Figure 1: The brain and spinal cord

INTRODUCTION

What Is An Acute Neurological Injury?

Explaining Spinal Cord Injury, Stroke, and Traumatic Brain Injury

YOu May Wonder Why I wrote about three different neurological injuries, rather than about spinal cord injury (SCI) alone. If you’ve experienced an SCI, stroke, or traumatic brain injury (TBI), your injury is considered an acute neurological injury (ANI). These three conditions result in many of the same physical disabilities: paralysis and loss of sensation, of course, but also difficulty eating, sleeping, breathing, exercising, having a bowel movement, communicating (speaking, hearing, and understanding language), and performing many activities of daily living. They also share many psychological and mental health disorders: anxiety, depression, emotional lability, grief, and post-traumatic stress disorder (PTSD).

ANIs share many of the same therapies and treatments—during hospital care and outpatient rehabilitation—which is why the person next to you at physical therapy may be going through the same balance and walking exercises as you, even though you’ve had a stroke and she’s had a TBI. Many of the medications are the same, and many assistive devices are useful for anyone with an ANI. Whether you’ve experienced a stroke, SCI, or TBI, you may find the advice given here to be helpful for your recovery. You’ll also, of course, find advice for your particular ANI throughout.

To help you understand the physical aspects of the ANIs, here’s a brief anatomy lesson (Figure 1). Dr. David Goldstein, chief of the Autonomic Medicine Section at the National Institute of Neurological Disorders and Stroke, describes the central nervous system as “like a Tootsie Roll pop. The brain is the candy. The spinal cord is the stick. The chewy chocolate center is the brainstem.”¹ The brain consists of all tissues within your skull from the brainstem upward. It’s divided into four lobes based on their overlying neurocranial bones. Counterclockwise, they are the frontal, parietal, occipital, and temporal lobes. In Figure 1, the temporal lobe was removed to expose the hippocampus (center of memory and learning), Broca’s area (center of speech and language), and the corpus callosum (a large collection of nerves that connect the two halves of the brain). The cerebrum of the brain is the uppermost region of the central nervous system. With the cerebellum, it controls all voluntary actions of the human body. The cerebral cortex is the outer layer of nerves in the cerebrum and is the largest site of nerve connections, processing of information, and source of movement and activities. It plays a key role in thought, memory, language, and consciousness. The spinal cord begins where the bottom of the brain (the brainstem) exits the skull. The upper part of the spinal cord is the cervical region, with seven vertebrae. The brain receives blood and nutrition via the carotid arteries in the front and the vertebral arteries in the back (not shown).

The Three ANIs: Spinal Cord Injury, Stroke, and Traumatic Brain Injury

Spinal Cord Injury (SCI): SCI is damage to the spinal cord that causes immediate changes in function of the body at or below the site of injury. The extent of the injury is determined by the vertebrae of the spine, which are divided into four parts, each with its own number of bones. Just below the entrance to the brain are the cervical vertebrae (C1 to C7, Figure 2A), followed by the thoracic (T1 to T12), the lumbar (L1 to L5), and finally the sacral vertebrae (S1 to S5) at the bottom. Doctors “map” the spinal cord to the body by using sensation to identify regions of the skin, called dermatomes, that are supplied by nerves that exit the spinal cord at specific sites. For example, the thumb and forefinger are innervated by C6, while the nipples are innervated by T6 (Figure 2B). These sites are also where nerves that control muscle movement (motor neurons) exit the spinal cord, so that damage to C6 will paralyze the wrist flexors, triceps, and thumb and forefinger (Figure 2C). The higher the SCI (the closer to your brain), the more severe the motor and sensory deficits. Above T1 to C7, you will be a tetraplegic, with weakness in both your legs and hands (Figures 2B and 2C). Long-term outcomes range widely, from full recovery to permanent tetraplegia (also called quadriplegia, meaning paralysis and/or loss of sensation in all four limbs) or paraplegia (paralysis and/or loss of sensation only in the legs, usually). Paraplegia occurs when the injury is below T1. An SCI diagnosis is made by both clinical exam and imaging (Figure 3).

Figure 2. The vertebrae, dermatomes, and associated functional deficits

Figure 3: SCI with vertebrae damage and spinal cord contusion

Stroke: Stroke is a sudden loss of blood flow to a part of the brain, which causes cells to die. There are three major types of stroke (Figure 4): 1) ischemic, due to decreased blood flow from local blockage of a blood vessel; 2) embolic, due to decreased blood flow from a clot that travels up the carotid or vertebral artery; and 3) hemorrhagic, due to leakage or rupture of a blood vessel, causing bleeding into the brain. Stroke damage can resemble that of SCI because the death of cells in the part of the brain that senses or moves limbs can be similar. In the case of stroke, however, this usually occurs on only one side of your body. Stroke is also unique in that it can cause difficulty with speech (understanding or speaking language) or loss of vision on one side (rarely, TBI can have similar effects). A stroke diagnosis is made by both clinical exam and imaging.

Figure 4: A. Embolic white line is an embolus stuck in a narrow vessel (1), B. Ischemic brain swelling due to lack of blood flow from embolus in (A) (2), C. Hemorrhagic Stroke blood in the brain from a leaking blood vessel (3), D. Normal

Traumatic Brain Injury (TBI): TBI (Figure 5) is damage to the brain resulting from an external mechanical force, such as the rapid acceleration and deceleration that occurs with a car accident or if your head hits a heavy object. Diagnosis can be easily made when the force causes bleeding or a skull fracture. Localized injuries are more frequent in TBI, and they are particularly common in the lower part of the frontal lobes, which are involved in “executive functions,” such as social behavior, emotions, smell, and judgment. However, when the injury is widespread, there isn’t much damage evident on a CT scan. Diffusion tensor imaging (DTI), which shows white matter tracts (the axons of the nerves) separate from the gray matter (the bodies of the nerves), is an excellent way to show diffuse damage. This appears as “white matter hyperintensities” (a starlike object in the deeper parts of the brain). Symptoms such as paralysis or difficulty with language may occur when the TBI is more severe.

Figure 5: TBI showing frontal contusions (1 and 2), subdural hematoma (3), and traumatic subarachnoid hemorrhage (4) compared to normal (right)

The Autonomic Nervous System

The autonomic nervous system (ANS; Figure 6) is the main controller of your body’s internal environment. It automatically maintains your blood pressure, heart rate, respiration, digestion, and body temperature. There are two major components: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). These work together and in opposition to control these functions every day. Unfortunately, damage to the brainstem or spinal cord disrupts the SNS and PNS, causing many problems. Chapters 9 through 14 discuss how damage to the ANS can make your life very difficult. Even worse, there are very few therapies to rehabilitate or restore it.

Figure 6. Autonomic nervous system

How This Book Can Help You

What you’ll find in the pages ahead is everything I’ve learned—as a patient and as a doctor—about recovery after ANI. I’ll take you from initial injury, through recovery, and all the way to leading your best life as an ANI survivor. You’ll read about new devices, drugs, therapies, and approaches to “rewire” the brain that offer the possibility of actually restoring function. You’ll also learn about the concept of neuroplasticity, the brain’s ability to change how it performs a specific function by establishing new connections between nerves to restore these functions. Throughout it all, I’ll remind you about the importance of goal setting, resilience, and tapping into the power of your mind.

One of the hardest parts of experiencing an ANI is the psychological trauma. Grappling with a “new normal” is profoundly difficult, mentally and emotionally. And, unlike a musculoskeletal injury, where the damage is visible, an ANI is hidden, and it often places an enormous burden on you and your family. Wrapping your mind around what you’ve experienced is the first step in your recovery, and this book contains advice to help you get there. This ability to deal with the psychological consequences of your injury not only starts your journey—it’s also important every step of the way.

The information in this book is meant to educate and inspire you on your rehabilitation and recovery journey. It will show you the enormous variety of approaches to help you regain function. There are strong opinions on treatments to try and therapies to avoid. This isn’t a prescription—it’s a supplement to the recommendations of your medical team. Each person is unique, as is each ANI. Use what you learn in this book to have more in-depth conversations with your doctor and your therapy team.

Part 1 takes you through the initial injury and the power of your mind in the healing process. Part 2 shows you the vast landscape of neurorehabilitation and examines the similarities and differences between Western and Eastern medicine to provide multiple approaches to your recovery. Part 3 addresses many common medical problems you may face after ANI. In Part 4, you’ll learn about adaptive devices that can help you enjoy a rewarding and meaningful life. And you’ll learn about new and innovative therapies on the horizon and how to maintain your resilience despite years of disability. But first, we’ll start at the beginning and learn how to deal with your initial grief, so you can start to heal.

Having an ANI is one of the most serious challenges anyone will face. Ultimately, what I’ve learned is that each day offers opportunities for joy. I hope this book will help you on your journey back to a meaningful life.