Perhaps you have grown up hearing that a concussion is a bruise to the brain. Or, maybe after a hit to the head, you have been told: “You’ll be fine — you just got your bell rung.”

While these are common beliefs, they are inaccurate. First, bruising suggests bleeding, and a concussed brain does not bleed. In fact, images of a concussed brain may look normal as concussions generally do not show up on MRI or CT scans.

This is because a concussion is an injury that disrupts the normal functioning of the brain. In other words, it can temporarily change how the brain works but does not change the appearance of the brain. These changes, which can show up symptomatically throughout the entire body, may affect mood, cause blurry or double vision, produce balance problems, create increased sensitivity to light and sound, and be the root of behavior changes.

Since brain injuries are not visible to the eye, someone with a concussion may “look” normal and may be accused of “faking it” or be directed to “just walk it off.” But a concussion can be a very serious injury, identified mainly by concussion symptoms that you cannot just “walk off.” It is important to have an awareness of the many indicators of concussion.

Many people have difficulty identifying concussion symptoms because indicators may not appear for hours, days, or even weeks after the initial hit to the head or blow to the body. It is therefore important to be aware of the large variety of symptoms that may result from a concussion.

Symptoms of a concussion generally affect four areas: thinking and remembering; your physical body; mood and emotions; and sleep. If you are suffering from a concussion, you may find your thoughts are fuzzy or you don’t feel quite right. Or you may find you have trouble concentrating, thinking, studying or remembering. You may physically have trouble balancing or have blurred or double vision. You may experience headaches, nausea, vomiting, extreme fatigue or loss of energy. Your emotions and mood may be different. You may feel irritable, sad, depressed or more anxious than usual. You may find you are sleeping more than usual, less than usual or have difficulty falling asleep. However, it is important to understand that you need only one of these symptoms to indicate a concussion.

It is important to keep in mind that recovery typically means someone has lost certain abilities temporarily and will regain them. For a person with a brain injury — even an injury as common as a concussion — although he or she may look the same, the changes to the brain may be long-lasting and adjustment is an ongoing process. Often, concussion recovery in young children and teens can take longer than usual. Symptoms can last for days, weeks or longer. Sometimes, recovering from a concussion may take months or years. And, some people may never fully recover from a concussion. The good news is that most people recover quickly and fully from concussions. Generally, recovery includes getting plenty of rest, avoiding physical activity and limiting school work. In some cases, special eye therapies, occupational therapy or balance exercises may be necessary to expedite recovery.

The Centers for Disease Control and Prevention and the Oregon Concussion Awareness and Management Program each have helpful information about concussions and healing from them afterwards.

Kayt Zundel, MPA, MS
Program Director
OHSU ThinkFirst Oregon
Brain and Spinal Cord Injury Prevention

Patients and their family members have been bringing me clippings from that famous medical journal, “The Wall Street Journal,” asking me if it’s true that Alzheimer’s research is now focused on something called “tau.”

As I wrote in an earlier blog post, the leading hypothesis until very recently was that “amyloid,” the stuff in the brain plaques in Alzheimer’s, was the cause of the disease due to toxic effects on brain cells. I also noted previously that some studies completed last summer showed that although some drugs did reduce the amount of amyloid in the brain, the patients did not benefit clinically. There have been a variety of reactions to those findings, but one reaction has been to try to find an alternative “therapeutic target.”

When Dr. Alzheimer looked through his microscope at that first patient’s brain 100 years ago, he saw both plaques (made of amyloid, a protein) and tangles (made of tau, a different protein) in the brain tissue. All along there have been scientists who have promoted the “tau hypothesis,” suggesting that aggregated forms of tau in the tangles are toxic to the brain and more relevant to Alzheimer’s disease than amyloid.

So the “news” in the Wall Street Journal is not actually news, but the trend is a new one and a real one. There is one “anti-tau” therapy that is being tested in later-stage clinical trials. But most other therapies that might fight the tau aren’t yet being tested in humans. In fact, my lab is shifting its emphasis from amyloid to tau as a “therapeutic target” and we are hopeful that this will be a more fruitful target of therapy.

Continue to follow this blog to learn more about our research into tau-targeted therapies.

Joseph Quinn, M.D.
Professor of Neurology
Layton Aging & Alzheimer’s Disease Center
OHSU Brain Institute

The recent shootings at the Clackamas Town Center mall and then at the elementary school in Newtown, Conn., made me think about emotional distress, and the ways in which it mirrors physical pain. When we talk about emotional suffering, it is almost impossible to avoid pain-related words. We say: “She hurt my feelings.” Or: “He broke her heart.” This is not just an idiosyncrasy of the English language; a similar pattern has been documented in a host of languages.

Why do we do this? Why this apparent conflation of physical pain and emotional distress? It turns out that the neural circuits important for emotional distress — feelings of social isolation, grief, jealousy, and shame — have much in common with those responsible for pain following physical injury.

For example, imaging studies show that the areas of the brain that “light up” when an experimental subject is made to feel “left out” by other players in a computer game coincide with those activated by a physical pain stimulus. A similar pattern is seen if subjects are asked to remember breaking up with a romantic partner.

The overlap is strongest in those parts of the brain thought to be important in the suffering or “avoidance” aspect of physical pain. This idea that physical and emotional pain have parallel underpinnings in the brain makes sense if we think of the importance of relationships with other people for a social species such as ourselves. For example, an infant or child abandoned by his or her parents is unlikely to flourish, and may not survive. In evolutionary terms, isolation and loss of social relationships could hamper survival and reduce fitness just as much as physical injury.

This parallel processing of emotional and physical pain has some concrete implications. One prediction is that individuals who are more susceptible to development of chronic pain are also relatively sensitive to social pain. There is some evidence to support this idea, in patients and in the lab. For example, experimental subjects who were more sensitive to heat pain were also found to be more distressed when excluded from a virtual ball game. Another prediction is that an individual’s social environment will influence his or her sensitivity to pain, and could even contribute to or protect from chronic pain.

Consistent with this, there is evidence that social loss (such as the death of a spouse) sometimes exacerbates chronic pain. On the other hand, social support may reduce pain. For example, the presence of a doula (a non-medical person who helps in childbirth) has been shown in some studies to reduce the need for pain medications for women in labor. The importance of the social environment for pain, especially chronic pain, is one of the reasons that the most successful approaches to pain management are multidisciplinary, and involve specialists in psychology as well as physical medicine.

In a sense then, just as physical pain has a protective function — alerting us to physical injury — emotional pain could warn of social loss or disconnection. Hopefully, just as physical pain causes us to seek healing, emotional pain motivates us to strengthen social bonds, and work to prevent such distressing events in the future.

Mary Heinricher, Ph.D.
Professor, departments of Neurological Surgery and Behavioral Neuroscience
OHSU Brain Institute

What if we could predict who would one day go on to develop Alzheimer’s disease?

There is no definitive test for Alzheimer’s disease. Neurologists and others who specialize in treating dementia are very accurate in diagnosing Alzheimer’s disease once symptoms have begun. Memory or other thinking problems and performance on different kinds of cognitive tests give a good indication of whether someone has dementia or another condition that can cause memory problems. Once a diagnosis of Alzheimer’s disease or other dementia is made, treatment and family planning can begin.

There has been a lot of recent research into tests that might be able to diagnose very early Alzheimer disease or even predict who might one day develop the disease. This research is still unproven, but many see promise in it.  If we could develop a test for Alzheimer’s disease before symptoms emerge, maybe we could identify better treatments for those who go on to develop the disease. And maybe we could help find ways to prevent Alzheimer’s disease from developing in the first place.

One of the most active areas of research in Alzheimer’s disease in recent years has been around testing for a protein called amyloid. People with Alzheimer’s disease develop clumps of amyloid protein in their brains over time. Many researchers think that the accumulation of amyloid leads to the destruction of brain cells. A test for amyloid in patients with early cognitive problems or at risk of Alzheimer’s disease might signal who is going to go on to develop symptoms of Alzheimer’s disease and who is not.

One way to test for amyloid is through the use of a very specialized brain scan. The Food and Drug Administration recently approved a compound called florbetapir that can “tag” amyloid while a patient undergoes a PET scan. This is an exciting new technology, but still largely unproven. It is not clear that everyone who is found to have amyloid on such a scan has Alzheimer’s disease or will even go on to develop it one day.

This raises some important questions. Who should get this test and who shouldn’t? When would this test be most useful? What does a “positive” test tell us about future risk of Alzheimer’s disease?

A recent survey by myself and other researchers at OHSU’s Brain Institute asked dementia specialists from around the country these sorts of questions. The survey found that specialists were optimistic that this test for amyloid could help diagnose early Alzheimer’s disease and maybe even predict future disease. But they were also concerned that results might be misunderstood. Physicians need to counsel patients on the meaning of amyloid testing before patients undergo it.

We still have much to learn about how Alzheimer’s disease develops and how best to treat it. While no predictive test for Alzheimer’s disease currently exists, all indications are that we are making meaningful strides in this direction.

Eran Klein, M.D., Ph.D.
Assistant professor, Department of Neurology
OHSU Brain Institute

Before I became a physician, I used to think that heart attacks and strokes were problems for men, and that the only thing women had to worry about was breast cancer.

Then, during my training, I learned that a significant number of women would come to the hospital with strokes, and overall they tend not to recover as well. Looking at the literature, of the 700,000 strokes that occur per year in the United States, about 370,000 occur in women. Furthermore, of the 180,000 people who die from stroke each year, more than 100,000 of them are women. This number is much higher than breast cancer-related deaths (about 39,000).

So the question is: why the discrepancy? Well, the real answer is … we aren’t sure.

But there are many theories for this discrepancy that are being investigated. For starters, women overall tend to live longer than men, and stroke risk increases as we get older. Therefore, by simple math, women have more strokes.

This, however, doesn’t explain why women (without acute treatment) recover less favorably than men with similar types of stroke. Some of the theories include differences in blood vessel diameter (men being larger than women), as well as gender differences in cellular physiology (estrogen in females, for example).  There continues to be much research on this topic. But whatever the cause might be, it doesn’t change the reality that we all should realize: stroke is hardly only a male disease.

So women should understand overall risk factors for stroke, and some special considerations for women:

• Risk factors that increase your chances of having a stroke include high blood pressure, heart disease, smoking, diabetes and high cholesterol. Women should regularly monitor their blood pressure, cholesterol and other health factors, and should stop smoking if they smoke.

• some studies have shown hormone replacement therapy in post menopausal women can increase the risk of stroke. Women should talk to their doctors about the therapy and any risks.

While we aren’t sure why women are more likely to suffer a stroke, we do know these tips can help women decrease their risk of stroke and aid in their chance for a long and healthy life.

Hormozd Bozorgchami, M.D.
Instructor, Oregon Stroke Center
OHSU Brain Institute

The OHSU Brain Institute has been a national leader in brain and neurology research for years. And that leadership role has been confirmed once again by a new analysis of federal research funding to U.S. medical schools for 2012.

The Blue Ridge Institute for Medical Research, a non-profit group based in North Carolina, ranked OHSU fifth in the nation in total research grants in the neurosciences awarded by the National Institutes of Health (NIH) in 2012.

OHSU was in the top two institutions on the West Coast, after the University of California at San Diego.

Blue Ridge also ranked OHSU highly in both the neurology and neurosurgery areas. Each area was ranked 14th in the nation.

Independent assessments like Blue Ridge’s provide a useful, though not definitive, measurement of how the school fits into the nation’s overall biomedical research picture.

Our ranking represents more than simply dollars and research accomplishments. It highlights our work in striving to learn as much as we can about the brain and neurological diseases, from Alzheimer’s and Parkinson’s to stroke and multiple sclerosis and a range of other disorders. And all that learning gets transferred — every day — into cutting edge treatment for our patients.

Because that, of course, is what our work and knowledge are focused on: finding ways to better treat our patients today — and maybe cure them tomorrow.

Dennis Bourdette, M.D.
Professor and Chair, Department of Neurology
OHSU Brain Institute

The depiction of Judgment Day on the façade of the Cathedral of Notre Dame in Paris shows an angel weighing the good and evil of souls to determine where they should go. Hanging on one side are devils tilting the scale in the wrong direction.

In making decisions about treating neurologic illnesses, physicians and their patients weigh risks and benefits of any treatment. For us, the devil is in the details of those risks and benefits. If we underestimate risks or overestimate benefits, the scales can tilt in the wrong direction.

How do physicians make decisions about benefits and risks? For drugs that are
approved by the Food and Drug Administration (FDA) for a given condition, we have good information about the benefit of the given drug based on the research done to get FDA approval. This research typically examined the benefits of the drug in comparison to a placebo and involved hundreds of patients who received the drug or placebo.

This assessment of benefit, however, is not perfect. The clinical research gives information about the benefits of the drug to a group of patients, whereas physicians have to decide the probability that the drug will help one patient — namely the person sitting in front of us waiting for our recommendation. That person may be quite different from the people who were enrolled in the clinical trial.

The people enrolled in clinical trials have to meet specific enrollment criteria and our specific patient may be quite different. He or she may be older, may have other illnesses or be taking other medications that might decrease the benefit of the drug.

Physicians also commonly use medications that are FDA approved for one illness to treat another condition, referred to as “off label” use. For instance, many anti-seizure medications are used to treat certain types of pain. Sometimes there is good evidence from research that this “off-label” use is beneficial. Other times the physician is basing the decision on personal experience and limited published research. “Off-label” use of medications, while common, is often based on less extensive published experience, making decisions about benefit challenging.

What about risks? How do physicians make decisions about risks of therapy? This is even more challenging than predicting benefit, particularly for new medications.

Information about side effects from medications is gathered during clinical trials of the drug. But this information is just the beginning. Because the initial clinical research may have involved only a few hundred patients, it is not until the drug is FDA approved and used in many more patients that rarer and serious side effects may become apparent. The drug may also be used in older or sicker patients than those in the clinical trials and these individuals may be more likely to experience side effects. It is only with time that we gain a full appreciation of the risks of drugs.

So what is a patient to do? When discussing a treatment with your physician, find out whether or not the drug is FDA approved for the condition your doctor is prescribing it for. If not, find out whether there is any research supporting its use and what your doctor’s experience has been with the drug for this “off-label” use.

Find out how long the drug has been on the market. If it is a new drug, you should be aware that less is known about its safety than a drug that has been around for a few years or longer. Find out if there is an alternative drug that may have a longer safety track record and, if so, ask why your doctor is recommending the new drug. Finally, be clear on what benefits you should expect from the drug and also what the common side effects and potential serious side effects are for the drug.

There is an old adage for doctors: “Be neither first nor last to prescribe a new drug.” We avoid being first so there is time to learn about side effects. Being last means that we would not be keeping up and taking advantage of true treatment advances.  This adage can be modified for patients to: ”Don’t be the first to take a new drug unless there is a very good reason to do so, and don’t be the last if the new drug can help you.”

Dennis Bourdette, M.D.
Professor and Chair, Department of Neurology
OHSU Brain Institute

Feeling blue? It may be more than just the Portland winter weather getting you down if you have Parkinson’s disease.

About one-third of people with Parkinson’s disease suffer from clinical depression at any point in time and two-thirds will experience a depressive episode at some point during the course of the disease. The symptoms of depression include feeling worried, sad, tearful, tired, guilty, irritable, or unloved. People can lose interest in activities, have changes in sleeping and eating patterns and feel life is not worth living.

Depression is probably more common in persons with Parkinson’s due to a combination of factors. Dealing with a chronic disease can cause some depression and the neurochemical changes that occur from the disease appear to also have mood effects.

If you are feeling down and blue, be sure to talk to your doctor. If depressive symptoms are severe and you have thoughts of wanting to hurt yourself, you should call 911 or get to an emergency room for evaluation. Depression is one of the biggest factors in how people with Parkinson’s rate their quality of life. But the condition is often under recognized.

The good news is that there are therapies that can help treat depression.

Behavioral therapy with a counselor or a psychologist may be helpful. There also are two primary classes of medications specifically for depression that are used in Parkinson’s. One class is the selective serotonin reuptake inhibitors (or SSRIs) which include medications like citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft).

The other class is the tricyclic antidepressants, which include amitriptyline and nortriptyline. Treating the Parkinson’s symptoms with medications that work on dopamine may also help to improve depression.

Finally, exercise, which also is helpful for the motor symptoms of Parkinson’s, may also improve mood. So get on your warm coat and rain boots and get out for a walk or head to the gym for an indoor workout. And above all, let your doctor know if you are experiencing symptoms of depression.

Amie Peterson, M.D.
Assistant Professor of Neurology
OHSU Parkinson Center of Oregon
OHSU Brain Institute

My first couple of blog posts were focused on directions in research on Alzheimer’s disease. So this time I’d like to turn to the routine clinical care of patients with Alzheimer’s disease and other dementias.

As the Affordable Care Act takes effect in the next few years, there will be an increased emphasis on outcomes rather than procedures. This makes good sense, but it remains to be seen how this idea is going to be enacted.

For example, in the case of heart attack or stroke, we might measure outcomes like survival, length of hospital stay, disability, or re-admission within the months after hospital discharge. With cancer, we could look at cure rates or length of survival after diagnosis.

But what are the important outcomes for patients with dementia? Preservation of cognitive function? Preservation of “activities of daily living?” Optimizing quality of life? Delay in nursing home placement? Avoidance of emergency room visits with behavior crisis? Minimizing caregiver distress? Something else?

You get different answers depending on whether you ask doctors, nurses, psychologists, social workers, or other health care workers. And the arguments go round and round without resolution.

One of the challenges is that there is little evidence that medical care can impact any of the outcomes listed above. So some experts are hesitant to propose that our dementia care system be evaluated on the basis of outcomes that it can’t control. One of the other challenges is that the measurement of some ideal outcomes is challenging if not impossible. (For example, how do we really know the quality of life being experienced by a person who cannot express himself or herself?)

The point is that this is not an easy thing to do. But with or without the Affordable Care Act, it is important for us to better define the goals of dementia care so that we can evaluate and optimize our practices while we wait for the clinical research enterprise to bear fruit.

One of our efforts in this direction at the OHSU Brain Insitute has been the establishment of an “alumni advisory group” at the OHSU Layton Aging & Alzheimer’s Disease Center. These are widows and widowers of our former patients — veterans of Alzheimer’s disease from start to finish — who meet quarterly to advise us on our clinical practices. We are working with them to better define treatment goals, understanding that we need to focus on those that are measurable and at least plausible for modification by our care. We would welcome input from the public and invite you to comment below.

Joseph Quinn, M.D.
Professor of Neurology
Layton Aging & Alzheimer’s Disease Center
OHSU Brain Institute

In a broad sense, pain is much more than a sensation. Pain can be a lifesaver. Pain can be pleasure. Pain can be the gate to heaven. Pain can be just an emotional suffering.

When we talk about the physiologic meaning of pain, we can think of the pain system as the alarm system of the body. It is essential for the survival of the organism and complete loss of pain sensation is not compatible with survival.

The alarm is activated when a potential harm to the organism occurs, leading to activation of the pain receptor in a process we call “transduction.” The pain receptor then sends the signal to the brain through the peripheral nerve into the spinal cord,  up to the part of the brain that makes us perceive sensations. That part is called the thalamus. That is the normal process, and is the adequately functioning alarm.

Sometimes, the pain transmission system itself gets injured — from a disease or trauma — and starts sending signals along the pathways that is interpreted by the brain as pain. This is when the alarm system is broken and is continuously beeping. This is what we call neuropathic pain.

Neuropathic pain is common and is caused by a variety of conditions that affect a variety of components of the nervous system. It also is the disorder when pain, instead of being the sign of a problem, is in fact the problem itself. It can result from diseases such as diabetes, trauma and stroke, and it can result from diseases such as carpal tunnel syndrome and “trigeminal neuralgia” — a nerve disorder that causes a stabbing pain in parts of the face. The disorder can be mild or it can drive individuals to suicide.

There are effective drugs to treat neuropathic pain, but when all medical therapy fails, other options exist including alternative therapies.

Neurosurgeons can help in certain cases of neuropathic pain. Trigeminal neuralgia is one condition where neurosurgeons have a variety of options that can help alleviate the pain. These include a surgical procedure where a compressing vessel is moved away from the nerve (called microvascular decompression). Also, we can perform a minimally invasive thermal lesioning of the nerve that stops the pain for some time (called radiofrequency rhizotomy).

A technology that was developed two decades ago, called spinal cord stimulation, can also be very effective in treating neuropathic pain. Spinal cord stimulation uses a phenomena called the gate theory where the dysfunctional alarm is silenced or dampened by creating what is an essentially a white noise or alternative non-annoying beep to cancel the annoying dysfunctional alarm beep.

Ahmed Raslan, M.D.
Assistant Professor, Neurological Surgery
OHSU Brain Institute