind speeds of up to 70 miles per hour (mph) and cause minor damage to houses, such as windows and doors blown out and roof damage.  People would be damaged by flying debris.  A 5 psi overpressure creates wind speeds of up to 163 mph and can cause buildings to collapse and eardrums to burst.  Injuries and fatalities to Soldiers would be universal and widespread (Zipf, Cashdollar).  According to studies conducted by Skydex Technologies, the measured blast overpressure from a twenty seven pound (lb) trinitrotoluene (TNT) ground explosion, 21 feet away, for a Soldier wearing a helmet was 22 psi.  The threshold for lung damage begins to occur at 15 psi (Zipf, Cashdollar).  The blast overpressure is just the first wave that occurs after an IED detonates.  The next wave or secondary wave brings debris and projectiles flying through the air that can also strike the Soldier.  The third, or tertiary, force of the blast is strong enough to throw the Soldier out of the vehicle and possibly slam them into a wall, the ground or to the side of the vehicle they are riding in.   These types of injuries are sometimes called blast injuries, or barotraumas (Mashima, 2010).
TBI: What is it?
    The blast overpressure alone is enough to cause a Traumatic Brain Injury (TBI).  If the blast overpressure did not, being struck in the head by debris or a flying projectile most certainly would cause a serious brain injury.  A TBI is a "form of acquired brain injury, occurs when a sudden trauma causes damage to the brain. TBI can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue" (NINDS, NIH).   The Army's Deployment Health Clinical Center (DHCC) further defines TBI as "or a penetrating head injury that disrupts the function of the brain."  According to statistics compiled by the Department of Defense, over 178,000 service men and women who have deployed to Iraq or Afghanistan have suffered a Traumatic Brain Injury.  That is a rather striking number when you compare the amount of soldiers who were in Iraq during the surge was approximately 150,000 to 155,000. The Army has labeled Traumatic Brain Injuries as the "signature wound" of the War on Terror.  TBI has been known to affect a wide variety and range of functions that can affect an individuals' thinking, movement or motor-skills, speech, and emotions. Traumatic Brain Injuries can range from mild to severe. 

Mild TBI:
    Mild Traumatic Brain Injuries (mTBI) and its symptoms can be characterized by fatigue, dizziness, headaches, sleeplessness, irritability and inattention.  Some other symptoms that are associated with mTBI are nausea, sensitivity to light and/or sounds, changes in mood or behavior, and loss of smell (traumaticbraininjury.com).  While some of these symptoms may seem benign for Soldiers serving in combat, these symptoms should be taken seriously.  On the surface, Soldiers suffering from these symptoms could be over-looked or misdiagnosed.  mTBI can be very deceptive because the Soldier may show no signs of an outward injury.  It is essential that Soldiers who have been exposed to anything in combat that could cause a concussion or mTBI should be diagnosed and treated as soon as possible.  If untreated or undiagnosed, over time it may lead to a serious impairment.  
Moderate to Severe TBI:
    Moderate to Severe Traumatic Brain Injuries are usually more detailed and pronounced, and depend on a few factors to further diagnose.  Moderate TBI is defined by a loss of consciousness from 20 minutes to 6 hours.  Severe TBI is defined by a loss of consciousness greater than 6 hours.  Severe TBI can either be categorized as moderate or severe based upon (traumaticbraininjury.com):
"     Severity of initial injury
"     Rate/completeness of physiological recovery
"     Functions affected
"     Meaning of dysfunction to the individual
"     Resources available to aid recovery
"     Areas of function not affected by TBI
Severe TBI can also cause severe cognitive difficulties.  The after affects of moderate to severe TBI can include problems and difficulty with reading, writing, speaking, thinking or keeping thoughts together to name a few.  Just as mTBI symptoms can be difficult to diagnose, moderate to severe TBI symptoms can sometimes be subtle enough to hide serious brain damage.  Patients suffering from severe TBI may have difficulty with their emotions, e.g., irritability, aggression, and depression. The treatment and therapy can be long and arduous and even require chronic, long-term care.
Technology: Aiding and Assisting
    The future of treatments and aids to patients suffering from TBI, and to include a possible cure for TBI lay in assistive and interactive technology.  One such treatment could be in the form of a video game.  Kinetic Muscles, Inc., (KMI), based in Arizona, is working to address the rehabilitation needs of survivors of stroke or other neurological injuries.  It recently was announced that KMI has received a two-year Phase II Small Business Innovation Research grant from the Department of Defense. The grant will fund research into a new treatment for service members returning from active duty with TBI (Steinberg, 2010).  The first phase of the study produced some encouraging results that combine both the neuropsychological therapy and the technology of the digital game.  It appears that the gaming technology assist the TBI patients in their cognitive and motor-skills development.  What is making this an added bonus is the vast majority of Soldiers serving in combat are between 18-24, according to statistics by the Defense and Veterans Brain Injury Center (DVBIC), and are already popular with the 18-34 year olds who own video gaming systems.  The popular Wii Fit is also a great game that can aid and assist not only the patient, but the medical staff that is treating the patient because the Wii Fit creates a baseline and tracks and monitors your progress over time.  Another added feature of this technology is that a few of these game systems have an interactive, communications feature that is available.  This feature could be used to bring patients and families together during the rehabilitation process and to link other patients together.
    A Washington University School of Medicine team of researchers is generating new and exciting information "about a long-held theory about the separate functions and responsibilities of the left brain and the right brain. In the process, the researchers, led by Eric Leuthardt, PhD, and his graduate students Kimberly Wisneski and Nick Anderson, have applied their findings to a new neuroprosthetic strategy to improve the rehabilitation of stroke and trauma victims who have suffered damage to either the right or left half of the brain."  Dr. Leuthardt's team discovered where the left hemisphere of the brain was damaged; the right hemisphere still contained the electrical signals that could be used to initiate right side body movement.  Given this new found knowledge, the team realized the benefits for people who have suffered strokes and/or brain injuries.  Their next focus was the rehabilitation aspect and is what is called the Brain Computer Interface (BCI).  In order for the BCI to work, it would have to be adapted to work with signals from signals from one side of the brain.  This is most certainly a very exciting new breakthrough for a new and up in coming technology for patients suffering from TBI.
    A technology that has been in use for some time in the Pacific, at Tripler Army Medical Center in Hawaii, is Telemedicine.  Telemedicine, or telehealth, has been in use for over 10 years in that part of the world due to the expanse of the Pacific Ocean.  Using Video Teleconference (VTC) technology, Otolaryngology, Audiology, and Speech-Language Pathology (SLP) doctors are able to see and treat patients without having to be physically there.  This technology is now being pushed across the Department of Defense (DOD) and Veterans Affairs (VA) to treat patients suffering from TBI and other cognitive disorders.  The SLP's have used VTC for consultations of individual and group therapy.  The technology and its practice have gained positive results.  "Results support the use of telehealth for the assessment of cognitive-communication functions in adults with TBI who have sufficient cognitive skills to follow telehealth procedures. They concluded that telehealth has particular appeal for management of post-TBI cognitive-communication disorders because communication problems often become more apparent in the chronic stage post-injury after acute rehabilitation has ended, when the individual returns home and attempts to re-enter community life. A comparable study with veterans would have high relevance, as access to speech-language services in their local communities after discharge from acute care or rehabilitation facilities would be a significant advantage" (Mashima, 2010).
    The CampusReader is an exciting project, funded by the National Science Foundation (NSF) that is linking technology with education.  The project is combing the ever-popular iPad and "other emerging computer-based reading platforms to deliver quality supports to improve reading comprehension and retention. The focus is on integrating reading strategies with online textbooks" (CampusReader.org).  The CampusReader project has partnered with the University of Oregon, Tripler Army Medical Center, and the Portland Veterans Affairs Research Foundation.  The five year project is trying to meet the demands of a growing population of active duty service members and veterans who have or are returning from Iraq and Afghanistan who may not be able to meet the reading demands of post-secondary education.  The CampusReader project estimates that 15-20% of veterans suffer from a brain injury that is sufficient enough to impede their academic ability.   The projects aim is to aid students who "have cognitive impairments that impact high level text processing skills and result in diverse reading profiles with difficulties in skills such as discerning between relevant and irrelevant information, drawing inferences, connecting background knowledge to new learning and retaining and applying what was learned at a later date" (CampusReader.org).   Essentially, the goal for the software is to help students with cognitive impairments, sort out the relative information from the irrelevant. The technology behind the CampusReader project encompasses two tracks.  The first track involves the hardware and software that is developed by the CampusReader project itself.  As the technology and software code is changed and updated, the versions of software are made available for download.  This is accomplished through Google's Code site.  The second track is probably the most complex because it deals specifically with personalizing the technology to each individual and their personal needs.  Each person has a unique and different reading strategy.  "In essence, we will explore a means to personalize a reading device to provide strategies that fit a user's reading profile, as well as the changing context of reading for a college-level course" (CampusReader.org).  To learn more about this exciting and beneficial program, or sign up for updates, please visit campusreader.org.
    Another technology that the U.S. Navy is working towards developing is a way to distribute individual doses of medicine, in a timed and monitored environment.  The purpose is to reduce the risk of self-medication by patients.  This is being looked at for patients suffering from TBI as well.  Specifically, the Navy along with the Department of Defense's Telemedicine and Advanced Technology Resource Center is studying robots that dispense medication for returning service members who suffer from either TBI or psychological stress.  The U.S. Air Force Center for Excellence for Medical Media is looking to "education-based" treatment tools for TBI.  The Air Force Center for Excellence in Medical Media is hoping that the technology will improve the quality of life for its patients suffering from TBI.  And the Center of Excellence for Medical Multimedia (CEMM), through the office of the Surgeon General, has created Traumatic Brain Injury: The Journey Home, which is an interactive and comprehensive, web-based program that focuses on patients, family-members, and care-givers with what they call a "one-stop shop" of information.  The information that can be found on their website include information on the causes of TBI, the treatments available, symptoms, diagnosis and coping techniques (Rockey, 2010).
The Future: What's Ahead   
For all that technology is doing to aid, assist and even help treat our service members who currently suffer from Traumatic Brain Injuries, the DOD is working with Universities and private industry to lessen the effects of TBI.  One area that is showing promise is blast shields for helmets.  Paul Radovitzky, an Associate Professor with the Massachusetts Institute of Technology (MIT), is looking into just such a way to mitigate the effects of blast injuries to our Soldiers.  Paul and his research team that are part of the Institute for Soldier Nanotechnology at MIT worked to create computer models to show how the explosions affect the brain.  "The models integrate with unprecedented detail the anatomical features of the head, including the skull, sinuses, cerebrospinal fluid and layers of gray and white matter, as well as the physical characteristics of the blast wave."  In order to create the models, Radovitzky collaborated with Dr. David Moore, a neurologist with the Defense and Veterans Brain Injury Center (DVBIC) at Walter Reed Medical Center.  There, they used Magnetic Resonance Imaging (MRI) to create models of the head.  "The researchers then added data collected from colleagues' studies of how the brain tissue of pigs responds to mechanical events, such as shocks. They also included details about the explosion that creates the blast wave upon detonation, including the explosive type, mass and location relative to the target."  
The test focused on comparing how the brain would respond to the same blast wave over three scenarios: a head with no helmet, a head with helmet, and a head with helmet and face shield.  The helmet used for the test was the Army's Advanced Combat Helmet (ACH) that is currently worn by Soldiers throughout the Army.  In all three scenarios, the blast wave struck the head from the front.  Radovitzky's team learned that wearing the ACH alone did not lessen the effects of the blast; however, it did not make the effects worse. "As currently designed and deployed -- slightly delayed the arrival of the blast wave, it didn't significantly mitigate the wave's effects on brain tissue."  There is some good news though: When employing the face shield "the models showed a significant reduction in the magnitude of stresses on the brain when a face shield was employed, because the shield impeded direct transmission of blast waves to the face."  That is certainly some very good news for the researchers and for Soldiers.  And lastly, according to a recent story in the USA Today, by Gregg Zoroya, a study released by the Army and researchers with the Lawrence Livermore National Laboratory in California, found that if Soldiers went up one size larger in the ACH, "an eighth of an inch more in cushion could decrease the force of an impact to the skull by 24%." 
This next technology may not deter the effects of the blast, but it will most certainly tell you and your doctor if you have suffered a brain injury.  BAE Systems has been awarded a contract by the US Army for the Headborne Energy Analysis & Diagnostic System (HEADS), HEADS Generation II helmet sensors.  These sensors when placed inside the helmet will provide a visual display that will be used to determine whether a Soldier has sustained a combat related brain injury.  The Generation II HEADS sensor is equipped with a programmable color LED that will activate in the event of a blast.  This illuminating LED can immediately alert medical personnel to check out the possibly injured Soldier. "The HEADS package is extremely sensitive and is automatically activated when it senses an event."  The sensor will then record the event, and store the data so that it can be retrieved and downloaded using either a USB or wireless connection.  "The HEADS sensor provides medical professionals with a detailed analysis of an impact by recording accelerations and atmospheric pressures associated with a significant event such as an improvised explosive device explosion."  Eventually, the data collected can hopefully one day lead to better enhancements to protect Soldiers. 
Conclusion:  Wrapping it Up
    There is no doubt that serving during war is a dangerous proposition.  It has only been within the last 10 years and during the wars in Iraq and Afghanistan that the medical community and the U.S. military have really learned and studied the effects of brain injuries.  Of the technologies mentioned above are not all that there is in use; there are other technologies; such as, laptops, pda's, cell phones, pagers, etc.  Alone, or together, it is not enough.  More testing and more research needs to be conducted to not only try and prevent or mitigate the injuries, but to better detect and cure/rehabilitate those individuals.   The National Institutes of Health (NIH) has ongoing clinical trials for a variety of studies for patients suffering from Traumatic Brain Injuries.  These studies include Evaluation of Outcome Measures for Patients Diagnosed with TBI, Cognitive Assistive Technology and Service Delivery for Service Members with TBI at WRAMC and Moving a Paralyzed hand through a brain computer interface controlled by the affected hemisphere after stroke or TBI.  There seems to be no stopping or slowing down in the research and treatment areas to assist those suffering from this debilitating injury.  Those who suffer from TBI have families and lives of their own; they all deserve to be able to live their lives to the fullest and follower their dreams.  It is my sincerest hope that the resources that were used to equip, train and send these great warriors to battle, we could take a significant portion of that to be used to help mitigate, diagnose, treat and possibly Traumatic Brain Injuries in patients everywhere. 

Bibliography:
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Fischer, H. U.S. Congressional Research Service.  U.S. Military Casualty Statistics: Operation
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Mashima, P. A. (2010, November 02). Using Telehealth to Treat Combat-Related Traumatic Brain Injury. The ASHA Leader. Retrieved April 3, 2011, from click here
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SKYDEX Technologies: Helping You Protect Soldiers. (n.d.).  Retrieved April 2, 2011, from   click here

Bibliography:  Continued

Steinberg, Scott. (2010). Game on. On Patrol, Retrieved on April 12, 2011 from http://usoonpatrol.org/archives/2010/10/01/game-on
Traumatic Brain Injury." Welcome to PDHealth.mil. N.p., n.d. Web. 1 Apr. 2011. http://www.pdhealth.mil/TBI.asp
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Chuck Corbitt, Student The University of Alabama College of Human Environmental Sciences Institute for Interactive Technology Working towards an MS in Interactive Technology

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