American Neuropsychiatric Association (ANPA): Annual Meeting

DENVER – A simple illusion created using a mirror provides a low-cost, low-risk therapy for phantom limb pain in the intensive care unit, a study has shown.

Investigators at Walter Reed Army Medical Center have reported that mirror therapy for phantom limb pain was strikingly effective in a randomized, sham-controlled trial when used on an outpatient basis in rehabilitation therapy for individuals capable of sitting upright in a chair (N. Engl. J. Med. 2007;357:2206-7). But it can work in a bed-bound ICU patient as well, Dr. Nicholas H. Carter reported at the annual meeting of the American Neuropsychiatric Association.

He presented a case report involving a 24-year-old woman with systemic lupus erythematosus who developed severe, drug-refractory phantom limb and stump pain following a series of surgeries that culminated in an above-the-knee amputation of her left leg. Her hospitalization was prolonged because of numerous complications, including pneumonia, bilateral pneumothoraxes, sepsis, and pericardial effusion with tamponade. She had stump pain that improved only modestly, from 10 on a 10-point scale to 8, in response to hydromorphone. The patient also had two to three episodes of excruciating phantom limb pain per day, each lasting 10-15 minutes; numerous medications failed to provide any relief.

With the patient in a semi–Fowler’s position in her ICU bed and her stump and pelvis draped with sheets, a 2-by-3-foot mirror was positioned between her legs in the parasagittal plane so she could see the reflection of her exposed bare right leg.

Immediately prior to the initial session of mirror therapy the patient rated her stump pain as a 9, and 10 minutes earlier she had experienced what she described as a shock of phantom limb pain. After viewing the mirror for just 3 minutes, the patient reported that her stump pain had decreased to 4, with no further phantom limb sensations, according to Dr. Carter of Brown University, Providence, R.I.

The mirror was brought out again every time the patient felt the onset of phantom limb pain. She reported that 3-5 minutes of viewing the mirror typically decreased the phantom limb pain intensity from 7 to 3. Instead of lasting 10-15 minutes, as previously, the episodes now lasted about 5 minutes and decreased in number from two to three per day to one truncated episode per day or none. This was accompanied by complete resolution of the intense phantom itch.

Interestingly, the patient’s stump pain responded only to her first viewing of the mirror, Dr. Carter said. Subsequent sessions or mirror therapy had no substantial benefit for the stump pain.

This case sheds little new light on the mechanism of benefit for mirror therapy, a topic of considerable debate in the medical literature, he noted.

Some researchers have theorized that limb amputation may cause central neurologic remapping and deranged cortical output, which gets interpreted as pain. The theory that proprioceptive memory of the amputated limb accounts for phantom limb pain enjoys wide popularity.

Regardless, it’s axiomatic that when multiple senses provide conflicting input to the brain, vision trumps. Mirror therapy might activate mirror neurons in the brain hemisphere contralateral to the amputated limb and provide visual feedback against painful proprioceptive stimuli, Dr. Carter suggested.

He said he had no relevant financial disclosures.

DENVER – A simple illusion created using a mirror provides a low-cost, low-risk therapy for phantom limb pain in the intensive care unit, a study has shown.

Investigators at Walter Reed Army Medical Center have reported that mirror therapy for phantom limb pain was strikingly effective in a randomized, sham-controlled trial when used on an outpatient basis in rehabilitation therapy for individuals capable of sitting upright in a chair (N. Engl. J. Med. 2007;357:2206-7). But it can work in a bed-bound ICU patient as well, Dr. Nicholas H. Carter reported at the annual meeting of the American Neuropsychiatric Association.

He presented a case report involving a 24-year-old woman with systemic lupus erythematosus who developed severe, drug-refractory phantom limb and stump pain following a series of surgeries that culminated in an above-the-knee amputation of her left leg. Her hospitalization was prolonged because of numerous complications, including pneumonia, bilateral pneumothoraxes, sepsis, and pericardial effusion with tamponade. She had stump pain that improved only modestly, from 10 on a 10-point scale to 8, in response to hydromorphone. The patient also had two to three episodes of excruciating phantom limb pain per day, each lasting 10-15 minutes; numerous medications failed to provide any relief.

With the patient in a semi–Fowler’s position in her ICU bed and her stump and pelvis draped with sheets, a 2-by-3-foot mirror was positioned between her legs in the parasagittal plane so she could see the reflection of her exposed bare right leg.

Immediately prior to the initial session of mirror therapy the patient rated her stump pain as a 9, and 10 minutes earlier she had experienced what she described as a shock of phantom limb pain. After viewing the mirror for just 3 minutes, the patient reported that her stump pain had decreased to 4, with no further phantom limb sensations, according to Dr. Carter of Brown University, Providence, R.I.

The mirror was brought out again every time the patient felt the onset of phantom limb pain. She reported that 3-5 minutes of viewing the mirror typically decreased the phantom limb pain intensity from 7 to 3. Instead of lasting 10-15 minutes, as previously, the episodes now lasted about 5 minutes and decreased in number from two to three per day to one truncated episode per day or none. This was accompanied by complete resolution of the intense phantom itch.

Interestingly, the patient’s stump pain responded only to her first viewing of the mirror, Dr. Carter said. Subsequent sessions or mirror therapy had no substantial benefit for the stump pain.

This case sheds little new light on the mechanism of benefit for mirror therapy, a topic of considerable debate in the medical literature, he noted.

Some researchers have theorized that limb amputation may cause central neurologic remapping and deranged cortical output, which gets interpreted as pain. The theory that proprioceptive memory of the amputated limb accounts for phantom limb pain enjoys wide popularity.

Regardless, it’s axiomatic that when multiple senses provide conflicting input to the brain, vision trumps. Mirror therapy might activate mirror neurons in the brain hemisphere contralateral to the amputated limb and provide visual feedback against painful proprioceptive stimuli, Dr. Carter suggested.

He said he had no relevant financial disclosures.

DENVER – A simple illusion created using a mirror provides a low-cost, low-risk therapy for phantom limb pain in the intensive care unit, a study has shown.

Investigators at Walter Reed Army Medical Center have reported that mirror therapy for phantom limb pain was strikingly effective in a randomized, sham-controlled trial when used on an outpatient basis in rehabilitation therapy for individuals capable of sitting upright in a chair (N. Engl. J. Med. 2007;357:2206-7). But it can work in a bed-bound ICU patient as well, Dr. Nicholas H. Carter reported at the annual meeting of the American Neuropsychiatric Association.

He presented a case report involving a 24-year-old woman with systemic lupus erythematosus who developed severe, drug-refractory phantom limb and stump pain following a series of surgeries that culminated in an above-the-knee amputation of her left leg. Her hospitalization was prolonged because of numerous complications, including pneumonia, bilateral pneumothoraxes, sepsis, and pericardial effusion with tamponade. She had stump pain that improved only modestly, from 10 on a 10-point scale to 8, in response to hydromorphone. The patient also had two to three episodes of excruciating phantom limb pain per day, each lasting 10-15 minutes; numerous medications failed to provide any relief.

With the patient in a semi–Fowler’s position in her ICU bed and her stump and pelvis draped with sheets, a 2-by-3-foot mirror was positioned between her legs in the parasagittal plane so she could see the reflection of her exposed bare right leg.

Immediately prior to the initial session of mirror therapy the patient rated her stump pain as a 9, and 10 minutes earlier she had experienced what she described as a shock of phantom limb pain. After viewing the mirror for just 3 minutes, the patient reported that her stump pain had decreased to 4, with no further phantom limb sensations, according to Dr. Carter of Brown University, Providence, R.I.

The mirror was brought out again every time the patient felt the onset of phantom limb pain. She reported that 3-5 minutes of viewing the mirror typically decreased the phantom limb pain intensity from 7 to 3. Instead of lasting 10-15 minutes, as previously, the episodes now lasted about 5 minutes and decreased in number from two to three per day to one truncated episode per day or none. This was accompanied by complete resolution of the intense phantom itch.

Interestingly, the patient’s stump pain responded only to her first viewing of the mirror, Dr. Carter said. Subsequent sessions or mirror therapy had no substantial benefit for the stump pain.

This case sheds little new light on the mechanism of benefit for mirror therapy, a topic of considerable debate in the medical literature, he noted.

Some researchers have theorized that limb amputation may cause central neurologic remapping and deranged cortical output, which gets interpreted as pain. The theory that proprioceptive memory of the amputated limb accounts for phantom limb pain enjoys wide popularity.

Regardless, it’s axiomatic that when multiple senses provide conflicting input to the brain, vision trumps. Mirror therapy might activate mirror neurons in the brain hemisphere contralateral to the amputated limb and provide visual feedback against painful proprioceptive stimuli, Dr. Carter suggested.

He said he had no relevant financial disclosures.

DENVER – A simple illusion created using a mirror provides a low-cost, low-risk therapy for phantom limb pain in the intensive care unit, a study has shown.

Investigators at Walter Reed Army Medical Center have reported that mirror therapy for phantom limb pain was strikingly effective in a randomized, sham-controlled trial when used on an outpatient basis in rehabilitation therapy for individuals capable of sitting upright in a chair (N. Engl. J. Med. 2007;357:2206-7). But it can work in a bed-bound ICU patient as well, Dr. Nicholas H. Carter reported at the annual meeting of the American Neuropsychiatric Association.

He presented a case report involving a 24-year-old woman with systemic lupus erythematosus who developed severe, drug-refractory phantom limb and stump pain following a series of surgeries that culminated in an above-the-knee amputation of her left leg. Her hospitalization was prolonged because of numerous complications, including pneumonia, bilateral pneumothoraxes, sepsis, and pericardial effusion with tamponade. She had stump pain that improved only modestly, from 10 on a 10-point scale to 8, in response to hydromorphone. The patient also had two to three episodes of excruciating phantom limb pain per day, each lasting 10-15 minutes; numerous medications failed to provide any relief.

With the patient in a semi–Fowler’s position in her ICU bed and her stump and pelvis draped with sheets, a 2-by-3-foot mirror was positioned between her legs in the parasagittal plane so she could see the reflection of her exposed bare right leg.

Immediately prior to the initial session of mirror therapy the patient rated her stump pain as a 9, and 10 minutes earlier she had experienced what she described as a shock of phantom limb pain. After viewing the mirror for just 3 minutes, the patient reported that her stump pain had decreased to 4, with no further phantom limb sensations, according to Dr. Carter of Brown University, Providence, R.I.

The mirror was brought out again every time the patient felt the onset of phantom limb pain. She reported that 3-5 minutes of viewing the mirror typically decreased the phantom limb pain intensity from 7 to 3. Instead of lasting 10-15 minutes, as previously, the episodes now lasted about 5 minutes and decreased in number from two to three per day to one truncated episode per day or none. This was accompanied by complete resolution of the intense phantom itch.

Interestingly, the patient’s stump pain responded only to her first viewing of the mirror, Dr. Carter said. Subsequent sessions or mirror therapy had no substantial benefit for the stump pain.

This case sheds little new light on the mechanism of benefit for mirror therapy, a topic of considerable debate in the medical literature, he noted.

Some researchers have theorized that limb amputation may cause central neurologic remapping and deranged cortical output, which gets interpreted as pain. The theory that proprioceptive memory of the amputated limb accounts for phantom limb pain enjoys wide popularity.

Regardless, it’s axiomatic that when multiple senses provide conflicting input to the brain, vision trumps. Mirror therapy might activate mirror neurons in the brain hemisphere contralateral to the amputated limb and provide visual feedback against painful proprioceptive stimuli, Dr. Carter suggested.

He said he had no relevant financial disclosures.

DENVER – A simple illusion created using a mirror provides a low-cost, low-risk therapy for phantom limb pain in the intensive care unit, a study has shown.

Investigators at Walter Reed Army Medical Center have reported that mirror therapy for phantom limb pain was strikingly effective in a randomized, sham-controlled trial when used on an outpatient basis in rehabilitation therapy for individuals capable of sitting upright in a chair (N. Engl. J. Med. 2007;357:2206-7). But it can work in a bed-bound ICU patient as well, Dr. Nicholas H. Carter reported at the annual meeting of the American Neuropsychiatric Association.

He presented a case report involving a 24-year-old woman with systemic lupus erythematosus who developed severe, drug-refractory phantom limb and stump pain following a series of surgeries that culminated in an above-the-knee amputation of her left leg. Her hospitalization was prolonged because of numerous complications, including pneumonia, bilateral pneumothoraxes, sepsis, and pericardial effusion with tamponade. She had stump pain that improved only modestly, from 10 on a 10-point scale to 8, in response to hydromorphone. The patient also had two to three episodes of excruciating phantom limb pain per day, each lasting 10-15 minutes; numerous medications failed to provide any relief.

With the patient in a semi–Fowler’s position in her ICU bed and her stump and pelvis draped with sheets, a 2-by-3-foot mirror was positioned between her legs in the parasagittal plane so she could see the reflection of her exposed bare right leg.

Immediately prior to the initial session of mirror therapy the patient rated her stump pain as a 9, and 10 minutes earlier she had experienced what she described as a shock of phantom limb pain. After viewing the mirror for just 3 minutes, the patient reported that her stump pain had decreased to 4, with no further phantom limb sensations, according to Dr. Carter of Brown University, Providence, R.I.

The mirror was brought out again every time the patient felt the onset of phantom limb pain. She reported that 3-5 minutes of viewing the mirror typically decreased the phantom limb pain intensity from 7 to 3. Instead of lasting 10-15 minutes, as previously, the episodes now lasted about 5 minutes and decreased in number from two to three per day to one truncated episode per day or none. This was accompanied by complete resolution of the intense phantom itch.

Interestingly, the patient’s stump pain responded only to her first viewing of the mirror, Dr. Carter said. Subsequent sessions or mirror therapy had no substantial benefit for the stump pain.

This case sheds little new light on the mechanism of benefit for mirror therapy, a topic of considerable debate in the medical literature, he noted.

Some researchers have theorized that limb amputation may cause central neurologic remapping and deranged cortical output, which gets interpreted as pain. The theory that proprioceptive memory of the amputated limb accounts for phantom limb pain enjoys wide popularity.

Regardless, it’s axiomatic that when multiple senses provide conflicting input to the brain, vision trumps. Mirror therapy might activate mirror neurons in the brain hemisphere contralateral to the amputated limb and provide visual feedback against painful proprioceptive stimuli, Dr. Carter suggested.

He said he had no relevant financial disclosures.

DENVER – A simple illusion created using a mirror provides a low-cost, low-risk therapy for phantom limb pain in the intensive care unit, a study has shown.

Investigators at Walter Reed Army Medical Center have reported that mirror therapy for phantom limb pain was strikingly effective in a randomized, sham-controlled trial when used on an outpatient basis in rehabilitation therapy for individuals capable of sitting upright in a chair (N. Engl. J. Med. 2007;357:2206-7). But it can work in a bed-bound ICU patient as well, Dr. Nicholas H. Carter reported at the annual meeting of the American Neuropsychiatric Association.

He presented a case report involving a 24-year-old woman with systemic lupus erythematosus who developed severe, drug-refractory phantom limb and stump pain following a series of surgeries that culminated in an above-the-knee amputation of her left leg. Her hospitalization was prolonged because of numerous complications, including pneumonia, bilateral pneumothoraxes, sepsis, and pericardial effusion with tamponade. She had stump pain that improved only modestly, from 10 on a 10-point scale to 8, in response to hydromorphone. The patient also had two to three episodes of excruciating phantom limb pain per day, each lasting 10-15 minutes; numerous medications failed to provide any relief.

With the patient in a semi–Fowler’s position in her ICU bed and her stump and pelvis draped with sheets, a 2-by-3-foot mirror was positioned between her legs in the parasagittal plane so she could see the reflection of her exposed bare right leg.

Immediately prior to the initial session of mirror therapy the patient rated her stump pain as a 9, and 10 minutes earlier she had experienced what she described as a shock of phantom limb pain. After viewing the mirror for just 3 minutes, the patient reported that her stump pain had decreased to 4, with no further phantom limb sensations, according to Dr. Carter of Brown University, Providence, R.I.

The mirror was brought out again every time the patient felt the onset of phantom limb pain. She reported that 3-5 minutes of viewing the mirror typically decreased the phantom limb pain intensity from 7 to 3. Instead of lasting 10-15 minutes, as previously, the episodes now lasted about 5 minutes and decreased in number from two to three per day to one truncated episode per day or none. This was accompanied by complete resolution of the intense phantom itch.

Interestingly, the patient’s stump pain responded only to her first viewing of the mirror, Dr. Carter said. Subsequent sessions or mirror therapy had no substantial benefit for the stump pain.

This case sheds little new light on the mechanism of benefit for mirror therapy, a topic of considerable debate in the medical literature, he noted.

Some researchers have theorized that limb amputation may cause central neurologic remapping and deranged cortical output, which gets interpreted as pain. The theory that proprioceptive memory of the amputated limb accounts for phantom limb pain enjoys wide popularity.

Regardless, it’s axiomatic that when multiple senses provide conflicting input to the brain, vision trumps. Mirror therapy might activate mirror neurons in the brain hemisphere contralateral to the amputated limb and provide visual feedback against painful proprioceptive stimuli, Dr. Carter suggested.

He said he had no relevant financial disclosures.

DENVER – Psychostimulants administered for attention-deficit/hyperactivity disorder quelled comorbid anxiety in the majority of patients in a retrospective study. Moreover, concomitant therapy with an atypical antipsychotic agent did not necessarily protect against an increase in anxiety in the 134-patient study.

The 134 youths, mean age 10.2 years, all met DSM-IV criteria for attention-deficit/hyperactivity disorder (ADHD). They were evaluated in terms of the change over time in anxiety scores on the parent-completed Achenbach Child Behavior Checklist.

Eighty children were on psychostimulant medication only. The other 54 were on a psychostimulant plus an atypical antipsychotic agent, Dr. Drake D. Duane said at the annual meeting of the American Neuropsychiatric Association.

Twenty-four patients were deemed to have clinically significant anxiety, based on a baseline Achenbach anxiety T score greater than 65 prior to going on psychostimulant-only therapy. Upon follow-up after a minimum of 4 months on psychostimulant therapy, 20 of the 24 (83%) had a reduction in their parent-reported anxiety T score to less than 65.

Only 3 patients (5%) with a baseline anxiety score less than 65 had an increase in anxiety score to more than 65 while on psychostimulant-only therapy, according to Dr. Duane of the Institute for Developmental Behavioral Neurology at Arizona State University, Tempe.

Fifteen of the 54 patients placed on a psychostimulant plus an atypical antipsychotic medication had a pretreatment anxiety score above 65; 7 (47%) of them showed an on-treatment drop below the 65-point threshold. Twelve of the 39 patients (31%) with an initial anxiety score less than 65 showed an on-treatment increase in anxiety score to greater than 65.

Dr. Duane declared having no financial conflicts.

DENVER – Psychostimulants administered for attention-deficit/hyperactivity disorder quelled comorbid anxiety in the majority of patients in a retrospective study. Moreover, concomitant therapy with an atypical antipsychotic agent did not necessarily protect against an increase in anxiety in the 134-patient study.

The 134 youths, mean age 10.2 years, all met DSM-IV criteria for attention-deficit/hyperactivity disorder (ADHD). They were evaluated in terms of the change over time in anxiety scores on the parent-completed Achenbach Child Behavior Checklist.

Eighty children were on psychostimulant medication only. The other 54 were on a psychostimulant plus an atypical antipsychotic agent, Dr. Drake D. Duane said at the annual meeting of the American Neuropsychiatric Association.

Twenty-four patients were deemed to have clinically significant anxiety, based on a baseline Achenbach anxiety T score greater than 65 prior to going on psychostimulant-only therapy. Upon follow-up after a minimum of 4 months on psychostimulant therapy, 20 of the 24 (83%) had a reduction in their parent-reported anxiety T score to less than 65.

Only 3 patients (5%) with a baseline anxiety score less than 65 had an increase in anxiety score to more than 65 while on psychostimulant-only therapy, according to Dr. Duane of the Institute for Developmental Behavioral Neurology at Arizona State University, Tempe.

Fifteen of the 54 patients placed on a psychostimulant plus an atypical antipsychotic medication had a pretreatment anxiety score above 65; 7 (47%) of them showed an on-treatment drop below the 65-point threshold. Twelve of the 39 patients (31%) with an initial anxiety score less than 65 showed an on-treatment increase in anxiety score to greater than 65.

Dr. Duane declared having no financial conflicts.

DENVER – Psychostimulants administered for attention-deficit/hyperactivity disorder quelled comorbid anxiety in the majority of patients in a retrospective study. Moreover, concomitant therapy with an atypical antipsychotic agent did not necessarily protect against an increase in anxiety in the 134-patient study.

The 134 youths, mean age 10.2 years, all met DSM-IV criteria for attention-deficit/hyperactivity disorder (ADHD). They were evaluated in terms of the change over time in anxiety scores on the parent-completed Achenbach Child Behavior Checklist.

Eighty children were on psychostimulant medication only. The other 54 were on a psychostimulant plus an atypical antipsychotic agent, Dr. Drake D. Duane said at the annual meeting of the American Neuropsychiatric Association.

Twenty-four patients were deemed to have clinically significant anxiety, based on a baseline Achenbach anxiety T score greater than 65 prior to going on psychostimulant-only therapy. Upon follow-up after a minimum of 4 months on psychostimulant therapy, 20 of the 24 (83%) had a reduction in their parent-reported anxiety T score to less than 65.

Only 3 patients (5%) with a baseline anxiety score less than 65 had an increase in anxiety score to more than 65 while on psychostimulant-only therapy, according to Dr. Duane of the Institute for Developmental Behavioral Neurology at Arizona State University, Tempe.

Fifteen of the 54 patients placed on a psychostimulant plus an atypical antipsychotic medication had a pretreatment anxiety score above 65; 7 (47%) of them showed an on-treatment drop below the 65-point threshold. Twelve of the 39 patients (31%) with an initial anxiety score less than 65 showed an on-treatment increase in anxiety score to greater than 65.

Dr. Duane declared having no financial conflicts.

DENVER – Psychostimulants administered for attention-deficit/hyperactivity disorder quelled comorbid anxiety in the majority of patients in a retrospective study. Moreover, concomitant therapy with an atypical antipsychotic agent did not necessarily protect against an increase in anxiety in the 134-patient study.

The 134 youths, mean age 10.2 years, all met DSM-IV criteria for attention-deficit/hyperactivity disorder (ADHD). They were evaluated in terms of the change over time in anxiety scores on the parent-completed Achenbach Child Behavior Checklist.

Eighty children were on psychostimulant medication only. The other 54 were on a psychostimulant plus an atypical antipsychotic agent, Dr. Drake D. Duane said at the annual meeting of the American Neuropsychiatric Association.

Twenty-four patients were deemed to have clinically significant anxiety, based on a baseline Achenbach anxiety T score greater than 65 prior to going on psychostimulant-only therapy. Upon follow-up after a minimum of 4 months on psychostimulant therapy, 20 of the 24 (83%) had a reduction in their parent-reported anxiety T score to less than 65.

Only 3 patients (5%) with a baseline anxiety score less than 65 had an increase in anxiety score to more than 65 while on psychostimulant-only therapy, according to Dr. Duane of the Institute for Developmental Behavioral Neurology at Arizona State University, Tempe.

Fifteen of the 54 patients placed on a psychostimulant plus an atypical antipsychotic medication had a pretreatment anxiety score above 65; 7 (47%) of them showed an on-treatment drop below the 65-point threshold. Twelve of the 39 patients (31%) with an initial anxiety score less than 65 showed an on-treatment increase in anxiety score to greater than 65.

Dr. Duane declared having no financial conflicts.

DENVER – Psychostimulants administered for attention-deficit/hyperactivity disorder quelled comorbid anxiety in the majority of patients in a retrospective study. Moreover, concomitant therapy with an atypical antipsychotic agent did not necessarily protect against an increase in anxiety in the 134-patient study.

The 134 youths, mean age 10.2 years, all met DSM-IV criteria for attention-deficit/hyperactivity disorder (ADHD). They were evaluated in terms of the change over time in anxiety scores on the parent-completed Achenbach Child Behavior Checklist.

Eighty children were on psychostimulant medication only. The other 54 were on a psychostimulant plus an atypical antipsychotic agent, Dr. Drake D. Duane said at the annual meeting of the American Neuropsychiatric Association.

Twenty-four patients were deemed to have clinically significant anxiety, based on a baseline Achenbach anxiety T score greater than 65 prior to going on psychostimulant-only therapy. Upon follow-up after a minimum of 4 months on psychostimulant therapy, 20 of the 24 (83%) had a reduction in their parent-reported anxiety T score to less than 65.

Only 3 patients (5%) with a baseline anxiety score less than 65 had an increase in anxiety score to more than 65 while on psychostimulant-only therapy, according to Dr. Duane of the Institute for Developmental Behavioral Neurology at Arizona State University, Tempe.

Fifteen of the 54 patients placed on a psychostimulant plus an atypical antipsychotic medication had a pretreatment anxiety score above 65; 7 (47%) of them showed an on-treatment drop below the 65-point threshold. Twelve of the 39 patients (31%) with an initial anxiety score less than 65 showed an on-treatment increase in anxiety score to greater than 65.

Dr. Duane declared having no financial conflicts.

DENVER – Psychostimulants administered for attention-deficit/hyperactivity disorder quelled comorbid anxiety in the majority of patients in a retrospective study. Moreover, concomitant therapy with an atypical antipsychotic agent did not necessarily protect against an increase in anxiety in the 134-patient study.

The 134 youths, mean age 10.2 years, all met DSM-IV criteria for attention-deficit/hyperactivity disorder (ADHD). They were evaluated in terms of the change over time in anxiety scores on the parent-completed Achenbach Child Behavior Checklist.

Eighty children were on psychostimulant medication only. The other 54 were on a psychostimulant plus an atypical antipsychotic agent, Dr. Drake D. Duane said at the annual meeting of the American Neuropsychiatric Association.

Twenty-four patients were deemed to have clinically significant anxiety, based on a baseline Achenbach anxiety T score greater than 65 prior to going on psychostimulant-only therapy. Upon follow-up after a minimum of 4 months on psychostimulant therapy, 20 of the 24 (83%) had a reduction in their parent-reported anxiety T score to less than 65.

Only 3 patients (5%) with a baseline anxiety score less than 65 had an increase in anxiety score to more than 65 while on psychostimulant-only therapy, according to Dr. Duane of the Institute for Developmental Behavioral Neurology at Arizona State University, Tempe.

Fifteen of the 54 patients placed on a psychostimulant plus an atypical antipsychotic medication had a pretreatment anxiety score above 65; 7 (47%) of them showed an on-treatment drop below the 65-point threshold. Twelve of the 39 patients (31%) with an initial anxiety score less than 65 showed an on-treatment increase in anxiety score to greater than 65.

Dr. Duane declared having no financial conflicts.

DENVER – Civilian physicians can expect to encounter numerous cases of blast-related traumatic brain injury, the signature wound of the wars in Iraq and Afghanistan.

That’s because more than half of military personnel returning from those conflicts use civilian medical services rather than the Veterans Affairs health care system, Dr. Evan D. Murray said at the annual meeting of the American Neuropsychiatric Association.

Photo credit: Bruce Jancin

"You will see these patients. It’s important to be able to recognize the clinical manifestations and choose appropriate treatments," added Dr. Murray, a neurologist at McLean Hospital and Harvard Medical School, Boston.

The government estimates that in excess of 150,000 troops in Iraq and Afghanistan have experienced traumatic brain injury since the start of conflict. In 2009, 79% of the nearly 28,000 traumatic brain injuries sustained by U.S. military personnel in those two countries were mild. These injuries are thought to be due largely to the powerful shock wave of high pressure that radiates from an improvised explosive device and reverberates through the skull. Moreover, the injured troops are often physically thrown as well, with resultant acceleration injury.

Dr. David X. Cifu, national director of the VA Physical Medicine and Rehabilitation Office, said he would like to see lots more returning troops utilize the totally free health care they are entitled to through the VA system for 5 years after coming home. He stressed that civilian physicians should steer ex-military patients with blast-related traumatic brain injury (TBI) to the VA, whose national TBI program is unequaled.

"This is not your grandfather’s VA. This is a pretty amazing place. I’ve worked in academia for more than 20 years, and at the VA, we provide way better brain injury services than our university – and our university is extremely good," said Dr. Cifu, professor and chairman of the department of physical medicine and rehabilitation at Virginia Commonwealth University, Richmond.

With congressional prodding, the VA has organized from scratch a comprehensive system of care for active duty military personnel and veterans with TBI. All veterans of the wars in Iraq and Afghanistan who show up at any VA clinic for any reason must undergo a mandatory four-question screen for mild TBI (see box). If they answer all four questions affirmatively, they get scheduled for a comprehensive TBI evaluation within 30 days by a multidisciplinary team at one of the more than 100 specialized rehabilitation sites in the VA system. Each of these teams consists of a neurologist or psychiatrist with TBI expertise, a physical medicine and rehabilitation physician, a psychologist, a speech and language pathologist, and occupational, physical, and recreational therapists. Telemedicine consults are available.

The most challenging cases are referred to one of four statewide polytrauma rehabilitation centers. A fifth polytrauma rehabilitation center is due to open in San Antonio this fall.

Of nearly 470,000 veterans screened for mild TBI through the VA’s mandatory program between April 2007 and Sept. 2010, roughly 20% answered all four questions affirmatively, indicating they had been exposed to a TBI. Follow-up evaluation at one of the more than 100 specialty clinics showed that 39% of those with a positive screen – or 8% of all returning service personnel – had a symptomatic TBI at that time.

Dr. Cifu coauthored a joint Department of Veterans Affairs and Department of Defense clinical practice guideline on the management of mild TBI. He recommended it as highly useful for non-VA physicians as well.

Polytrauma is a term used within the VA to describe individuals with TBI and another physical injury or psychological trauma. Particularly common is the constellation of chronic pain, post-traumatic stress disorder, depression, polysubstance use, and residual TBI symptoms such as headache, fatigue, and mental slowness.

"These are folks that aren’t getting well the way you read in the textbooks," Dr. Cifu observed.

Indeed, while in the civilian world roughly 97% of individuals who sustain a mild brain injury such as a sports concussion will be well a year later, that figure is substantially lower – more like 80% – for polytrauma patients in the VA system.

Among the factors contributing to poor outcomes in military personnel with polytrauma are the abundant physical and psychological stressors of the combat zone, delayed diagnosis of TBI, and the common occurrence of exposure to multiple TBIs.

"We have lots of folks who report 3, 5, 7, 10, 15 [TBIs]. We really don’t know what multiple blast injuries mean in terms of outcome. We have to understand this better," according to Dr. Cifu.

Pre-exposure factors may also contribute to polytrauma. About half of troops in Iraq and Afghanistan are volunteers, often fresh out of high school. Some have had a difficult upbringing that may render them less resilient to injury. The National Guard reservists are generally far older and often not optimally physically fit, he continued.

Louis M. French, Psy.D., said that he and his coinvestigators have found that among military personnel with mild TBI and bodily injuries, those with more severe bodily injuries reported less TBI-related neurobehavioral symptoms such as headache, forgetfulness, anxiety, and depression than did those with relatively minor bodily injuries.

It’s a paradoxical finding. One possible explanation is that people who are very seriously injured are happy to be alive and simply ignore minor neurobehavioral symptoms. Also, it’s easier for people who are more seriously injured to see tangible improvement resulting from their rehabilitation program, as when they start to walk again or get a prosthetic device, said Dr. French, director of the traumatic brain injury service at Walter Reed Army Medical Center in Washington.

In a recent study, Dr. French and coworkers found that 55% of service members with mild TBI reported symptoms consistent with the diagnosis of post-concussive disorder 12 months later.

"These are very different trajectories than you’d expect to see in a civilian population," he observed.

Dr. Michael Pollanen of Toronto, who is chief forensic pathologist for Ontario, said that his emerging hypothesis is that blast-related TBI might be a variant of diffuse axonal injury that leads to a distinctive syndrome of neuropsychiatric impairment. He has seen such injuries at the cellular level under the microscope at autopsy; now the search is on for a means of identifying diffuse axonal injury in blast survivors.

Four Items Screen for Mild TBI

• Question 1: Were you exposed to a trauma or blast while in Operation Enduring Freedom/Operation Iraqi Freedom?

• Question 2: As a result of the trauma or blast did you have a loss or alteration in consciousness (see stars, have bell rung, feel disoriented or confused)?

• Question 3: Did you develop problems with headache, insomnia, dizziness, thinking, or behavior immediately to soon after the trauma or blast?

• Question 4: Do you still have the problems with headache, insomnia, dizziness, thinking difficulties or behavior that you developed immediately to soon after the trauma or blast?

None of the speakers reported any financial conflicts.

DENVER – Civilian physicians can expect to encounter numerous cases of blast-related traumatic brain injury, the signature wound of the wars in Iraq and Afghanistan.

That’s because more than half of military personnel returning from those conflicts use civilian medical services rather than the Veterans Affairs health care system, Dr. Evan D. Murray said at the annual meeting of the American Neuropsychiatric Association.

Photo credit: Bruce Jancin

"You will see these patients. It’s important to be able to recognize the clinical manifestations and choose appropriate treatments," added Dr. Murray, a neurologist at McLean Hospital and Harvard Medical School, Boston.

The government estimates that in excess of 150,000 troops in Iraq and Afghanistan have experienced traumatic brain injury since the start of conflict. In 2009, 79% of the nearly 28,000 traumatic brain injuries sustained by U.S. military personnel in those two countries were mild. These injuries are thought to be due largely to the powerful shock wave of high pressure that radiates from an improvised explosive device and reverberates through the skull. Moreover, the injured troops are often physically thrown as well, with resultant acceleration injury.

Dr. David X. Cifu, national director of the VA Physical Medicine and Rehabilitation Office, said he would like to see lots more returning troops utilize the totally free health care they are entitled to through the VA system for 5 years after coming home. He stressed that civilian physicians should steer ex-military patients with blast-related traumatic brain injury (TBI) to the VA, whose national TBI program is unequaled.

"This is not your grandfather’s VA. This is a pretty amazing place. I’ve worked in academia for more than 20 years, and at the VA, we provide way better brain injury services than our university – and our university is extremely good," said Dr. Cifu, professor and chairman of the department of physical medicine and rehabilitation at Virginia Commonwealth University, Richmond.

With congressional prodding, the VA has organized from scratch a comprehensive system of care for active duty military personnel and veterans with TBI. All veterans of the wars in Iraq and Afghanistan who show up at any VA clinic for any reason must undergo a mandatory four-question screen for mild TBI (see box). If they answer all four questions affirmatively, they get scheduled for a comprehensive TBI evaluation within 30 days by a multidisciplinary team at one of the more than 100 specialized rehabilitation sites in the VA system. Each of these teams consists of a neurologist or psychiatrist with TBI expertise, a physical medicine and rehabilitation physician, a psychologist, a speech and language pathologist, and occupational, physical, and recreational therapists. Telemedicine consults are available.

The most challenging cases are referred to one of four statewide polytrauma rehabilitation centers. A fifth polytrauma rehabilitation center is due to open in San Antonio this fall.

Of nearly 470,000 veterans screened for mild TBI through the VA’s mandatory program between April 2007 and Sept. 2010, roughly 20% answered all four questions affirmatively, indicating they had been exposed to a TBI. Follow-up evaluation at one of the more than 100 specialty clinics showed that 39% of those with a positive screen – or 8% of all returning service personnel – had a symptomatic TBI at that time.

Dr. Cifu coauthored a joint Department of Veterans Affairs and Department of Defense clinical practice guideline on the management of mild TBI. He recommended it as highly useful for non-VA physicians as well.

Polytrauma is a term used within the VA to describe individuals with TBI and another physical injury or psychological trauma. Particularly common is the constellation of chronic pain, post-traumatic stress disorder, depression, polysubstance use, and residual TBI symptoms such as headache, fatigue, and mental slowness.

"These are folks that aren’t getting well the way you read in the textbooks," Dr. Cifu observed.

Indeed, while in the civilian world roughly 97% of individuals who sustain a mild brain injury such as a sports concussion will be well a year later, that figure is substantially lower – more like 80% – for polytrauma patients in the VA system.

Among the factors contributing to poor outcomes in military personnel with polytrauma are the abundant physical and psychological stressors of the combat zone, delayed diagnosis of TBI, and the common occurrence of exposure to multiple TBIs.

"We have lots of folks who report 3, 5, 7, 10, 15 [TBIs]. We really don’t know what multiple blast injuries mean in terms of outcome. We have to understand this better," according to Dr. Cifu.

Pre-exposure factors may also contribute to polytrauma. About half of troops in Iraq and Afghanistan are volunteers, often fresh out of high school. Some have had a difficult upbringing that may render them less resilient to injury. The National Guard reservists are generally far older and often not optimally physically fit, he continued.

Louis M. French, Psy.D., said that he and his coinvestigators have found that among military personnel with mild TBI and bodily injuries, those with more severe bodily injuries reported less TBI-related neurobehavioral symptoms such as headache, forgetfulness, anxiety, and depression than did those with relatively minor bodily injuries.

It’s a paradoxical finding. One possible explanation is that people who are very seriously injured are happy to be alive and simply ignore minor neurobehavioral symptoms. Also, it’s easier for people who are more seriously injured to see tangible improvement resulting from their rehabilitation program, as when they start to walk again or get a prosthetic device, said Dr. French, director of the traumatic brain injury service at Walter Reed Army Medical Center in Washington.

In a recent study, Dr. French and coworkers found that 55% of service members with mild TBI reported symptoms consistent with the diagnosis of post-concussive disorder 12 months later.

"These are very different trajectories than you’d expect to see in a civilian population," he observed.

Dr. Michael Pollanen of Toronto, who is chief forensic pathologist for Ontario, said that his emerging hypothesis is that blast-related TBI might be a variant of diffuse axonal injury that leads to a distinctive syndrome of neuropsychiatric impairment. He has seen such injuries at the cellular level under the microscope at autopsy; now the search is on for a means of identifying diffuse axonal injury in blast survivors.

Four Items Screen for Mild TBI

• Question 1: Were you exposed to a trauma or blast while in Operation Enduring Freedom/Operation Iraqi Freedom?

• Question 2: As a result of the trauma or blast did you have a loss or alteration in consciousness (see stars, have bell rung, feel disoriented or confused)?

• Question 3: Did you develop problems with headache, insomnia, dizziness, thinking, or behavior immediately to soon after the trauma or blast?

• Question 4: Do you still have the problems with headache, insomnia, dizziness, thinking difficulties or behavior that you developed immediately to soon after the trauma or blast?

None of the speakers reported any financial conflicts.

DENVER – Civilian physicians can expect to encounter numerous cases of blast-related traumatic brain injury, the signature wound of the wars in Iraq and Afghanistan.

That’s because more than half of military personnel returning from those conflicts use civilian medical services rather than the Veterans Affairs health care system, Dr. Evan D. Murray said at the annual meeting of the American Neuropsychiatric Association.

Photo credit: Bruce Jancin

"You will see these patients. It’s important to be able to recognize the clinical manifestations and choose appropriate treatments," added Dr. Murray, a neurologist at McLean Hospital and Harvard Medical School, Boston.

The government estimates that in excess of 150,000 troops in Iraq and Afghanistan have experienced traumatic brain injury since the start of conflict. In 2009, 79% of the nearly 28,000 traumatic brain injuries sustained by U.S. military personnel in those two countries were mild. These injuries are thought to be due largely to the powerful shock wave of high pressure that radiates from an improvised explosive device and reverberates through the skull. Moreover, the injured troops are often physically thrown as well, with resultant acceleration injury.

Dr. David X. Cifu, national director of the VA Physical Medicine and Rehabilitation Office, said he would like to see lots more returning troops utilize the totally free health care they are entitled to through the VA system for 5 years after coming home. He stressed that civilian physicians should steer ex-military patients with blast-related traumatic brain injury (TBI) to the VA, whose national TBI program is unequaled.

"This is not your grandfather’s VA. This is a pretty amazing place. I’ve worked in academia for more than 20 years, and at the VA, we provide way better brain injury services than our university – and our university is extremely good," said Dr. Cifu, professor and chairman of the department of physical medicine and rehabilitation at Virginia Commonwealth University, Richmond.

With congressional prodding, the VA has organized from scratch a comprehensive system of care for active duty military personnel and veterans with TBI. All veterans of the wars in Iraq and Afghanistan who show up at any VA clinic for any reason must undergo a mandatory four-question screen for mild TBI (see box). If they answer all four questions affirmatively, they get scheduled for a comprehensive TBI evaluation within 30 days by a multidisciplinary team at one of the more than 100 specialized rehabilitation sites in the VA system. Each of these teams consists of a neurologist or psychiatrist with TBI expertise, a physical medicine and rehabilitation physician, a psychologist, a speech and language pathologist, and occupational, physical, and recreational therapists. Telemedicine consults are available.

The most challenging cases are referred to one of four statewide polytrauma rehabilitation centers. A fifth polytrauma rehabilitation center is due to open in San Antonio this fall.

Of nearly 470,000 veterans screened for mild TBI through the VA’s mandatory program between April 2007 and Sept. 2010, roughly 20% answered all four questions affirmatively, indicating they had been exposed to a TBI. Follow-up evaluation at one of the more than 100 specialty clinics showed that 39% of those with a positive screen – or 8% of all returning service personnel – had a symptomatic TBI at that time.

Dr. Cifu coauthored a joint Department of Veterans Affairs and Department of Defense clinical practice guideline on the management of mild TBI. He recommended it as highly useful for non-VA physicians as well.

Polytrauma is a term used within the VA to describe individuals with TBI and another physical injury or psychological trauma. Particularly common is the constellation of chronic pain, post-traumatic stress disorder, depression, polysubstance use, and residual TBI symptoms such as headache, fatigue, and mental slowness.

"These are folks that aren’t getting well the way you read in the textbooks," Dr. Cifu observed.

Indeed, while in the civilian world roughly 97% of individuals who sustain a mild brain injury such as a sports concussion will be well a year later, that figure is substantially lower – more like 80% – for polytrauma patients in the VA system.

Among the factors contributing to poor outcomes in military personnel with polytrauma are the abundant physical and psychological stressors of the combat zone, delayed diagnosis of TBI, and the common occurrence of exposure to multiple TBIs.

"We have lots of folks who report 3, 5, 7, 10, 15 [TBIs]. We really don’t know what multiple blast injuries mean in terms of outcome. We have to understand this better," according to Dr. Cifu.

Pre-exposure factors may also contribute to polytrauma. About half of troops in Iraq and Afghanistan are volunteers, often fresh out of high school. Some have had a difficult upbringing that may render them less resilient to injury. The National Guard reservists are generally far older and often not optimally physically fit, he continued.

Louis M. French, Psy.D., said that he and his coinvestigators have found that among military personnel with mild TBI and bodily injuries, those with more severe bodily injuries reported less TBI-related neurobehavioral symptoms such as headache, forgetfulness, anxiety, and depression than did those with relatively minor bodily injuries.

It’s a paradoxical finding. One possible explanation is that people who are very seriously injured are happy to be alive and simply ignore minor neurobehavioral symptoms. Also, it’s easier for people who are more seriously injured to see tangible improvement resulting from their rehabilitation program, as when they start to walk again or get a prosthetic device, said Dr. French, director of the traumatic brain injury service at Walter Reed Army Medical Center in Washington.

In a recent study, Dr. French and coworkers found that 55% of service members with mild TBI reported symptoms consistent with the diagnosis of post-concussive disorder 12 months later.

"These are very different trajectories than you’d expect to see in a civilian population," he observed.

Dr. Michael Pollanen of Toronto, who is chief forensic pathologist for Ontario, said that his emerging hypothesis is that blast-related TBI might be a variant of diffuse axonal injury that leads to a distinctive syndrome of neuropsychiatric impairment. He has seen such injuries at the cellular level under the microscope at autopsy; now the search is on for a means of identifying diffuse axonal injury in blast survivors.

Four Items Screen for Mild TBI

• Question 1: Were you exposed to a trauma or blast while in Operation Enduring Freedom/Operation Iraqi Freedom?

• Question 2: As a result of the trauma or blast did you have a loss or alteration in consciousness (see stars, have bell rung, feel disoriented or confused)?

• Question 3: Did you develop problems with headache, insomnia, dizziness, thinking, or behavior immediately to soon after the trauma or blast?

• Question 4: Do you still have the problems with headache, insomnia, dizziness, thinking difficulties or behavior that you developed immediately to soon after the trauma or blast?

None of the speakers reported any financial conflicts.

DENVER – Civilian physicians can expect to encounter numerous cases of blast-related traumatic brain injury, the signature wound of the wars in Iraq and Afghanistan.

That’s because more than half of military personnel returning from those conflicts use civilian medical services rather than the Veterans Affairs health care system, Dr. Evan D. Murray said at the annual meeting of the American Neuropsychiatric Association.

Photo credit: Bruce Jancin

"You will see these patients. It’s important to be able to recognize the clinical manifestations and choose appropriate treatments," added Dr. Murray, a neurologist at McLean Hospital and Harvard Medical School, Boston.

The government estimates that in excess of 150,000 troops in Iraq and Afghanistan have experienced traumatic brain injury since the start of conflict. In 2009, 79% of the nearly 28,000 traumatic brain injuries sustained by U.S. military personnel in those two countries were mild. These injuries are thought to be due largely to the powerful shock wave of high pressure that radiates from an improvised explosive device and reverberates through the skull. Moreover, the injured troops are often physically thrown as well, with resultant acceleration injury.

Dr. David X. Cifu, national director of the VA Physical Medicine and Rehabilitation Office, said he would like to see lots more returning troops utilize the totally free health care they are entitled to through the VA system for 5 years after coming home. He stressed that civilian physicians should steer ex-military patients with blast-related traumatic brain injury (TBI) to the VA, whose national TBI program is unequaled.

"This is not your grandfather’s VA. This is a pretty amazing place. I’ve worked in academia for more than 20 years, and at the VA, we provide way better brain injury services than our university – and our university is extremely good," said Dr. Cifu, professor and chairman of the department of physical medicine and rehabilitation at Virginia Commonwealth University, Richmond.

With congressional prodding, the VA has organized from scratch a comprehensive system of care for active duty military personnel and veterans with TBI. All veterans of the wars in Iraq and Afghanistan who show up at any VA clinic for any reason must undergo a mandatory four-question screen for mild TBI (see box). If they answer all four questions affirmatively, they get scheduled for a comprehensive TBI evaluation within 30 days by a multidisciplinary team at one of the more than 100 specialized rehabilitation sites in the VA system. Each of these teams consists of a neurologist or psychiatrist with TBI expertise, a physical medicine and rehabilitation physician, a psychologist, a speech and language pathologist, and occupational, physical, and recreational therapists. Telemedicine consults are available.

The most challenging cases are referred to one of four statewide polytrauma rehabilitation centers. A fifth polytrauma rehabilitation center is due to open in San Antonio this fall.

Of nearly 470,000 veterans screened for mild TBI through the VA’s mandatory program between April 2007 and Sept. 2010, roughly 20% answered all four questions affirmatively, indicating they had been exposed to a TBI. Follow-up evaluation at one of the more than 100 specialty clinics showed that 39% of those with a positive screen – or 8% of all returning service personnel – had a symptomatic TBI at that time.

Dr. Cifu coauthored a joint Department of Veterans Affairs and Department of Defense clinical practice guideline on the management of mild TBI. He recommended it as highly useful for non-VA physicians as well.

Polytrauma is a term used within the VA to describe individuals with TBI and another physical injury or psychological trauma. Particularly common is the constellation of chronic pain, post-traumatic stress disorder, depression, polysubstance use, and residual TBI symptoms such as headache, fatigue, and mental slowness.

"These are folks that aren’t getting well the way you read in the textbooks," Dr. Cifu observed.

Indeed, while in the civilian world roughly 97% of individuals who sustain a mild brain injury such as a sports concussion will be well a year later, that figure is substantially lower – more like 80% – for polytrauma patients in the VA system.

Among the factors contributing to poor outcomes in military personnel with polytrauma are the abundant physical and psychological stressors of the combat zone, delayed diagnosis of TBI, and the common occurrence of exposure to multiple TBIs.

"We have lots of folks who report 3, 5, 7, 10, 15 [TBIs]. We really don’t know what multiple blast injuries mean in terms of outcome. We have to understand this better," according to Dr. Cifu.

Pre-exposure factors may also contribute to polytrauma. About half of troops in Iraq and Afghanistan are volunteers, often fresh out of high school. Some have had a difficult upbringing that may render them less resilient to injury. The National Guard reservists are generally far older and often not optimally physically fit, he continued.

Louis M. French, Psy.D., said that he and his coinvestigators have found that among military personnel with mild TBI and bodily injuries, those with more severe bodily injuries reported less TBI-related neurobehavioral symptoms such as headache, forgetfulness, anxiety, and depression than did those with relatively minor bodily injuries.

It’s a paradoxical finding. One possible explanation is that people who are very seriously injured are happy to be alive and simply ignore minor neurobehavioral symptoms. Also, it’s easier for people who are more seriously injured to see tangible improvement resulting from their rehabilitation program, as when they start to walk again or get a prosthetic device, said Dr. French, director of the traumatic brain injury service at Walter Reed Army Medical Center in Washington.

In a recent study, Dr. French and coworkers found that 55% of service members with mild TBI reported symptoms consistent with the diagnosis of post-concussive disorder 12 months later.

"These are very different trajectories than you’d expect to see in a civilian population," he observed.

Dr. Michael Pollanen of Toronto, who is chief forensic pathologist for Ontario, said that his emerging hypothesis is that blast-related TBI might be a variant of diffuse axonal injury that leads to a distinctive syndrome of neuropsychiatric impairment. He has seen such injuries at the cellular level under the microscope at autopsy; now the search is on for a means of identifying diffuse axonal injury in blast survivors.

Four Items Screen for Mild TBI

• Question 1: Were you exposed to a trauma or blast while in Operation Enduring Freedom/Operation Iraqi Freedom?

• Question 2: As a result of the trauma or blast did you have a loss or alteration in consciousness (see stars, have bell rung, feel disoriented or confused)?

• Question 3: Did you develop problems with headache, insomnia, dizziness, thinking, or behavior immediately to soon after the trauma or blast?

• Question 4: Do you still have the problems with headache, insomnia, dizziness, thinking difficulties or behavior that you developed immediately to soon after the trauma or blast?

None of the speakers reported any financial conflicts.

DENVER – Civilian physicians can expect to encounter numerous cases of blast-related traumatic brain injury, the signature wound of the wars in Iraq and Afghanistan.

That’s because more than half of military personnel returning from those conflicts use civilian medical services rather than the Veterans Affairs health care system, Dr. Evan D. Murray said at the annual meeting of the American Neuropsychiatric Association.

Photo credit: Bruce Jancin

"You will see these patients. It’s important to be able to recognize the clinical manifestations and choose appropriate treatments," added Dr. Murray, a neurologist at McLean Hospital and Harvard Medical School, Boston.

The government estimates that in excess of 150,000 troops in Iraq and Afghanistan have experienced traumatic brain injury since the start of conflict. In 2009, 79% of the nearly 28,000 traumatic brain injuries sustained by U.S. military personnel in those two countries were mild. These injuries are thought to be due largely to the powerful shock wave of high pressure that radiates from an improvised explosive device and reverberates through the skull. Moreover, the injured troops are often physically thrown as well, with resultant acceleration injury.

Dr. David X. Cifu, national director of the VA Physical Medicine and Rehabilitation Office, said he would like to see lots more returning troops utilize the totally free health care they are entitled to through the VA system for 5 years after coming home. He stressed that civilian physicians should steer ex-military patients with blast-related traumatic brain injury (TBI) to the VA, whose national TBI program is unequaled.

"This is not your grandfather’s VA. This is a pretty amazing place. I’ve worked in academia for more than 20 years, and at the VA, we provide way better brain injury services than our university – and our university is extremely good," said Dr. Cifu, professor and chairman of the department of physical medicine and rehabilitation at Virginia Commonwealth University, Richmond.

With congressional prodding, the VA has organized from scratch a comprehensive system of care for active duty military personnel and veterans with TBI. All veterans of the wars in Iraq and Afghanistan who show up at any VA clinic for any reason must undergo a mandatory four-question screen for mild TBI (see box). If they answer all four questions affirmatively, they get scheduled for a comprehensive TBI evaluation within 30 days by a multidisciplinary team at one of the more than 100 specialized rehabilitation sites in the VA system. Each of these teams consists of a neurologist or psychiatrist with TBI expertise, a physical medicine and rehabilitation physician, a psychologist, a speech and language pathologist, and occupational, physical, and recreational therapists. Telemedicine consults are available.

The most challenging cases are referred to one of four statewide polytrauma rehabilitation centers. A fifth polytrauma rehabilitation center is due to open in San Antonio this fall.

Of nearly 470,000 veterans screened for mild TBI through the VA’s mandatory program between April 2007 and Sept. 2010, roughly 20% answered all four questions affirmatively, indicating they had been exposed to a TBI. Follow-up evaluation at one of the more than 100 specialty clinics showed that 39% of those with a positive screen – or 8% of all returning service personnel – had a symptomatic TBI at that time.

Dr. Cifu coauthored a joint Department of Veterans Affairs and Department of Defense clinical practice guideline on the management of mild TBI. He recommended it as highly useful for non-VA physicians as well.

Polytrauma is a term used within the VA to describe individuals with TBI and another physical injury or psychological trauma. Particularly common is the constellation of chronic pain, post-traumatic stress disorder, depression, polysubstance use, and residual TBI symptoms such as headache, fatigue, and mental slowness.

"These are folks that aren’t getting well the way you read in the textbooks," Dr. Cifu observed.

Indeed, while in the civilian world roughly 97% of individuals who sustain a mild brain injury such as a sports concussion will be well a year later, that figure is substantially lower – more like 80% – for polytrauma patients in the VA system.

Among the factors contributing to poor outcomes in military personnel with polytrauma are the abundant physical and psychological stressors of the combat zone, delayed diagnosis of TBI, and the common occurrence of exposure to multiple TBIs.

"We have lots of folks who report 3, 5, 7, 10, 15 [TBIs]. We really don’t know what multiple blast injuries mean in terms of outcome. We have to understand this better," according to Dr. Cifu.

Pre-exposure factors may also contribute to polytrauma. About half of troops in Iraq and Afghanistan are volunteers, often fresh out of high school. Some have had a difficult upbringing that may render them less resilient to injury. The National Guard reservists are generally far older and often not optimally physically fit, he continued.

Louis M. French, Psy.D., said that he and his coinvestigators have found that among military personnel with mild TBI and bodily injuries, those with more severe bodily injuries reported less TBI-related neurobehavioral symptoms such as headache, forgetfulness, anxiety, and depression than did those with relatively minor bodily injuries.

It’s a paradoxical finding. One possible explanation is that people who are very seriously injured are happy to be alive and simply ignore minor neurobehavioral symptoms. Also, it’s easier for people who are more seriously injured to see tangible improvement resulting from their rehabilitation program, as when they start to walk again or get a prosthetic device, said Dr. French, director of the traumatic brain injury service at Walter Reed Army Medical Center in Washington.

In a recent study, Dr. French and coworkers found that 55% of service members with mild TBI reported symptoms consistent with the diagnosis of post-concussive disorder 12 months later.

"These are very different trajectories than you’d expect to see in a civilian population," he observed.

Dr. Michael Pollanen of Toronto, who is chief forensic pathologist for Ontario, said that his emerging hypothesis is that blast-related TBI might be a variant of diffuse axonal injury that leads to a distinctive syndrome of neuropsychiatric impairment. He has seen such injuries at the cellular level under the microscope at autopsy; now the search is on for a means of identifying diffuse axonal injury in blast survivors.

Four Items Screen for Mild TBI

• Question 1: Were you exposed to a trauma or blast while in Operation Enduring Freedom/Operation Iraqi Freedom?

• Question 2: As a result of the trauma or blast did you have a loss or alteration in consciousness (see stars, have bell rung, feel disoriented or confused)?

• Question 3: Did you develop problems with headache, insomnia, dizziness, thinking, or behavior immediately to soon after the trauma or blast?

• Question 4: Do you still have the problems with headache, insomnia, dizziness, thinking difficulties or behavior that you developed immediately to soon after the trauma or blast?

None of the speakers reported any financial conflicts.

DENVER – Civilian physicians can expect to encounter numerous cases of blast-related traumatic brain injury, the signature wound of the wars in Iraq and Afghanistan.

That’s because more than half of military personnel returning from those conflicts use civilian medical services rather than the Veterans Affairs health care system, Dr. Evan D. Murray said at the annual meeting of the American Neuropsychiatric Association.

Photo credit: Bruce Jancin

"You will see these patients. It’s important to be able to recognize the clinical manifestations and choose appropriate treatments," added Dr. Murray, a neurologist at McLean Hospital and Harvard Medical School, Boston.

The government estimates that in excess of 150,000 troops in Iraq and Afghanistan have experienced traumatic brain injury since the start of conflict. In 2009, 79% of the nearly 28,000 traumatic brain injuries sustained by U.S. military personnel in those two countries were mild. These injuries are thought to be due largely to the powerful shock wave of high pressure that radiates from an improvised explosive device and reverberates through the skull. Moreover, the injured troops are often physically thrown as well, with resultant acceleration injury.

Dr. David X. Cifu, national director of the VA Physical Medicine and Rehabilitation Office, said he would like to see lots more returning troops utilize the totally free health care they are entitled to through the VA system for 5 years after coming home. He stressed that civilian physicians should steer ex-military patients with blast-related traumatic brain injury (TBI) to the VA, whose national TBI program is unequaled.

"This is not your grandfather’s VA. This is a pretty amazing place. I’ve worked in academia for more than 20 years, and at the VA, we provide way better brain injury services than our university – and our university is extremely good," said Dr. Cifu, professor and chairman of the department of physical medicine and rehabilitation at Virginia Commonwealth University, Richmond.

With congressional prodding, the VA has organized from scratch a comprehensive system of care for active duty military personnel and veterans with TBI. All veterans of the wars in Iraq and Afghanistan who show up at any VA clinic for any reason must undergo a mandatory four-question screen for mild TBI (see box). If they answer all four questions affirmatively, they get scheduled for a comprehensive TBI evaluation within 30 days by a multidisciplinary team at one of the more than 100 specialized rehabilitation sites in the VA system. Each of these teams consists of a neurologist or psychiatrist with TBI expertise, a physical medicine and rehabilitation physician, a psychologist, a speech and language pathologist, and occupational, physical, and recreational therapists. Telemedicine consults are available.

The most challenging cases are referred to one of four statewide polytrauma rehabilitation centers. A fifth polytrauma rehabilitation center is due to open in San Antonio this fall.

Of nearly 470,000 veterans screened for mild TBI through the VA’s mandatory program between April 2007 and Sept. 2010, roughly 20% answered all four questions affirmatively, indicating they had been exposed to a TBI. Follow-up evaluation at one of the more than 100 specialty clinics showed that 39% of those with a positive screen – or 8% of all returning service personnel – had a symptomatic TBI at that time.

Dr. Cifu coauthored a joint Department of Veterans Affairs and Department of Defense clinical practice guideline on the management of mild TBI. He recommended it as highly useful for non-VA physicians as well.

Polytrauma is a term used within the VA to describe individuals with TBI and another physical injury or psychological trauma. Particularly common is the constellation of chronic pain, post-traumatic stress disorder, depression, polysubstance use, and residual TBI symptoms such as headache, fatigue, and mental slowness.

"These are folks that aren’t getting well the way you read in the textbooks," Dr. Cifu observed.

Indeed, while in the civilian world roughly 97% of individuals who sustain a mild brain injury such as a sports concussion will be well a year later, that figure is substantially lower – more like 80% – for polytrauma patients in the VA system.

Among the factors contributing to poor outcomes in military personnel with polytrauma are the abundant physical and psychological stressors of the combat zone, delayed diagnosis of TBI, and the common occurrence of exposure to multiple TBIs.

"We have lots of folks who report 3, 5, 7, 10, 15 [TBIs]. We really don’t know what multiple blast injuries mean in terms of outcome. We have to understand this better," according to Dr. Cifu.

Pre-exposure factors may also contribute to polytrauma. About half of troops in Iraq and Afghanistan are volunteers, often fresh out of high school. Some have had a difficult upbringing that may render them less resilient to injury. The National Guard reservists are generally far older and often not optimally physically fit, he continued.

Louis M. French, Psy.D., said that he and his coinvestigators have found that among military personnel with mild TBI and bodily injuries, those with more severe bodily injuries reported less TBI-related neurobehavioral symptoms such as headache, forgetfulness, anxiety, and depression than did those with relatively minor bodily injuries.

It’s a paradoxical finding. One possible explanation is that people who are very seriously injured are happy to be alive and simply ignore minor neurobehavioral symptoms. Also, it’s easier for people who are more seriously injured to see tangible improvement resulting from their rehabilitation program, as when they start to walk again or get a prosthetic device, said Dr. French, director of the traumatic brain injury service at Walter Reed Army Medical Center in Washington.

In a recent study, Dr. French and coworkers found that 55% of service members with mild TBI reported symptoms consistent with the diagnosis of post-concussive disorder 12 months later.

"These are very different trajectories than you’d expect to see in a civilian population," he observed.

Dr. Michael Pollanen of Toronto, who is chief forensic pathologist for Ontario, said that his emerging hypothesis is that blast-related TBI might be a variant of diffuse axonal injury that leads to a distinctive syndrome of neuropsychiatric impairment. He has seen such injuries at the cellular level under the microscope at autopsy; now the search is on for a means of identifying diffuse axonal injury in blast survivors.

Four Items Screen for Mild TBI

• Question 1: Were you exposed to a trauma or blast while in Operation Enduring Freedom/Operation Iraqi Freedom?

• Question 2: As a result of the trauma or blast did you have a loss or alteration in consciousness (see stars, have bell rung, feel disoriented or confused)?

• Question 3: Did you develop problems with headache, insomnia, dizziness, thinking, or behavior immediately to soon after the trauma or blast?

• Question 4: Do you still have the problems with headache, insomnia, dizziness, thinking difficulties or behavior that you developed immediately to soon after the trauma or blast?

None of the speakers reported any financial conflicts.

DENVER – Civilian physicians can expect to encounter numerous cases of blast-related traumatic brain injury, the signature wound of the wars in Iraq and Afghanistan.

That’s because more than half of military personnel returning from those conflicts use civilian medical services rather than the Veterans Affairs health care system, Dr. Evan D. Murray said at the annual meeting of the American Neuropsychiatric Association.

Photo credit: Bruce Jancin

"You will see these patients. It’s important to be able to recognize the clinical manifestations and choose appropriate treatments," added Dr. Murray, a neurologist at McLean Hospital and Harvard Medical School, Boston.

The government estimates that in excess of 150,000 troops in Iraq and Afghanistan have experienced traumatic brain injury since the start of conflict. In 2009, 79% of the nearly 28,000 traumatic brain injuries sustained by U.S. military personnel in those two countries were mild. These injuries are thought to be due largely to the powerful shock wave of high pressure that radiates from an improvised explosive device and reverberates through the skull. Moreover, the injured troops are often physically thrown as well, with resultant acceleration injury.

Dr. David X. Cifu, national director of the VA Physical Medicine and Rehabilitation Office, said he would like to see lots more returning troops utilize the totally free health care they are entitled to through the VA system for 5 years after coming home. He stressed that civilian physicians should steer ex-military patients with blast-related traumatic brain injury (TBI) to the VA, whose national TBI program is unequaled.

"This is not your grandfather’s VA. This is a pretty amazing place. I’ve worked in academia for more than 20 years, and at the VA, we provide way better brain injury services than our university – and our university is extremely good," said Dr. Cifu, professor and chairman of the department of physical medicine and rehabilitation at Virginia Commonwealth University, Richmond.

With congressional prodding, the VA has organized from scratch a comprehensive system of care for active duty military personnel and veterans with TBI. All veterans of the wars in Iraq and Afghanistan who show up at any VA clinic for any reason must undergo a mandatory four-question screen for mild TBI (see box). If they answer all four questions affirmatively, they get scheduled for a comprehensive TBI evaluation within 30 days by a multidisciplinary team at one of the more than 100 specialized rehabilitation sites in the VA system. Each of these teams consists of a neurologist or psychiatrist with TBI expertise, a physical medicine and rehabilitation physician, a psychologist, a speech and language pathologist, and occupational, physical, and recreational therapists. Telemedicine consults are available.

The most challenging cases are referred to one of four statewide polytrauma rehabilitation centers. A fifth polytrauma rehabilitation center is due to open in San Antonio this fall.

Of nearly 470,000 veterans screened for mild TBI through the VA’s mandatory program between April 2007 and Sept. 2010, roughly 20% answered all four questions affirmatively, indicating they had been exposed to a TBI. Follow-up evaluation at one of the more than 100 specialty clinics showed that 39% of those with a positive screen – or 8% of all returning service personnel – had a symptomatic TBI at that time.

Dr. Cifu coauthored a joint Department of Veterans Affairs and Department of Defense clinical practice guideline on the management of mild TBI. He recommended it as highly useful for non-VA physicians as well.

Polytrauma is a term used within the VA to describe individuals with TBI and another physical injury or psychological trauma. Particularly common is the constellation of chronic pain, post-traumatic stress disorder, depression, polysubstance use, and residual TBI symptoms such as headache, fatigue, and mental slowness.

"These are folks that aren’t getting well the way you read in the textbooks," Dr. Cifu observed.

Indeed, while in the civilian world roughly 97% of individuals who sustain a mild brain injury such as a sports concussion will be well a year later, that figure is substantially lower – more like 80% – for polytrauma patients in the VA system.

Among the factors contributing to poor outcomes in military personnel with polytrauma are the abundant physical and psychological stressors of the combat zone, delayed diagnosis of TBI, and the common occurrence of exposure to multiple TBIs.

"We have lots of folks who report 3, 5, 7, 10, 15 [TBIs]. We really don’t know what multiple blast injuries mean in terms of outcome. We have to understand this better," according to Dr. Cifu.

Pre-exposure factors may also contribute to polytrauma. About half of troops in Iraq and Afghanistan are volunteers, often fresh out of high school. Some have had a difficult upbringing that may render them less resilient to injury. The National Guard reservists are generally far older and often not optimally physically fit, he continued.

Louis M. French, Psy.D., said that he and his coinvestigators have found that among military personnel with mild TBI and bodily injuries, those with more severe bodily injuries reported less TBI-related neurobehavioral symptoms such as headache, forgetfulness, anxiety, and depression than did those with relatively minor bodily injuries.

It’s a paradoxical finding. One possible explanation is that people who are very seriously injured are happy to be alive and simply ignore minor neurobehavioral symptoms. Also, it’s easier for people who are more seriously injured to see tangible improvement resulting from their rehabilitation program, as when they start to walk again or get a prosthetic device, said Dr. French, director of the traumatic brain injury service at Walter Reed Army Medical Center in Washington.

In a recent study, Dr. French and coworkers found that 55% of service members with mild TBI reported symptoms consistent with the diagnosis of post-concussive disorder 12 months later.

"These are very different trajectories than you’d expect to see in a civilian population," he observed.

Dr. Michael Pollanen of Toronto, who is chief forensic pathologist for Ontario, said that his emerging hypothesis is that blast-related TBI might be a variant of diffuse axonal injury that leads to a distinctive syndrome of neuropsychiatric impairment. He has seen such injuries at the cellular level under the microscope at autopsy; now the search is on for a means of identifying diffuse axonal injury in blast survivors.

Four Items Screen for Mild TBI

• Question 1: Were you exposed to a trauma or blast while in Operation Enduring Freedom/Operation Iraqi Freedom?

• Question 2: As a result of the trauma or blast did you have a loss or alteration in consciousness (see stars, have bell rung, feel disoriented or confused)?

• Question 3: Did you develop problems with headache, insomnia, dizziness, thinking, or behavior immediately to soon after the trauma or blast?

• Question 4: Do you still have the problems with headache, insomnia, dizziness, thinking difficulties or behavior that you developed immediately to soon after the trauma or blast?

None of the speakers reported any financial conflicts.

DENVER – Civilian physicians can expect to encounter numerous cases of blast-related traumatic brain injury, the signature wound of the wars in Iraq and Afghanistan.

That’s because more than half of military personnel returning from those conflicts use civilian medical services rather than the Veterans Affairs health care system, Dr. Evan D. Murray said at the annual meeting of the American Neuropsychiatric Association.

Photo credit: Bruce Jancin

"You will see these patients. It’s important to be able to recognize the clinical manifestations and choose appropriate treatments," added Dr. Murray, a neurologist at McLean Hospital and Harvard Medical School, Boston.

The government estimates that in excess of 150,000 troops in Iraq and Afghanistan have experienced traumatic brain injury since the start of conflict. In 2009, 79% of the nearly 28,000 traumatic brain injuries sustained by U.S. military personnel in those two countries were mild. These injuries are thought to be due largely to the powerful shock wave of high pressure that radiates from an improvised explosive device and reverberates through the skull. Moreover, the injured troops are often physically thrown as well, with resultant acceleration injury.

Dr. David X. Cifu, national director of the VA Physical Medicine and Rehabilitation Office, said he would like to see lots more returning troops utilize the totally free health care they are entitled to through the VA system for 5 years after coming home. He stressed that civilian physicians should steer ex-military patients with blast-related traumatic brain injury (TBI) to the VA, whose national TBI program is unequaled.

"This is not your grandfather’s VA. This is a pretty amazing place. I’ve worked in academia for more than 20 years, and at the VA, we provide way better brain injury services than our university – and our university is extremely good," said Dr. Cifu, professor and chairman of the department of physical medicine and rehabilitation at Virginia Commonwealth University, Richmond.

With congressional prodding, the VA has organized from scratch a comprehensive system of care for active duty military personnel and veterans with TBI. All veterans of the wars in Iraq and Afghanistan who show up at any VA clinic for any reason must undergo a mandatory four-question screen for mild TBI (see box). If they answer all four questions affirmatively, they get scheduled for a comprehensive TBI evaluation within 30 days by a multidisciplinary team at one of the more than 100 specialized rehabilitation sites in the VA system. Each of these teams consists of a neurologist or psychiatrist with TBI expertise, a physical medicine and rehabilitation physician, a psychologist, a speech and language pathologist, and occupational, physical, and recreational therapists. Telemedicine consults are available.

The most challenging cases are referred to one of four statewide polytrauma rehabilitation centers. A fifth polytrauma rehabilitation center is due to open in San Antonio this fall.

Of nearly 470,000 veterans screened for mild TBI through the VA’s mandatory program between April 2007 and Sept. 2010, roughly 20% answered all four questions affirmatively, indicating they had been exposed to a TBI. Follow-up evaluation at one of the more than 100 specialty clinics showed that 39% of those with a positive screen – or 8% of all returning service personnel – had a symptomatic TBI at that time.

Dr. Cifu coauthored a joint Department of Veterans Affairs and Department of Defense clinical practice guideline on the management of mild TBI. He recommended it as highly useful for non-VA physicians as well.

Polytrauma is a term used within the VA to describe individuals with TBI and another physical injury or psychological trauma. Particularly common is the constellation of chronic pain, post-traumatic stress disorder, depression, polysubstance use, and residual TBI symptoms such as headache, fatigue, and mental slowness.

"These are folks that aren’t getting well the way you read in the textbooks," Dr. Cifu observed.

Indeed, while in the civilian world roughly 97% of individuals who sustain a mild brain injury such as a sports concussion will be well a year later, that figure is substantially lower – more like 80% – for polytrauma patients in the VA system.

Among the factors contributing to poor outcomes in military personnel with polytrauma are the abundant physical and psychological stressors of the combat zone, delayed diagnosis of TBI, and the common occurrence of exposure to multiple TBIs.

"We have lots of folks who report 3, 5, 7, 10, 15 [TBIs]. We really don’t know what multiple blast injuries mean in terms of outcome. We have to understand this better," according to Dr. Cifu.

Pre-exposure factors may also contribute to polytrauma. About half of troops in Iraq and Afghanistan are volunteers, often fresh out of high school. Some have had a difficult upbringing that may render them less resilient to injury. The National Guard reservists are generally far older and often not optimally physically fit, he continued.

Louis M. French, Psy.D., said that he and his coinvestigators have found that among military personnel with mild TBI and bodily injuries, those with more severe bodily injuries reported less TBI-related neurobehavioral symptoms such as headache, forgetfulness, anxiety, and depression than did those with relatively minor bodily injuries.

It’s a paradoxical finding. One possible explanation is that people who are very seriously injured are happy to be alive and simply ignore minor neurobehavioral symptoms. Also, it’s easier for people who are more seriously injured to see tangible improvement resulting from their rehabilitation program, as when they start to walk again or get a prosthetic device, said Dr. French, director of the traumatic brain injury service at Walter Reed Army Medical Center in Washington.

In a recent study, Dr. French and coworkers found that 55% of service members with mild TBI reported symptoms consistent with the diagnosis of post-concussive disorder 12 months later.

"These are very different trajectories than you’d expect to see in a civilian population," he observed.

Dr. Michael Pollanen of Toronto, who is chief forensic pathologist for Ontario, said that his emerging hypothesis is that blast-related TBI might be a variant of diffuse axonal injury that leads to a distinctive syndrome of neuropsychiatric impairment. He has seen such injuries at the cellular level under the microscope at autopsy; now the search is on for a means of identifying diffuse axonal injury in blast survivors.

Four Items Screen for Mild TBI

• Question 1: Were you exposed to a trauma or blast while in Operation Enduring Freedom/Operation Iraqi Freedom?

• Question 2: As a result of the trauma or blast did you have a loss or alteration in consciousness (see stars, have bell rung, feel disoriented or confused)?

• Question 3: Did you develop problems with headache, insomnia, dizziness, thinking, or behavior immediately to soon after the trauma or blast?

• Question 4: Do you still have the problems with headache, insomnia, dizziness, thinking difficulties or behavior that you developed immediately to soon after the trauma or blast?

None of the speakers reported any financial conflicts.

DENVER – Civilian physicians can expect to encounter numerous cases of blast-related traumatic brain injury, the signature wound of the wars in Iraq and Afghanistan.

That’s because more than half of military personnel returning from those conflicts use civilian medical services rather than the Veterans Affairs health care system, Dr. Evan D. Murray said at the annual meeting of the American Neuropsychiatric Association.

Photo credit: Bruce Jancin

"You will see these patients. It’s important to be able to recognize the clinical manifestations and choose appropriate treatments," added Dr. Murray, a neurologist at McLean Hospital and Harvard Medical School, Boston.

The government estimates that in excess of 150,000 troops in Iraq and Afghanistan have experienced traumatic brain injury since the start of conflict. In 2009, 79% of the nearly 28,000 traumatic brain injuries sustained by U.S. military personnel in those two countries were mild. These injuries are thought to be due largely to the powerful shock wave of high pressure that radiates from an improvised explosive device and reverberates through the skull. Moreover, the injured troops are often physically thrown as well, with resultant acceleration injury.

Dr. David X. Cifu, national director of the VA Physical Medicine and Rehabilitation Office, said he would like to see lots more returning troops utilize the totally free health care they are entitled to through the VA system for 5 years after coming home. He stressed that civilian physicians should steer ex-military patients with blast-related traumatic brain injury (TBI) to the VA, whose national TBI program is unequaled.

"This is not your grandfather’s VA. This is a pretty amazing place. I’ve worked in academia for more than 20 years, and at the VA, we provide way better brain injury services than our university – and our university is extremely good," said Dr. Cifu, professor and chairman of the department of physical medicine and rehabilitation at Virginia Commonwealth University, Richmond.

With congressional prodding, the VA has organized from scratch a comprehensive system of care for active duty military personnel and veterans with TBI. All veterans of the wars in Iraq and Afghanistan who show up at any VA clinic for any reason must undergo a mandatory four-question screen for mild TBI (see box). If they answer all four questions affirmatively, they get scheduled for a comprehensive TBI evaluation within 30 days by a multidisciplinary team at one of the more than 100 specialized rehabilitation sites in the VA system. Each of these teams consists of a neurologist or psychiatrist with TBI expertise, a physical medicine and rehabilitation physician, a psychologist, a speech and language pathologist, and occupational, physical, and recreational therapists. Telemedicine consults are available.

The most challenging cases are referred to one of four statewide polytrauma rehabilitation centers. A fifth polytrauma rehabilitation center is due to open in San Antonio this fall.

Of nearly 470,000 veterans screened for mild TBI through the VA’s mandatory program between April 2007 and Sept. 2010, roughly 20% answered all four questions affirmatively, indicating they had been exposed to a TBI. Follow-up evaluation at one of the more than 100 specialty clinics showed that 39% of those with a positive screen – or 8% of all returning service personnel – had a symptomatic TBI at that time.

Dr. Cifu coauthored a joint Department of Veterans Affairs and Department of Defense clinical practice guideline on the management of mild TBI. He recommended it as highly useful for non-VA physicians as well.

Polytrauma is a term used within the VA to describe individuals with TBI and another physical injury or psychological trauma. Particularly common is the constellation of chronic pain, post-traumatic stress disorder, depression, polysubstance use, and residual TBI symptoms such as headache, fatigue, and mental slowness.

"These are folks that aren’t getting well the way you read in the textbooks," Dr. Cifu observed.

Indeed, while in the civilian world roughly 97% of individuals who sustain a mild brain injury such as a sports concussion will be well a year later, that figure is substantially lower – more like 80% – for polytrauma patients in the VA system.

Among the factors contributing to poor outcomes in military personnel with polytrauma are the abundant physical and psychological stressors of the combat zone, delayed diagnosis of TBI, and the common occurrence of exposure to multiple TBIs.

"We have lots of folks who report 3, 5, 7, 10, 15 [TBIs]. We really don’t know what multiple blast injuries mean in terms of outcome. We have to understand this better," according to Dr. Cifu.

Pre-exposure factors may also contribute to polytrauma. About half of troops in Iraq and Afghanistan are volunteers, often fresh out of high school. Some have had a difficult upbringing that may render them less resilient to injury. The National Guard reservists are generally far older and often not optimally physically fit, he continued.

Louis M. French, Psy.D., said that he and his coinvestigators have found that among military personnel with mild TBI and bodily injuries, those with more severe bodily injuries reported less TBI-related neurobehavioral symptoms such as headache, forgetfulness, anxiety, and depression than did those with relatively minor bodily injuries.

It’s a paradoxical finding. One possible explanation is that people who are very seriously injured are happy to be alive and simply ignore minor neurobehavioral symptoms. Also, it’s easier for people who are more seriously injured to see tangible improvement resulting from their rehabilitation program, as when they start to walk again or get a prosthetic device, said Dr. French, director of the traumatic brain injury service at Walter Reed Army Medical Center in Washington.

In a recent study, Dr. French and coworkers found that 55% of service members with mild TBI reported symptoms consistent with the diagnosis of post-concussive disorder 12 months later.

"These are very different trajectories than you’d expect to see in a civilian population," he observed.

Dr. Michael Pollanen of Toronto, who is chief forensic pathologist for Ontario, said that his emerging hypothesis is that blast-related TBI might be a variant of diffuse axonal injury that leads to a distinctive syndrome of neuropsychiatric impairment. He has seen such injuries at the cellular level under the microscope at autopsy; now the search is on for a means of identifying diffuse axonal injury in blast survivors.

Four Items Screen for Mild TBI

• Question 1: Were you exposed to a trauma or blast while in Operation Enduring Freedom/Operation Iraqi Freedom?

• Question 2: As a result of the trauma or blast did you have a loss or alteration in consciousness (see stars, have bell rung, feel disoriented or confused)?

• Question 3: Did you develop problems with headache, insomnia, dizziness, thinking, or behavior immediately to soon after the trauma or blast?

• Question 4: Do you still have the problems with headache, insomnia, dizziness, thinking difficulties or behavior that you developed immediately to soon after the trauma or blast?

None of the speakers reported any financial conflicts.

DENVER — The P300 evoked-potential component of the EEG may provide a readily accessible early window on cognitive decline well in advance of the irreversible changes leading to dementia.

That’s the working hypothesis of Dr. Eric Braverman, who noted that the P300 is an easy-to-administer test that takes just 10 minutes and is well suited for use as a screening tool for middle-aged patients in primary care physicians’ offices.

"My vision is that we’re all going to have laptop brain-health checkups," he declared at the annual meetingof the American Neuropsychiatric Association.

He drew a parallel between dementia and coronary heart disease: Much as electrophysiological deterioration of the heart (as elicited by an exercise treadmill test) is generally antecedent to the massive metabolic derangement of an MI, he is convinced that electrophysiological deterioration in the brain (as expressed in delayed P300 evoked-potential latency) precedes the hypometabolic changes seen on functional PET imaging.

"The P300 is like a stress test of the head to find early deterioration in the [electrophysiological] parameters of voltage – a marker of overall brain cellular atrophy – and latency, or brain-processing speed," according to Dr. Braverman of Cornell University, New York, who is the founder and director of PATH (Place for Achieving Total Health) Medical.

"Thirty-five years of experience have shown me that a positive metabolic PET scan generally results in my patients’ having deteriorated compliance, deteriorated management, and a deteriorated progression," he said. "I’ve come to realize that the PET scan is really amazingly helpful in seeing patients in mild cognitive impairment states that are very damaged. The issue for me in preventive medicine is, can I predict who’s going to get a bad PET scan, so we can break the process through all the techniques we have, from treating depression to nutritional therapy, hormonal therapy, and lifestyle therapy."

Dr. Braverman presented a study of 85 subjects with mild cognitive impairment who received a comprehensive medical evaluation, including functional FDG [¹⁸fluorodeoxyglucose]–PET imaging, neuropsychological testing, and P300. In all, 44 had hypometabolism on PET and the rest had normal brain metabolism. Both groups had a mean age in the mid-50s.

The key study finding was that the two groups differed significantly in terms of their P300 voltage and latency. The mean P300 latency was 346 ms in the group with hypometabolic PET findings, compared with 323 ms in the normal metabolic group. The mean P300 voltage was 3.25 mV in the hypometabolic group and 5.0 mV in those with normal metabolism on functional PET.

It’s known that P300 latency increases with advancing age at a rate of 7-10 ms per decade. Since the mean difference between the hypometabolic and normal metabolic PET groups was 23 ms, that means that the hypometabolic patients exhibited the slower brain-processing speeds that are more typical of individuals at least 20-30 years older, according to Dr. Braverman.

The next step in his research project will be to try to identify the combination of P300 latency and voltage values and neuropsychological test results that are optimally predictive of which patients with memory and attention complaints are sufficiently early in cognitive decline that they haven’t developed hypometabolism, he added.

Session chair Dr. Jeremy D. Schmahmann indicated that this novel preventive strategy is still far from ready for routine use in clinical practice.

"It’s an interesting beginning, and hopefully we’ll see it progress," commented Dr. Schmahmann, professor of neurology at Harvard Medical School and director of the ataxia unit and the laboratory of neuroanatomy and cerebellar neurobiology at Massachusetts General Hospital, both in Boston.

Dr. Braverman indicated he had no relevant financial interests.

DENVER — The P300 evoked-potential component of the EEG may provide a readily accessible early window on cognitive decline well in advance of the irreversible changes leading to dementia.

That’s the working hypothesis of Dr. Eric Braverman, who noted that the P300 is an easy-to-administer test that takes just 10 minutes and is well suited for use as a screening tool for middle-aged patients in primary care physicians’ offices.

"My vision is that we’re all going to have laptop brain-health checkups," he declared at the annual meetingof the American Neuropsychiatric Association.

He drew a parallel between dementia and coronary heart disease: Much as electrophysiological deterioration of the heart (as elicited by an exercise treadmill test) is generally antecedent to the massive metabolic derangement of an MI, he is convinced that electrophysiological deterioration in the brain (as expressed in delayed P300 evoked-potential latency) precedes the hypometabolic changes seen on functional PET imaging.

"The P300 is like a stress test of the head to find early deterioration in the [electrophysiological] parameters of voltage – a marker of overall brain cellular atrophy – and latency, or brain-processing speed," according to Dr. Braverman of Cornell University, New York, who is the founder and director of PATH (Place for Achieving Total Health) Medical.

"Thirty-five years of experience have shown me that a positive metabolic PET scan generally results in my patients’ having deteriorated compliance, deteriorated management, and a deteriorated progression," he said. "I’ve come to realize that the PET scan is really amazingly helpful in seeing patients in mild cognitive impairment states that are very damaged. The issue for me in preventive medicine is, can I predict who’s going to get a bad PET scan, so we can break the process through all the techniques we have, from treating depression to nutritional therapy, hormonal therapy, and lifestyle therapy."

Dr. Braverman presented a study of 85 subjects with mild cognitive impairment who received a comprehensive medical evaluation, including functional FDG [¹⁸fluorodeoxyglucose]–PET imaging, neuropsychological testing, and P300. In all, 44 had hypometabolism on PET and the rest had normal brain metabolism. Both groups had a mean age in the mid-50s.

The key study finding was that the two groups differed significantly in terms of their P300 voltage and latency. The mean P300 latency was 346 ms in the group with hypometabolic PET findings, compared with 323 ms in the normal metabolic group. The mean P300 voltage was 3.25 mV in the hypometabolic group and 5.0 mV in those with normal metabolism on functional PET.

It’s known that P300 latency increases with advancing age at a rate of 7-10 ms per decade. Since the mean difference between the hypometabolic and normal metabolic PET groups was 23 ms, that means that the hypometabolic patients exhibited the slower brain-processing speeds that are more typical of individuals at least 20-30 years older, according to Dr. Braverman.

The next step in his research project will be to try to identify the combination of P300 latency and voltage values and neuropsychological test results that are optimally predictive of which patients with memory and attention complaints are sufficiently early in cognitive decline that they haven’t developed hypometabolism, he added.

Session chair Dr. Jeremy D. Schmahmann indicated that this novel preventive strategy is still far from ready for routine use in clinical practice.

"It’s an interesting beginning, and hopefully we’ll see it progress," commented Dr. Schmahmann, professor of neurology at Harvard Medical School and director of the ataxia unit and the laboratory of neuroanatomy and cerebellar neurobiology at Massachusetts General Hospital, both in Boston.

Dr. Braverman indicated he had no relevant financial interests.

DENVER — The P300 evoked-potential component of the EEG may provide a readily accessible early window on cognitive decline well in advance of the irreversible changes leading to dementia.

That’s the working hypothesis of Dr. Eric Braverman, who noted that the P300 is an easy-to-administer test that takes just 10 minutes and is well suited for use as a screening tool for middle-aged patients in primary care physicians’ offices.

"My vision is that we’re all going to have laptop brain-health checkups," he declared at the annual meetingof the American Neuropsychiatric Association.

He drew a parallel between dementia and coronary heart disease: Much as electrophysiological deterioration of the heart (as elicited by an exercise treadmill test) is generally antecedent to the massive metabolic derangement of an MI, he is convinced that electrophysiological deterioration in the brain (as expressed in delayed P300 evoked-potential latency) precedes the hypometabolic changes seen on functional PET imaging.

"The P300 is like a stress test of the head to find early deterioration in the [electrophysiological] parameters of voltage – a marker of overall brain cellular atrophy – and latency, or brain-processing speed," according to Dr. Braverman of Cornell University, New York, who is the founder and director of PATH (Place for Achieving Total Health) Medical.

"Thirty-five years of experience have shown me that a positive metabolic PET scan generally results in my patients’ having deteriorated compliance, deteriorated management, and a deteriorated progression," he said. "I’ve come to realize that the PET scan is really amazingly helpful in seeing patients in mild cognitive impairment states that are very damaged. The issue for me in preventive medicine is, can I predict who’s going to get a bad PET scan, so we can break the process through all the techniques we have, from treating depression to nutritional therapy, hormonal therapy, and lifestyle therapy."

Dr. Braverman presented a study of 85 subjects with mild cognitive impairment who received a comprehensive medical evaluation, including functional FDG [¹⁸fluorodeoxyglucose]–PET imaging, neuropsychological testing, and P300. In all, 44 had hypometabolism on PET and the rest had normal brain metabolism. Both groups had a mean age in the mid-50s.

The key study finding was that the two groups differed significantly in terms of their P300 voltage and latency. The mean P300 latency was 346 ms in the group with hypometabolic PET findings, compared with 323 ms in the normal metabolic group. The mean P300 voltage was 3.25 mV in the hypometabolic group and 5.0 mV in those with normal metabolism on functional PET.

It’s known that P300 latency increases with advancing age at a rate of 7-10 ms per decade. Since the mean difference between the hypometabolic and normal metabolic PET groups was 23 ms, that means that the hypometabolic patients exhibited the slower brain-processing speeds that are more typical of individuals at least 20-30 years older, according to Dr. Braverman.

The next step in his research project will be to try to identify the combination of P300 latency and voltage values and neuropsychological test results that are optimally predictive of which patients with memory and attention complaints are sufficiently early in cognitive decline that they haven’t developed hypometabolism, he added.

Session chair Dr. Jeremy D. Schmahmann indicated that this novel preventive strategy is still far from ready for routine use in clinical practice.

"It’s an interesting beginning, and hopefully we’ll see it progress," commented Dr. Schmahmann, professor of neurology at Harvard Medical School and director of the ataxia unit and the laboratory of neuroanatomy and cerebellar neurobiology at Massachusetts General Hospital, both in Boston.

Dr. Braverman indicated he had no relevant financial interests.

DENVER — The P300 evoked-potential component of the EEG may provide a readily accessible early window on cognitive decline well in advance of the irreversible changes leading to dementia.

That’s the working hypothesis of Dr. Eric Braverman, who noted that the P300 is an easy-to-administer test that takes just 10 minutes and is well suited for use as a screening tool for middle-aged patients in primary care physicians’ offices.

"My vision is that we’re all going to have laptop brain-health checkups," he declared at the annual meetingof the American Neuropsychiatric Association.

He drew a parallel between dementia and coronary heart disease: Much as electrophysiological deterioration of the heart (as elicited by an exercise treadmill test) is generally antecedent to the massive metabolic derangement of an MI, he is convinced that electrophysiological deterioration in the brain (as expressed in delayed P300 evoked-potential latency) precedes the hypometabolic changes seen on functional PET imaging.

"The P300 is like a stress test of the head to find early deterioration in the [electrophysiological] parameters of voltage – a marker of overall brain cellular atrophy – and latency, or brain-processing speed," according to Dr. Braverman of Cornell University, New York, who is the founder and director of PATH (Place for Achieving Total Health) Medical.

"Thirty-five years of experience have shown me that a positive metabolic PET scan generally results in my patients’ having deteriorated compliance, deteriorated management, and a deteriorated progression," he said. "I’ve come to realize that the PET scan is really amazingly helpful in seeing patients in mild cognitive impairment states that are very damaged. The issue for me in preventive medicine is, can I predict who’s going to get a bad PET scan, so we can break the process through all the techniques we have, from treating depression to nutritional therapy, hormonal therapy, and lifestyle therapy."

Dr. Braverman presented a study of 85 subjects with mild cognitive impairment who received a comprehensive medical evaluation, including functional FDG [¹⁸fluorodeoxyglucose]–PET imaging, neuropsychological testing, and P300. In all, 44 had hypometabolism on PET and the rest had normal brain metabolism. Both groups had a mean age in the mid-50s.

The key study finding was that the two groups differed significantly in terms of their P300 voltage and latency. The mean P300 latency was 346 ms in the group with hypometabolic PET findings, compared with 323 ms in the normal metabolic group. The mean P300 voltage was 3.25 mV in the hypometabolic group and 5.0 mV in those with normal metabolism on functional PET.

It’s known that P300 latency increases with advancing age at a rate of 7-10 ms per decade. Since the mean difference between the hypometabolic and normal metabolic PET groups was 23 ms, that means that the hypometabolic patients exhibited the slower brain-processing speeds that are more typical of individuals at least 20-30 years older, according to Dr. Braverman.

The next step in his research project will be to try to identify the combination of P300 latency and voltage values and neuropsychological test results that are optimally predictive of which patients with memory and attention complaints are sufficiently early in cognitive decline that they haven’t developed hypometabolism, he added.

Session chair Dr. Jeremy D. Schmahmann indicated that this novel preventive strategy is still far from ready for routine use in clinical practice.

"It’s an interesting beginning, and hopefully we’ll see it progress," commented Dr. Schmahmann, professor of neurology at Harvard Medical School and director of the ataxia unit and the laboratory of neuroanatomy and cerebellar neurobiology at Massachusetts General Hospital, both in Boston.

Dr. Braverman indicated he had no relevant financial interests.

DENVER — The P300 evoked-potential component of the EEG may provide a readily accessible early window on cognitive decline well in advance of the irreversible changes leading to dementia.

That’s the working hypothesis of Dr. Eric Braverman, who noted that the P300 is an easy-to-administer test that takes just 10 minutes and is well suited for use as a screening tool for middle-aged patients in primary care physicians’ offices.

"My vision is that we’re all going to have laptop brain-health checkups," he declared at the annual meetingof the American Neuropsychiatric Association.

He drew a parallel between dementia and coronary heart disease: Much as electrophysiological deterioration of the heart (as elicited by an exercise treadmill test) is generally antecedent to the massive metabolic derangement of an MI, he is convinced that electrophysiological deterioration in the brain (as expressed in delayed P300 evoked-potential latency) precedes the hypometabolic changes seen on functional PET imaging.

"The P300 is like a stress test of the head to find early deterioration in the [electrophysiological] parameters of voltage – a marker of overall brain cellular atrophy – and latency, or brain-processing speed," according to Dr. Braverman of Cornell University, New York, who is the founder and director of PATH (Place for Achieving Total Health) Medical.

"Thirty-five years of experience have shown me that a positive metabolic PET scan generally results in my patients’ having deteriorated compliance, deteriorated management, and a deteriorated progression," he said. "I’ve come to realize that the PET scan is really amazingly helpful in seeing patients in mild cognitive impairment states that are very damaged. The issue for me in preventive medicine is, can I predict who’s going to get a bad PET scan, so we can break the process through all the techniques we have, from treating depression to nutritional therapy, hormonal therapy, and lifestyle therapy."

Dr. Braverman presented a study of 85 subjects with mild cognitive impairment who received a comprehensive medical evaluation, including functional FDG [¹⁸fluorodeoxyglucose]–PET imaging, neuropsychological testing, and P300. In all, 44 had hypometabolism on PET and the rest had normal brain metabolism. Both groups had a mean age in the mid-50s.

The key study finding was that the two groups differed significantly in terms of their P300 voltage and latency. The mean P300 latency was 346 ms in the group with hypometabolic PET findings, compared with 323 ms in the normal metabolic group. The mean P300 voltage was 3.25 mV in the hypometabolic group and 5.0 mV in those with normal metabolism on functional PET.

It’s known that P300 latency increases with advancing age at a rate of 7-10 ms per decade. Since the mean difference between the hypometabolic and normal metabolic PET groups was 23 ms, that means that the hypometabolic patients exhibited the slower brain-processing speeds that are more typical of individuals at least 20-30 years older, according to Dr. Braverman.

The next step in his research project will be to try to identify the combination of P300 latency and voltage values and neuropsychological test results that are optimally predictive of which patients with memory and attention complaints are sufficiently early in cognitive decline that they haven’t developed hypometabolism, he added.

Session chair Dr. Jeremy D. Schmahmann indicated that this novel preventive strategy is still far from ready for routine use in clinical practice.

"It’s an interesting beginning, and hopefully we’ll see it progress," commented Dr. Schmahmann, professor of neurology at Harvard Medical School and director of the ataxia unit and the laboratory of neuroanatomy and cerebellar neurobiology at Massachusetts General Hospital, both in Boston.

Dr. Braverman indicated he had no relevant financial interests.

DENVER — The P300 evoked-potential component of the EEG may provide a readily accessible early window on cognitive decline well in advance of the irreversible changes leading to dementia.

That’s the working hypothesis of Dr. Eric Braverman, who noted that the P300 is an easy-to-administer test that takes just 10 minutes and is well suited for use as a screening tool for middle-aged patients in primary care physicians’ offices.

"My vision is that we’re all going to have laptop brain-health checkups," he declared at the annual meetingof the American Neuropsychiatric Association.

He drew a parallel between dementia and coronary heart disease: Much as electrophysiological deterioration of the heart (as elicited by an exercise treadmill test) is generally antecedent to the massive metabolic derangement of an MI, he is convinced that electrophysiological deterioration in the brain (as expressed in delayed P300 evoked-potential latency) precedes the hypometabolic changes seen on functional PET imaging.

"The P300 is like a stress test of the head to find early deterioration in the [electrophysiological] parameters of voltage – a marker of overall brain cellular atrophy – and latency, or brain-processing speed," according to Dr. Braverman of Cornell University, New York, who is the founder and director of PATH (Place for Achieving Total Health) Medical.

"Thirty-five years of experience have shown me that a positive metabolic PET scan generally results in my patients’ having deteriorated compliance, deteriorated management, and a deteriorated progression," he said. "I’ve come to realize that the PET scan is really amazingly helpful in seeing patients in mild cognitive impairment states that are very damaged. The issue for me in preventive medicine is, can I predict who’s going to get a bad PET scan, so we can break the process through all the techniques we have, from treating depression to nutritional therapy, hormonal therapy, and lifestyle therapy."

Dr. Braverman presented a study of 85 subjects with mild cognitive impairment who received a comprehensive medical evaluation, including functional FDG [¹⁸fluorodeoxyglucose]–PET imaging, neuropsychological testing, and P300. In all, 44 had hypometabolism on PET and the rest had normal brain metabolism. Both groups had a mean age in the mid-50s.

The key study finding was that the two groups differed significantly in terms of their P300 voltage and latency. The mean P300 latency was 346 ms in the group with hypometabolic PET findings, compared with 323 ms in the normal metabolic group. The mean P300 voltage was 3.25 mV in the hypometabolic group and 5.0 mV in those with normal metabolism on functional PET.

It’s known that P300 latency increases with advancing age at a rate of 7-10 ms per decade. Since the mean difference between the hypometabolic and normal metabolic PET groups was 23 ms, that means that the hypometabolic patients exhibited the slower brain-processing speeds that are more typical of individuals at least 20-30 years older, according to Dr. Braverman.

The next step in his research project will be to try to identify the combination of P300 latency and voltage values and neuropsychological test results that are optimally predictive of which patients with memory and attention complaints are sufficiently early in cognitive decline that they haven’t developed hypometabolism, he added.

Session chair Dr. Jeremy D. Schmahmann indicated that this novel preventive strategy is still far from ready for routine use in clinical practice.

"It’s an interesting beginning, and hopefully we’ll see it progress," commented Dr. Schmahmann, professor of neurology at Harvard Medical School and director of the ataxia unit and the laboratory of neuroanatomy and cerebellar neurobiology at Massachusetts General Hospital, both in Boston.

Dr. Braverman indicated he had no relevant financial interests.

DENVER — The P300 evoked-potential component of the EEG may provide a readily accessible early window on cognitive decline well in advance of the irreversible changes leading to dementia.

That’s the working hypothesis of Dr. Eric Braverman, who noted that the P300 is an easy-to-administer test that takes just 10 minutes and is well suited for use as a screening tool for middle-aged patients in primary care physicians’ offices.

"My vision is that we’re all going to have laptop brain-health checkups," he declared at the annual meetingof the American Neuropsychiatric Association.

He drew a parallel between dementia and coronary heart disease: Much as electrophysiological deterioration of the heart (as elicited by an exercise treadmill test) is generally antecedent to the massive metabolic derangement of an MI, he is convinced that electrophysiological deterioration in the brain (as expressed in delayed P300 evoked-potential latency) precedes the hypometabolic changes seen on functional PET imaging.

"The P300 is like a stress test of the head to find early deterioration in the [electrophysiological] parameters of voltage – a marker of overall brain cellular atrophy – and latency, or brain-processing speed," according to Dr. Braverman of Cornell University, New York, who is the founder and director of PATH (Place for Achieving Total Health) Medical.

"Thirty-five years of experience have shown me that a positive metabolic PET scan generally results in my patients’ having deteriorated compliance, deteriorated management, and a deteriorated progression," he said. "I’ve come to realize that the PET scan is really amazingly helpful in seeing patients in mild cognitive impairment states that are very damaged. The issue for me in preventive medicine is, can I predict who’s going to get a bad PET scan, so we can break the process through all the techniques we have, from treating depression to nutritional therapy, hormonal therapy, and lifestyle therapy."

Dr. Braverman presented a study of 85 subjects with mild cognitive impairment who received a comprehensive medical evaluation, including functional FDG [¹⁸fluorodeoxyglucose]–PET imaging, neuropsychological testing, and P300. In all, 44 had hypometabolism on PET and the rest had normal brain metabolism. Both groups had a mean age in the mid-50s.

The key study finding was that the two groups differed significantly in terms of their P300 voltage and latency. The mean P300 latency was 346 ms in the group with hypometabolic PET findings, compared with 323 ms in the normal metabolic group. The mean P300 voltage was 3.25 mV in the hypometabolic group and 5.0 mV in those with normal metabolism on functional PET.

It’s known that P300 latency increases with advancing age at a rate of 7-10 ms per decade. Since the mean difference between the hypometabolic and normal metabolic PET groups was 23 ms, that means that the hypometabolic patients exhibited the slower brain-processing speeds that are more typical of individuals at least 20-30 years older, according to Dr. Braverman.

The next step in his research project will be to try to identify the combination of P300 latency and voltage values and neuropsychological test results that are optimally predictive of which patients with memory and attention complaints are sufficiently early in cognitive decline that they haven’t developed hypometabolism, he added.

Session chair Dr. Jeremy D. Schmahmann indicated that this novel preventive strategy is still far from ready for routine use in clinical practice.

"It’s an interesting beginning, and hopefully we’ll see it progress," commented Dr. Schmahmann, professor of neurology at Harvard Medical School and director of the ataxia unit and the laboratory of neuroanatomy and cerebellar neurobiology at Massachusetts General Hospital, both in Boston.

Dr. Braverman indicated he had no relevant financial interests.

DENVER — The P300 evoked-potential component of the EEG may provide a readily accessible early window on cognitive decline well in advance of the irreversible changes leading to dementia.

That’s the working hypothesis of Dr. Eric Braverman, who noted that the P300 is an easy-to-administer test that takes just 10 minutes and is well suited for use as a screening tool for middle-aged patients in primary care physicians’ offices.

"My vision is that we’re all going to have laptop brain-health checkups," he declared at the annual meetingof the American Neuropsychiatric Association.

He drew a parallel between dementia and coronary heart disease: Much as electrophysiological deterioration of the heart (as elicited by an exercise treadmill test) is generally antecedent to the massive metabolic derangement of an MI, he is convinced that electrophysiological deterioration in the brain (as expressed in delayed P300 evoked-potential latency) precedes the hypometabolic changes seen on functional PET imaging.

"The P300 is like a stress test of the head to find early deterioration in the [electrophysiological] parameters of voltage – a marker of overall brain cellular atrophy – and latency, or brain-processing speed," according to Dr. Braverman of Cornell University, New York, who is the founder and director of PATH (Place for Achieving Total Health) Medical.

"Thirty-five years of experience have shown me that a positive metabolic PET scan generally results in my patients’ having deteriorated compliance, deteriorated management, and a deteriorated progression," he said. "I’ve come to realize that the PET scan is really amazingly helpful in seeing patients in mild cognitive impairment states that are very damaged. The issue for me in preventive medicine is, can I predict who’s going to get a bad PET scan, so we can break the process through all the techniques we have, from treating depression to nutritional therapy, hormonal therapy, and lifestyle therapy."

Dr. Braverman presented a study of 85 subjects with mild cognitive impairment who received a comprehensive medical evaluation, including functional FDG [¹⁸fluorodeoxyglucose]–PET imaging, neuropsychological testing, and P300. In all, 44 had hypometabolism on PET and the rest had normal brain metabolism. Both groups had a mean age in the mid-50s.

The key study finding was that the two groups differed significantly in terms of their P300 voltage and latency. The mean P300 latency was 346 ms in the group with hypometabolic PET findings, compared with 323 ms in the normal metabolic group. The mean P300 voltage was 3.25 mV in the hypometabolic group and 5.0 mV in those with normal metabolism on functional PET.

It’s known that P300 latency increases with advancing age at a rate of 7-10 ms per decade. Since the mean difference between the hypometabolic and normal metabolic PET groups was 23 ms, that means that the hypometabolic patients exhibited the slower brain-processing speeds that are more typical of individuals at least 20-30 years older, according to Dr. Braverman.

The next step in his research project will be to try to identify the combination of P300 latency and voltage values and neuropsychological test results that are optimally predictive of which patients with memory and attention complaints are sufficiently early in cognitive decline that they haven’t developed hypometabolism, he added.

Session chair Dr. Jeremy D. Schmahmann indicated that this novel preventive strategy is still far from ready for routine use in clinical practice.

"It’s an interesting beginning, and hopefully we’ll see it progress," commented Dr. Schmahmann, professor of neurology at Harvard Medical School and director of the ataxia unit and the laboratory of neuroanatomy and cerebellar neurobiology at Massachusetts General Hospital, both in Boston.

Dr. Braverman indicated he had no relevant financial interests.

DENVER — The P300 evoked-potential component of the EEG may provide a readily accessible early window on cognitive decline well in advance of the irreversible changes leading to dementia.

That’s the working hypothesis of Dr. Eric Braverman, who noted that the P300 is an easy-to-administer test that takes just 10 minutes and is well suited for use as a screening tool for middle-aged patients in primary care physicians’ offices.

"My vision is that we’re all going to have laptop brain-health checkups," he declared at the annual meetingof the American Neuropsychiatric Association.

He drew a parallel between dementia and coronary heart disease: Much as electrophysiological deterioration of the heart (as elicited by an exercise treadmill test) is generally antecedent to the massive metabolic derangement of an MI, he is convinced that electrophysiological deterioration in the brain (as expressed in delayed P300 evoked-potential latency) precedes the hypometabolic changes seen on functional PET imaging.

"The P300 is like a stress test of the head to find early deterioration in the [electrophysiological] parameters of voltage – a marker of overall brain cellular atrophy – and latency, or brain-processing speed," according to Dr. Braverman of Cornell University, New York, who is the founder and director of PATH (Place for Achieving Total Health) Medical.

"Thirty-five years of experience have shown me that a positive metabolic PET scan generally results in my patients’ having deteriorated compliance, deteriorated management, and a deteriorated progression," he said. "I’ve come to realize that the PET scan is really amazingly helpful in seeing patients in mild cognitive impairment states that are very damaged. The issue for me in preventive medicine is, can I predict who’s going to get a bad PET scan, so we can break the process through all the techniques we have, from treating depression to nutritional therapy, hormonal therapy, and lifestyle therapy."

Dr. Braverman presented a study of 85 subjects with mild cognitive impairment who received a comprehensive medical evaluation, including functional FDG [¹⁸fluorodeoxyglucose]–PET imaging, neuropsychological testing, and P300. In all, 44 had hypometabolism on PET and the rest had normal brain metabolism. Both groups had a mean age in the mid-50s.

The key study finding was that the two groups differed significantly in terms of their P300 voltage and latency. The mean P300 latency was 346 ms in the group with hypometabolic PET findings, compared with 323 ms in the normal metabolic group. The mean P300 voltage was 3.25 mV in the hypometabolic group and 5.0 mV in those with normal metabolism on functional PET.

It’s known that P300 latency increases with advancing age at a rate of 7-10 ms per decade. Since the mean difference between the hypometabolic and normal metabolic PET groups was 23 ms, that means that the hypometabolic patients exhibited the slower brain-processing speeds that are more typical of individuals at least 20-30 years older, according to Dr. Braverman.

The next step in his research project will be to try to identify the combination of P300 latency and voltage values and neuropsychological test results that are optimally predictive of which patients with memory and attention complaints are sufficiently early in cognitive decline that they haven’t developed hypometabolism, he added.

Session chair Dr. Jeremy D. Schmahmann indicated that this novel preventive strategy is still far from ready for routine use in clinical practice.

"It’s an interesting beginning, and hopefully we’ll see it progress," commented Dr. Schmahmann, professor of neurology at Harvard Medical School and director of the ataxia unit and the laboratory of neuroanatomy and cerebellar neurobiology at Massachusetts General Hospital, both in Boston.

Dr. Braverman indicated he had no relevant financial interests.