neurology

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Play Through The Pain? Audition Season Means Injury Risk For Young Musicians

The Emerson String Quartet performs in 2004. Imagine a quartet without its instruments and it becomes more clear how unnatural their positions are, says neurologist Dr. Michael Charness. (AP Photo/Jennifer Szymaszek)

The Emerson String Quartet performs in 2004. Imagine a quartet without its instruments and it becomes more clear how unnatural their positions are, says neurologist Dr. Michael Charness. (Jennifer Szymaszek/AP)

By Ian Coss

Caitlin Cawley was only 15 when she developed tendinitis in both elbows. The condition is commonly known as “tennis elbow,” but Cawley wasn’t practicing her serve. She was studying classical percussion at a pre-college program for aspiring musicians.

She ignored the early signs until the prickling sensation grew to stabbing pain throughout her forearms so excruciating she had to stop playing. It took three months of rest for the inflammation in her tendons to subside, and she has had multiple flareups since then.

Now 21 and a senior at Boston University’s School of Music, Cawley is preparing to audition for graduate programs. So while most college applicants can breathe a sigh of relief now that their Jan. 1 deadline has passed, she and other music students are headed back to the practice rooms. Cawley currently averages six hours of independent practice a day, not including ensemble rehearsals. In her words: “Right now I’m doing as much work as I’ve ever done for music.”

Boston University senior Caitlin Cawley practices on the marimba (Photo: Ian Coss/WBUR)

Boston University senior Caitlin Cawley practices on the marimba. (Ian Coss for WBUR)

That diligence also means risk of injury. For Cawley and other young musicians, the question of this season is: How much practice can my body take before perfection turns to pain?

Their odds are not good. In the mid-2000s, a Chicago-based physician began surveying the incoming music students at a midwestern university, and after four years, the trend in the data was clear: Almost 80 percent of freshman “reported a history of playing-related pain.”

For players of string, keyboard and brass instruments the percentage was even higher. For percussionists like Cawley: 100 percent.

Dr. Michael Charness, who directs the Performing Arts Clinic at Brigham and Women’s Hospital, has treated thousands of musicians who play everything from bagpipes and sitars to violas and trombones.

He describes the crux of the problem: “If you look at a string quartet, it’s the most natural looking sight, but if you simply remove the instruments from their hands and pose them on stage, it’s nothing that we were ever really designed to do for any long period of time.” Continue reading

Are Skinny Jeans Bad For Your Health?

(James Mitch/Flickr)

(James Mitch/Flickr)

This is the kind of headline that can trigger a snarky response even in the most compassionate person: “Squatting in ‘skinny jeans’ can damage nerve and muscle fibres in legs and feet.”

Yes, it’s true: A case report published this week in the British Journal of Neurology, Neurosurgery and Psychiatry describes a 35-year-old woman who suffered serious muscle damage, swelling and nerve blockage after squatting in her super tight skinny jeans. (The jeans were so tight, in fact, that doctors had to cut them off to treat her.)

Here’s the top of the report (my bold added):

A 35-year-old woman presented with severe weakness of both ankles.

On the day prior to presentation, she had been helping a family member move house. This involved many hours of squatting while emptying cupboards. She had been wearing ‘skinny jeans’, and recalled that her jeans had felt increasingly tight and uncomfortable during the day. Later that evening, while walking home, she noticed bilateral foot drop and foot numbness, which caused her to trip and fall. She spent several hours lying on the ground before she was found.

On examination, her lower legs were markedly oedematous bilaterally, worse on the right side, and her jeans could only be removed by cutting them off. There was bilateral, severe global weakness of ankle and toe movements, somewhat more marked on the right… Sensation was impaired over the lateral aspects of both lower legs, and the dorsum and sole of both feet…Nerve conduction studies showed conduction block in both common peroneal nerves between the popliteal fossa and fibular head…

The story of the skinny jean medical emergency went viral, with fashionistas and feminists weighing in on whether the era of super-tight jeans is over. The New York Times did a piece headlined “Why You Shouldn’t Throw Out Your Skinny Jeans,” and interviewed the paper’s fashion director, who declared:

Not all skinny jeans are created equal, and it would be alarmism to jump to the conclusion that one pair of skinny jeans created health issues, ergo all skinny jeans are bad. I think the takeaway is skinny jeans are one thing, jeans that actually inhibit movement something else. Maybe we should call them straitjacket jeans. Those should be avoided.

Still, after reading the study, it’s hard not to feel a little empathy. Who among us hasn’t worn a heel just a bit too uncomfortably high, or a pair of movement-limiting pants (and don’t even get me started about thong underwear) in an attempt to feel better/younger/sexier? Continue reading

‘Only A Game’ Questions NFL Medical Advisor On Football Safety

(Kevin Domingue/Flickr Creative Commons)

(Kevin Domingue/Flickr Creative Commons)

I’ve said it before and I’ll say it again: A child of mine will play tackle football over my dead body. A young brain is too precious a thing to risk. And though the data are not all in, we know plenty about the potential brain damage of repeated head hits, including recent findings that linked youth football to cognitive impairment. Oh, and let’s not forget the 2013 study that found that a single season of contact-sports head blows could affect learning and memory.

So I was surprised to learn from an excellent commentary this morning by WBUR’s Bill Littlefield of Only a Game fame that a prominent Boston medical leader was touting football’s safety. From the Boston Globe here:

Dr. Elizabeth G. Nabel, the president of Brigham and Women’s Hospital and the National Football League’s new adviser, said Tuesday that football is safer than it has ever been, but she called on the NFL to commit more money to medical research and better educate the public about sports injuries.

Nabel, 63, in her first public comments as the NFL’s chief health and medical adviser, said that if her children were still young, she would allow them to play football. She noted that her son, now 29, played football in the eighth grade.

“I think football is getting safer all the time,” Nabel told reporters at the NFL’s offices in New York.

Really, Dr. Nabel? You’ll understand if I want to seek a second opinion — maybe from a former NFL player who can’t remember his own kids’ names.

Bill Littlefield’s commentary — As Concussion Crisis Mounts, NFL Turns To … Cardiology Specialist? — points out that Dr. Nabel’s impressive CV does not seem to include any expertise in brain trauma. He writes:

Experience as a hospital administrator would not seem to be the key qualification for a person charged with advising the heads of an industry where the most significant problem is a 30 percent rate of brain damage among the workforce.

He concludes: Continue reading

This Blind Man Climbs Every Mountain, And Now Has Run The Boston Marathon

Randy Pierce with his guide dog, Autumn, at WBUR (Robin Lubbock/WBUR)

Randy Pierce with his guide dog, Autumn, at WBUR (Robin Lubbock/WBUR)

Note: This post has been updated.

In 1989, Randy Pierce was fresh out of college, living in southern New Hampshire and working happily as a computer hardware designer. One day in fencing class, his instructor noticed that his blind spot was oddly enlarged. You need to go to the doctor, the instructor said. Today.

A neurological disease was attacking Pierce’s optic nerve. Within two weeks he had lost all the sight in his right eye, and half the sight in his left. In the following years, he lost the last remnants of his sight, and damage to his cerebellum destroyed his balance, landing him in a wheelchair.

On Monday, he ran the Boston Marathon. And he turned in a personal marathon best: 3 hours, 50 minutes and 37 seconds for the 26.2-mile course.

Pierce, 48, ran on Team With A Vision, which supports the Massachusetts Association for the Blind and Visually Impaired. He ran to raise money — and to make a point, about what he calls “ability awareness.”

“I have a disability — I can’t see,” he says. “We all have disabilities, things that we can’t do. I think it’s so much more important to put the focus of our lives on things we can do. And if something is important enough to you, I say anything is possible, you’re just going to have to problem-solve and persevere to get there.”

An example of problem-solving: Last year, Pierce became the first blind American to complete a Tough Mudder obstacle course, and last month he repeated the feat. (See the video below.)

From a platform 25 feet high, he had to leap out about 8 feet, grab a T-shaped, trapeze-like bar, swing farther out and release his grip at just the right moment to hit a remote hanging bell before plunging down into the muddy water below. He used his cane to feel for where the T-bar was, to form a mental image of it, and friends’ descriptions of where the bell was hanging.

The crowd went wild.

“You know, those are just moments — every one of those people out there would have told you this is impossible. Now they won’t,” Pierce says. “They’ll believe me when I say everything’s possible — or they’ll believe in themselves, which is the more important part.”

As for the perseverance Pierce talks about, he used it to fight his way out of the wheelchair that he occupied “for one year, eight months and 21 days — which tells you how I feel about it. Pretty challenging.”

Pierce’s wife, Tracy, says that somehow, his struggles and losses led him to adopt the supremely positive attitude that uplifts him now. Continue reading

Toward A Less Invasive Mode Of Deep Brain Stimulation

Imagine this futuristic tableau: A severely depressed person walks into her doctor’s office, sits in a specially designed chair with a coil around her head, and with little more than an IV injection, undergoes deep brain stimulation to treat her deep, dark psychological illness.

Well, that’s not going to happen any time soon, but engineers at MIT are working on the building blocks that could make that fictional scenario a reality.

They’ve developed a method — a proof-of-concept, really — to stimulate brain tissue using external magnetic fields and injected magnetic nanoparticles that resemble small bits of rust. This technique allows for direct stimulation of neurons, which could someday be an effective treatment for a variety of neurological diseases, like Parkinson’s, and even further in the future, for severe, treatment-resistant psychiatric disorders like depression, without the need for highly invasive brain implants or external connections. The research is published in the journal Science.

(Allan Ajifo/Flickr)

(Allan Ajifo/Flickr)

Current treatments have been effective in reducing or eliminating tremors associated with Parkinson’s but involve major brain surgery to implant wires that are connected to an outside power source.

Polina Anikeeva, an assistant professor of materials science and engineering at MIT, says the new research suggests a much less invasive possibility. I asked her to describe the research in an accessible way and here’s what she said:

First, I want to clearly say that we are still very far away from any clinical or even pre-clinical application, this is a first proof-of-concept study, looking at the possibility of using these materials to stimulate neurons deep in the brain.

What we’ve done is to give a simple injection of nanomaterials (iron oxide) that look like small bits of rust [but aren’t actually rust], deep into the brain. This allows us to deliver stimulus using a magnetic field, which is converted into heat by the little rust particules. Now we have a system where a magnetic field is applied from the outside and with a simple injection of the materials we can deliver the stimulas deep in the brain without the connectors and without the implants. We don’t have to be invasive in order to do the stimulation.

Continue reading

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When Presidential Brains Go Awry: Neuro Disorders In The Oval Office

Ronald Reagan’s family is still arguing about whether he had signs of Alzheimer’s during his time in the Oval Office. Here's the official portrait of the Reagans on the White House grounds in 1988. (Wikimedia Commons)

Ronald Reagan’s family is still arguing about whether he had signs of Alzheimer’s during his time in the Oval Office. Here’s the official portrait of the Reagans on the White House grounds in 1988. (Wikimedia Commons)

By Richard Knox

Thomas Jefferson probably suffered from migraines. Woodrow Wilson had a devastating stroke while in office. FDR was known to have seizure-like blank-outs. And Ronald Reagan’s own family is still arguing about whether he had signs of Alzheimer’s during his time in the Oval Office.

The health of presidents is a perennially intriguing subject. But this Presidents Day weekend, a New York neurologist is focusing new attention on the presidential disorders that arguably matter most: those of the brain and central nervous system.

“Do we really know about the health status of our leaders and should we?” asks Dr. Nicholas Silvestri. “I think in the case of neurologic illness, we should.”

Dr. Nicholas J. Silvestri

Dr. Nicholas J. Silvestri (Sandra Kicman, University at Buffalo)

Silvestri, a history buff on the faculty of the University at Buffalo School of Medicine and Biomedical Sciences, thinks commanders-in-chief ought to undergo neuropsychological testing just as regular recruits do.

And he wonders if the 48-year-old 25th Amendment, which provides for presidential succession if a president becomes unfit to govern, is really suited to determine cognitive or mental fitness. That’s a touchy matter the Constitution currently leaves entirely in political hands.

Now, of course, too rigorous a screen could deprive the nation of a truly great (if mentally flawed) president. Abraham Lincoln, for example, famously suffered from depression.

We’ll come back to the issue of how presidential brain unfitness should be determined. But first, let’s take a journey through the surprising twists and turns of the neurological history of U.S. presidents, guided by Silvestri. He pulled that history together for a Lincoln’s Birthday seminar in Buffalo, and described its high points in an interview.

Migraine, Seizures, Strokes

First stop: migraine headache. It’s a common ailment that doesn’t disqualify anyone from a highly responsible job. But still, migraines are “an extremely debilitating collection of neurological symptoms,” as the Migraine Research Foundation puts it — possibly a matter of concern in a president who needs to function at the top of his game during a crisis.

Silvestri says there’s evidence that John Adams, Jefferson, Lincoln, Dwight Eisenhower and John F. Kennedy suffered from migraines.

James Madison and FDR probably had seizure disorders, Silvestri says. From his college years, Madison was known to have spells that temporarily paralyzed him. “He would stare off, become immobile, and not react to his surroundings,” Silvestri says. It may be a reason Madison didn’t fight in the Revolution.

Silvestri thinks Madison’s spells were probably psychogenic seizures — a reaction to stress. “It’s what Freud describes as hysteria,” he says.

Whatever it was, Madison evidently grew out of it. The disorder didn’t prevent him from coauthoring the Constitution or the Federalist Papers, nor hinder him as president. “He was the last president to lead a field army in battle, during the War of 1812,” Silvestri notes.

FDR Didn’t Have Polio? 

FDR probably didn’t suffer from polio -- the disease he has long been associated with. Instead, many researchers think the evidence points to a different cause of FDR’s paralysis -- a rarer disease called Guillain-Barre syndrome. Here he is in 1943. (George R. Skadding/AP)

FDR probably didn’t suffer from polio — the disease he has long been associated with. Instead, many researchers think the evidence points to a different cause of FDR’s paralysis — a rarer disease called Guillain-Barre syndrome. Here he is in 1943. (George R. Skadding/AP)

FDR’s health problems are well known. They include the polio he supposedly suffered at the age of 39, his subsequent lifelong leg paralysis, and the soaring blood pressure that led to a fatal brain bleed two months after the Yalta Conference that carved up post-war Europe.

Less known are the seizures he had throughout his presidency. Continue reading

A Boxer’s Brain And The Evolution Of Sports-Related Head Injuries

(don's athletics/Flickr)

(don’s athletics/Flickr)

(This post originally appeared on Boston University’s Research News website as “Head Examiner: Neurologist Ann McKee Talks About Battered Brains, Tangled Tau, And The Future of Sports“)

By Barbara Moran

For Ann McKee, every brain tells a story. And sometimes it’s a tragic one. McKee, a professor of neurology and pathology at the Boston University School of Medicine (MED), is the director of neuropathology for the Veterans Affairs New England Healthcare System, and also directs BU’s Chronic Traumatic Encephalopathy Center. Chronic traumatic encephalopathy (CTE) is a degenerative brain disease found in athletes with a history of repetitive brain trauma. McKee first identified its telltale mark—tiny tangles of a protein called tau, clustered around blood vessels—in the dissected brain of a boxer who had been diagnosed with Alzheimer’s disease.

Although most people associate CTE with professional football players, McKee has found it in the brains of soccer, hockey, rugby, and baseball players as well. Her research has alerted the public to the long-term dangers of repetitive hits in sports and raised tough questions about safety. McKee was invited to speak about this growing public health concern at the annual meeting of the American Association for the Advancement of Science (AAAS), the world’s largest general scientific society, held in February 2015 in San Jose, CA. She told BU Research the story behind her discovery of CTE, and what it might mean for the future of sports.

BU Research: You’re a world expert on tau protein, which has been implicated in Alzheimer’s, CTE, and other brain diseases. Have you studied tau your whole career?

McKee: Yes. I love tau.

Why?

It’s beautiful, the way it collects throughout the nervous system and just sort of fills up the nerve cell. It’s always been quite lovely to look at, visually captivating. I mean, how crazy is that? But it’s true.

When you started studying tau, you were studying Alzheimer’s?

I was interested in Alzheimer’s, but I also worked on PSP (progressive supernuclear palsy), and something called corticobasal degeneration.

Those are not so famous.

No, they’re not so famous. But I got very involved in defining what these individual diseases looked like. It’s like being at the Smithsonian and being really interested in one collection of pottery or something. And once you start understanding it, you start seeing all these differences, and it’s like “Whoa!”

Brains with CTE show a distinct pattern of tau protein, seen here in brown. The two slides on the bottom come from the brain of a 66-year-old ex-NFL player. The slides on top are from a 65-year-old man without CTE. Photo courtesy of Ann McKee

Do you remember the first time you saw a brain with CTE?

Yes. It was phenomenally interesting. The first case was Paul Pender, a professional [middleweight] boxer here in the Boston area. He had twice been world champion. That was my first time seeing it under the microscope. I looked at the slide and it was like “Oh my God! This is so amazing. I’ve never seen anything like this.” It just blew my mind. That was 2003.

How did it look different than, say, a brain with Alzheimer’s?

Alzheimer’s disease has these beta amyloid plaques that look like small puffs of smoke throughout the brain. Continue reading

Study Finds Fivefold Increase In Alzheimer’s Deaths: Why It Matters

JAQ'S PhotoStorage/flickr

JAQ’S PhotoStorage/flickr

By Nell Lake
Guest contributor

Consider a hypothetical 70-year-old woman; she could be your mother, your sister, your wife. Call her Margaret. She’s becoming ever-more forgetful; one day she gets lost on her way home from the grocery store. A neurologist diagnoses Alzheimer’s.

Over the next five years, Margaret’s thinking continues to decline. She speaks less, confuses words, falls often. She needs a wheelchair, becomes incontinent. No longer able to manage her care, you move her to a nursing home. A year later, the disease has spread to the part of Margaret’s brain that controls swallowing; she has difficulty eating. Because of this she “aspirates” her food — bits of it enter her lungs, and Margaret develops pneumonia. Within weeks, her lungs stop working, and Margaret dies.

Margaret’s story is a difficult one, but common. It also illustrates a conundrum: Did Margaret die of pneumonia, or Alzheimer’s?

On some level, the answer doesn’t matter much: death is death. But as a matter of public health, the answer is deeply important: funding for medical research, new treatments and ultimately, someday, a cure, tends to flow toward the most widespread and deadly diseases. That’s why a new study out this week is getting so much attention; should its findings become widely accepted, they could substantially increase the pace and effectiveness of Alzheimer’s research in the U.S.

Massive Underreporting

The study, published Wednesday in the journal Neurology, confirmed what clinicians and researchers have long assumed: Alzheimer’s deaths have been greatly underreported.

The research found that 500,000 people die each year from Alzheimer’s — more than five times the number most recently reported by the CDC. That makes Alzheimer’s the third leading cause of death in the United States, after heart disease and cancer. Currently the CDC ranks Alzheimer’s sixth as a cause of mortality, with 84,000 deaths reported on death certificates.

The new report’s fuller accounting of Alzheimer’s deaths reinforces a basic but frequently overlooked fact: The illness is entirely fatal. A progressive brain disease that gradually impairs memory, reasoning and personality, Alzheimer’s eventually damages all brain functions, so that even walking, eating and breathing become impossible. Alzheimer’s kills because the brain is no longer able to keep the body alive. Continue reading

Specialist: My Prime Take-Home Points From ‘Dot Earth’ Reporter’s Stroke

 

 

This week, longtime New York Times reporter and popular “Dot Earth” blogger Andrew Revkin vividly describes his 2011 stroke in the first-person piece “My Lucky Stroke.” He includes these “prime take-home points”: “Take your body seriously. Time (wasted) is brain (lost). Question authority, but not too much. Old habits die hard.”

Dr. Lee Schwamm, chief of Massachusetts General Hospital’s stroke service and medical director of Mass General TeleHealth, would suggest that readers take away some rather different stroke lessons from Andy Revkin’s story. He shares them here.

By Dr. Lee H. Schwamm
Guest contributor

I congratulate the journalist and blogger Andy Revkin for courageously sharing the story of his stroke and his subsequent recovery. I also thank him for taking the time to share his personal experience for the benefit of his readers, and for the opportunity it presents to highlight some key learning points for patients, as we dissect his journey through the health-care system.

Mr. Revkin was relatively young and healthy, out for a run with his son, when he experienced stroke symptoms. All too often, when we think of stroke, we envision an older patient clutching their chest and being unable to move or speak. This stereotype is dangerous, both for patients and health-care providers, because it lowers our sensitivity to stroke-like symptoms in patients of any age.

Mr. Revkin and his son were concerned enough about his symptoms that he went home, but they didn’t appreciate the immediate seriousness of his condition and he took a shower, hoping his symptoms would resolve. Watch the video clip above showing a young news reporter having stroke-like symptoms, and ask yourself, would you have called 911 if you’d been present? You should have.

Without treatment to restore the blocked blood flow to the brain, 2 million nerve cells are dying every minute of continued stroke.

Then Mr. Revkin did what generations of doctors have advised us to do for a heart attack; namely, take some aspirin and call your doctor’s office. Unfortunately, when it comes to stroke, there are two types: those caused by blocked arteries (ischemic) and those caused by rupture of blood vessels (hemorrhagic). It’s not possible to tell just from symptoms if a stroke is ischemic or hemorrhagic; only a CAT scan or MRI can distinguish them.

Obviously, you don’t want to take an aspirin if you’re having bleeding in your brain, as it will make the bleeding worse. But it’s also not a great idea to take aspirin if it’s an ischemic stroke, especially not six aspirin, as Mr. Revkin did, because there are powerful clot-busting drugs that can be given to reverse the disability caused by ischemic stroke. These drugs — the main one is known as tPA — are only effective if they are given within the first 4.5 hours after the start of symptoms, and aspirin might increase the risk that the drugs could convert an ischemic stroke into a giant hemorrhage that could be fatal.

It’s also really important to realize, as Mr. Revkin mentions, that “time is brain.” Continue reading

Why To Exercise Today: Less Brain Shrinkage When You’re Old

(GWSA/flickr)

Drop that crossword puzzle and get moving!

Researchers report that physical exercise trumps mental games and social activities when it comes to keeping a robust, non-shrinking brain into old age.

From the news release:

Exercising regularly in old age may better protect against brain shrinkage than engaging in mental or social activities, according to a new study published in the October 23, 2012, print issue of Neurology, the medical journal of the American Academy of Neurology. Research suggests that brain shrinkage may lead to problems with memory and thinking.

“People in their seventies who participated in more physical exercise, including walking several times a week, had less brain shrinkage and other signs of aging in the brain than those who were less physically active,” said study author Alan J. Gow, PhD, with the University of Edinburgh in Scotland. “On the other hand, our study showed no real benefit to participating in mentally and socially stimulating activities on brain size, as seen on MRI scans, over the three-year time frame.”

Researchers looked at medical records of 638 people from Scotland born in 1936. The participants were given MRI scans at 73 years old.

The group gave details about their exercise habits, ranging from moving only in connection with necessary household chores to keeping fit with heavy exercise or participating in competitive sports several times per week. They also reported their participation in social and mentally stimulating activities. Continue reading