Yoga For Cognitive Disorders & Brain Injuries
Hey everyone! Here's a collection of information I found online and compiled relating to Yoga For Cognitive Disorders & Brain Injuries. This report was part of my requirement during my 500-hour Advanced Teacher Training Course. Sources are listed at the bottom of this article. Enjoy!
1. The Human Brain
The human brain is slightly complex! It gives us the ability to think, move, feel, see hear, taste and smell.. Governing how we perceive and move through the world. In addition to controlling our body and senses, it also receives information, analyzes information and stores information (our memories).
The human brain (Figure 1.1) reaches its’ full size around six years of age and is composed of 40% gray matter and 60% white matter. Gray matter is more pinkish-gray in color, and is home to neural cell bodies, axon terminals, dendrites, as well as all nerve synapses. White matter is composed of axons.
The brain has three parts: the cerebrum, the cerebellum, and the brain stem. (Figure 1.2) The brain uses 20% of the body’s oxygen supply and 20% of the blood flow (So greedy!). This nourishment is funneled through the blood vessels that connect to it via the heart. Without oxygen for 3-5 min., brain cells begin to die (nooooooo)
The brain is protected by dura mater (tough translucent membrane), cerebrospinal fluid (clear, water liquid), cranium (thicker in certain humans), in addition to a blood filtering process called the blood-brain barrier.
Structure and Function: (Figure 1.3)
THE CEREBRUM
Frontal Lobe
Behavior
Abstract thought processes
Problem solving
Attention
Creative thought
Some emotion
Intellect
Reflection
Judgment
Initiative
Inhibition
Coordination of movements
Generalized and mass movements
Some eye movements
Sense of smell
Muscle movements
Skilled movements
Some motor skills
Physical reaction
Libido (sexual urges)
Occipital Lobe
Vision
Reading
Parietal Lobe
Sense of touch (tactile sensation)
Appreciation of form through touch (stereognosis)
Response to internal stimuli (proprioception)
Sensory combination and comprehension
Some language and reading functions
Some visual functions
Temporal Lobe
Auditory memories
Some hearing
Visual memories
Some vision pathways
Other memory
Music
Fear
Some language
Some speech
Some behavior and emotions
Sense of identity
The hippocampus is a small organ located within the brain's medial temporal lobe and forms an important part of the limbic system, the region that regulates emotions. The hippocampus is associated mainly with memory, in particular long-term memory. The organ also plays an important role in spatial navigation.
Right Hemisphere (the representational hemisphere)
The right hemisphere controls the left side of the body
Temporal and spatial relationships
Analyzing nonverbal information
Communicating emotion
Left Hemisphere (the categorical hemisphere)
The left hemisphere controls the right side of the body
Produce and understand language
Corpus Callosum
Communication between the left and right side of the brain
THE CEREBELLUM
Balance
Posture
Cardiac, respiratory, and vasomotor centers
THE BRAIN STEM
Motor and sensory pathway to body and face
Vital centers: cardiac, respiratory, vasomotor
Hypothalamus
Moods and motivation
Sexual maturation
Temperature regulation
Hormonal body processes
Optic Chiasm
Vision and the optic nerve
Pituitary Gland
Hormonal body processes
Physical maturation
Growth (height and form)
Sexual maturation
Sexual functioning
Spinal Cord
Conduit and source of sensation and movement
Pineal Body
Unknown
Ventricles and Cerebral Aqueduct
Contains the cerebrospinal fluid that bathes the brain and spinal cord
Brain Cells (Figure 1.4a,1.4b)
There are about 100 billion neurons (cells that send and receive electrochemical signals to and from the brain and nervous system), and glial cells (providing support and insulation to neurons) located in the brain and spinal cord. There are many types and sizes ranging from .005mm to .1mm in diameter and a fraction of an inch to several feet in length. There are different types of neurons such as sensory neurons, motoneurons, and interneurons. Neurons cannot regrow after being damages except for neurons in the hippocampus (limbic system/short term memory)
Spinal Cord (Figure 1.5)
The vertebrae along the spine provide protection of the spinal cord, a bundle of nerves that connects the brain throughout various parts of the body. There are around 14 million neurons that send information in the spinal cord.
2. Cognitive disorders
What is cognition? (Figure 2.1)
Cognition is defined as the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses.
Cognitive disorders are a type of mental health disorders that affects learning, memory, perception, and problem solving. There are four major categories that most disorders are grouped into: delirium, dementia, amnesia, and developmental. Below is a list of subcategories of the main four along with additional conditions.(Fig. 2.2)
Delirium: an acutely disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of thought and speech.
Hyperactive delirium
hypoactive delirium
mixed delirium
Dementia: Dementia is a general term for loss of memory and other mental abilities severe enough to interfere with daily life. It is caused by physical changes in the brain.
Alzheimer’s
vascular
dementia with Lewy bodies-DLB
frontotemporal
mixed dementia
Parkinson’s disease
Creutzfeldt-Jakob disease
Huntington’s disease
Wernicke-Korsakoff Syndrome
Amnesia: a partial or total loss of memory.
Retrograde
Anterograde
Transient global
Infantile
Developmental Disorders: a group of psychiatric conditions originating in childhood that involve serious impairment in different areas
Developmental Coordination Disorder: A childhood developmental disorder marked by clumsiness in otherwise healthy kids.
Autism: Autism, or autism spectrum disorder, refers to a range of conditions characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication, as well as by unique strengths and differences. We now know that there is not one autism but many types, caused by different combinations of genetic and environmental influences. (Fig. 2.3)
Tourette’s: A nervous system disorder involving repetitive movements or unwanted sounds.
Stuttering: a speech disorder in which sounds, syllables, or words are repeated or prolonged, disrupting the normal flow of speech. These speech disruptions may be accompanied by struggling behaviors, such as rapid eye blinks or tremors of the lips
ADHD: Attention deficit hyperactivity disorder, symptoms include inattentive, hyperactive, impulsive.
Dyslexia: a general term for disorders that involve difficulty in learning to read or interpret words, letters, and other symbols, but that do not affect general intelligence.
Dysgraphia: inability to write coherently, as a symptom of brain disease or damage.
Many more...
Drug-Induced Cognitive Impairment
Drug-induced cognitive impairment happens typically in elderly patients when on drugs. This is important to recognize because people tend to become more prone to delirium and dementia. In most cases, the condition can be reduced by quitting the associated drug.
This condition is often overlooked in hospitals and instead attributed to “old age” when in fact patients are suffering the reaction from a drug, in addition to the cocktail of mixed drugs any one patient could be exposed to.
Known drugs linked to DICI: Benzodiazepines (Tranquilizers, Sleeping Pills), Opiates (Narcotics, pain meds), Tricyclic antidepressants, corticosteroids, fluoroquinolone antibiotics, H2-receptor antagonists, anticonvulsants and drugs used to treat Parkinson’s disease.
3. Cognitive Disorders and Yoga: A Focus on Alzheimer’s Disease, Ayurvedic Treatment, Asana, Pranayama, and Meditation
Dementia is not a specific disease. It's an overall term that describes a wide range of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities. Alzheimer's disease accounts for 60 to 80 percent of cases. Vascular dementia, which occurs after a stroke, is the second most common dementia type. But there are many other conditions that can cause symptoms of dementia, including some that are reversible, such as thyroid problems and vitamin deficiencies. (Fig. 3.1)
Alzheimer's is a type of dementia that causes problems with memory, thinking and behavior. Symptoms usually develop slowly and get worse over time, becoming severe enough to interfere with daily tasks. It is the sixth leading cause of death in the US.
One of the hallmarks of Alzheimer's disease is the accumulation of amyloid plaques (Fig. 3.2) between nerve cells (neurons) in the brain. Amyloid is a general term for protein fragments that the body produces normally. Beta amyloid is a fragment of a protein snipped from another protein called amyloid precursor protein (APP). In a healthy brain, these protein fragments would break down and be eliminated. In Alzheimer's disease, the fragments accumulate to form hard, insoluble plaques. Neurofibrillary tangles are insoluble twisted fibers found inside the brain's nerve cells. They primarily consist of a protein called tau, which forms part of a structure called a microtubule. The microtubule helps transport nutrients and other important substances from one part of the nerve cell to another. Axons are long threadlike extensions that conduct nerve impulses away from the nerve cell; dendrites are short branched thread-like extensions that conduct nerve impulses towards the nerve cell body. In Alzheimer's disease the tau protein is abnormal and the microtubule structures collapse.
As Alzheimer's disease progresses, brain tissue shrinks. However, the ventricles, chambers within the brain that contain cerebrospinal fluid, are noticeably enlarged. In the early stages of Alzheimer's disease, short-term memory begins to decline when the cells in the hippocampus degenerate. Those with the disease lose the ability to perform routine tasks. As Alzheimer's disease spreads through the cerebral cortex (the outer layer of the brain), judgment worsens, emotional outbursts may occur and language is impaired. Frustration, hostility, and irritability are common emotional features exhibited by patients with AD. Advancement of the disease leads to the death of more nerve cells and subsequent changes in behavior, such as wandering and agitation. In the final stages, people may lose the ability to feed themselves, speak, recognize people and control bodily functions. Memory worsens and may become almost non-existent. Constant care is typically necessary. On average, those with Alzheimer's live for 8 to 10 years after diagnosis, but this terminal disease can last for as long as 20 years.
The Ayurvedic Perspective
The sister science of yoga, Ayurveda, which deals with the balance and harmony of the body-mind, has its own outlook on Alzheimer’s. Several scientific studies have pointed to the efficacy of Ayurveda in treatment of Alzheimer’s symptoms, delaying it’s onset, and prevention. An entire body of literature in the Ayurvedic texts deals with the nervous system and disorders associated with it. Nervous system disorders, called 'VataVyadhi' (Vata-Disease) in Sanskrit, were thought to be brought on by imbalances of Vata, the biological air humor, the energy that moves through the brain and the nerves (the ancients considered nerve impulses to be a kind of wind or air traveling through the body) controlling both voluntary and involuntary functions. Hence, Vata derangements always involve some weakness, disturbance, or hypersensitivity of the nervous system. The list below shows the use of several herbs and their qualities and energetics for nervous system disorders, including memory loss typically seen in older adults, but only recently have there been mechanistic studies on the role of these herbs in nervous system disorders and dementias, including dementia associated with AD.
Ayurvedic Herbal Treatment Studies (Fig. 3.3)
Oral administration of a semi-purified extract of the Ashwagandha (W. somnifera) root reversed behavioral deficits, plaque load, and accumulation of beta-amyloid peptides in mouse models of AD.
Direct injection of curcumin (Turmeric) into the brains of the mice with AD not only hampered further development of plaque but also reduced the plaque levels [33]. AD symptoms characterized by inflammation and oxidation were also eased by curcumin's powerful antioxidant and anti-inflammatory properties.
Brahmi (also known as Bacopa) is a bitter-tasting creeper plant found in damp and marshy areas and is commonly used in Ayurvedic medicine as a nerve tonic, diuretic, and cardiotonic. BM extract-treated neurons expressed a lower level of reactive oxygen species, suggesting that Brahmi restrained intracellular oxidative stress
Shankhpushpi is a common plant in India, where the whole plant is used in various formulae as a nervine tonic for improvement of memory and cognitive function. It is believed that Shankhpushpi calms the nerves by regulating the body's production of the stress hormones, adrenaline, and cortisol. It is also recommended for nervous disorders such as stress, anxiety, mental fatigue, and insomnia. A significant increase in dendritic intersections, branching points, and dendritic processes arising from the soma of neurons in the amygdale region in CT-treated rats was observed in comparison with age-matched saline controls, suggesting that CT enhances memory by increasing the functional growth of neurons
Gotu kola is one of the important rejuvenating herbs for nerve and brain cells and is believed to be capable of increasing intelligence, longevity, and memory. Gotu kola extracts reversed the beta-amyloid pathology in the brains of mice and modulated the components of the oxidative stress response.
Jyotishmati (Celastrus paniculatus) is a treasured medicinal herb that is revered for its effects on the brain and has been used for centuries in Ayurveda for sharpening the memory and improving concentration and cognitive function.
A key component to remember when receiving Ayurvedic treatment and nutrition guidelines is that the pathogenesis of each person's condition is unique, and so the diet must be fit to the individual and the unique root causes of the condition in your body. Reduction of Vata related foods is the typical strategy for minimizing an aggravated Vata-disease.
Warm Your Veggies
According to ayurveda, a completely raw food diet is actually not recommended for the Vata dosha. Vatas are known to have a sensitive digestive system. Raw foods are cooling and more challenging to break down, which can deplete the agni (digestive fire).Warming at least some of your food and incorporating warming spices into your diet can help by beginning the breaking down process of the food as well as providing some much needed warmth to a weak agni.
Oil, Oil, Oil!
It may seem too simple to make a big difference, but oil is seriously a magic potion. Vatas don’t just suffer from dry skin, they also tend towards a dry digestive system, nervous system and brain.
Nervous system disorders or VataVyadhi in Sanskrit, are thrown out of balance by the Vata ‘wind’ energy that moves throughout the brain and the nerves, controlling both voluntary and involuntary movement. Taking oil internally as well as slathering it on topically can be a game changer. It is prescribed to place oil on the entire body from scalp to feet and everywhere in between and also to taken internally.
Sesame oil is a big one for Vata’s because of its warming abilities.
Coconut oil is great for brain function, but by itself may be too cooling. Take with cayenne pepper or other warming herbs or mix with heavier oil such as sesame.
Extra virgin olive oil for both skin and internally.
Ghee, though not technically an oil, is used as such and a very important Ayurvedic food for the Vata dosha.
Additional Treatments
Nasya - This intranasal delivery of medicated oils and dry herbal powders is a practical, rapid, and easy way to deliver the therapeutic herbs into the Central Nervous System (CNS). These medicated oils, require that the herbs be cooked in oil water over a low flame until all of the water evaporates. Recently there has been a growing interest in this intranasal delivery method as it directly moves across the BBB and targets the CNS, thereby reducing side effects.
Abhyanga - A simple massage with an herbalized oil with friction-like and deep strokes. This form of massage heightens the brain function and increases blood flow to the brain. It also reduces levels of cortisol (stress hormone), arginine vasopressin, and a salivary stress protein. It is also believed to relax the tight junctions between endothelial cells in the CNS vessels, allowing entry of ‘medicines’ into the CNS.
Transcranial Oleation Therapy treats nervous system disorders. They are non-invasive therapies such as:
Shirodhara and ShiroSeka- a gentle dripping or continuous stream of warm, herbalized oil on the forehead. Studies suggest that this may influence hormonal and cerebral blood flow. The medicated oil also permeates the skin cells and the frontal lobe and prefrontal cortex.
Shirobasti - Medicated oil is poured and retained on the head in a special cap for 30 to 45 minutes.
ShiroAbhyanga - Medicated oil is smeared on the head followed by a full-body herbalized oil massage.
Naturopathic: Sleep, supplementation and nutrition to achieve optimal cellular health and homeostasis (physiological balance), positive mental attitude
Asana, Pranayama, and Meditation: Moving through the Five Koshas and The Vital Essences (Fig. 3.4, 3.5)
What’s happening in the subtle/energy body with Alzheimer’s?
When we age we are constantly moving more and more towards Vata, bones become brittle, skin dry, memory becomes faded, hair turns grey (so cool!). These are all common effects of aging. However, as we move from gross to subtle to more subtle in the body, we notice with Alzheimer’s that vata has become too excessive in the body, leading to neurological disorders and manifesting through out the Koshas of the body. In the Annamaya kosha (physical body) this can be seen as an excessive amount of dry and space.
Literally, there is more space being created in the brain as brain cells become damaged, leaving large holes in the brain (Fig. 3.2). This physical manifestation of emptiness naturally translates to the next two levels of the subtle body, pranamaya kosha (energy body) and manomaya kosha (mind body), with symptoms of depleted Ajna (crown chakra), as memory and thinking, orientation, comprehension, calculation, learning capacity, language and judgement all begin to become depleted. Eventually the disease will begin to progress downwards through each chakra, eventually limiting speech, movement, and even using the bathroom.
This Vata disorder points to the answer, nutritionally cultivate the opposing qualities of Vata in order to restore health and ojas (vigor) to the body in addition to medicinal and herbal treatments mentioned above. Restoring Ojas and Tejas to the body
What are the emotional reflections of this issue? (Fig. 3.6)
Early in the disease, people may experience irritability, anxiety or depression. Later in the disease, people may develop: Agitation (verbal or physical outbursts, general emotional distress, restlessness, pacing, shredding paper or tissues) Sleep disturbances. Delusions. Hallucinations.
How Can Yoga Help?
Yoga offers a personal journey of growth and self-discovery for each practitioner. It also offers ways to join in community with others. Alzheimer’s and other forms of dementia significantly challenge both self-awareness and the ability of individuals in community to connect.
There are great challenges not only for patients with AD but also their caregivers. The practice of yoga can help them both deal with the issues that they are dealing with. With patients being at different levels of awareness as the disease arises, there is often varied levels of emotional frustration (Vata), anger (Pitta), and fear (Vata).The practice of yoga offers many benefits for the central nervous system and energetic body. (Fig 3.7)
Growth.
Self Discovery.
Relaxation methods.
Retraining and practice in basic motor skills.
Catharsis through joyful movement and images
Powerful non-verbal means of connection and communication.
Catharsis/Release through the pathways.
Connecting neural pathways through association.
Exercise and the mind-body connection.
Breath Awareness (thoughts, feelings, physical sensations)
Community.
If an individual with this issue shows up in a general yoga class and makes the issue known to you as the teacher, what concerns or special considerations would you make in your class? (Fig 3.8)
It’s important to remember that each individual will be dealing with a unique set of challenges despite being grouped into the diagnosis of Alzheimer’s. Always remember to follow intelligence of present-moment awareness when guiding students.
There are three types of classes that you may encounter an AD patient.
Group Class for AD Patients at a Memory Care Facility or Assisted Living
Chair Yoga
Breathing exercises w/ finger tapping.
Laughter Yoga
One of the surest ways to reach catharsis, relaxation, and communal connection is laughter, the focus of Laughter Yoga. The idea of this yoga form is that even pretending to laugh brings many of the same psychological and physiological benefits of laughing for real, and participants might even find themselves actually laughing!
Private Session
Chair Yoga/Breathing techniques/Mantra w/ Finger Tapping
Kirtan Kriya Yoga Singing Exercise Instructions (Fig. 3.9)
Repeat the Saa Taa Naa Maa sounds (or mantra) while sitting with your spine straight.
If possible, your focus of concentration is the L form (see illustration at right), while your eyes are closed. With each syllable, imagine the sound flowing in through the top of your head and out the middle of your forehead (your third eye point).
For two minutes, sing in your normal voice.
For the next two minutes, sing in a whisper.
For the next four minutes, say the sound silently to yourself.
Then reverse the order, whispering for two minutes, and then out loud for two minutes, for a total of twelve minutes.
To come out of the exercise, inhale very deeply, stretch your hands above your head, and then bring them down slowly in a sweeping motion as you exhale.
The finger positions, are very important in this kriya (see illustration below).
On Saa, touch the index fingers of each hand to your thumbs.
On Taa, touch your middle fingers to your thumbs.
On Naa, touch your ring fingers to your thumbs.
On Maa, touch your little fingers to your thumbs.
Public Class with an individual with beginning-stage symptoms of AD. How would you instruct the individual to modify the practice?
Welcome them to sit in sukhasana or lay in savasana at any point in the class.
Offer support and options for all students.
Guide them through visual and auditory instruction.
Make eye contact.
Encouraging those with AD to journal and/or talk about the effects of yoga and meditation in their life whether during a class or afterward can be helpful as well. Teachers are encouraged to notate what practices for a particular student yield the most positive results.
Healing Potential
With Ayurvedic treatments, yoga, pranayama, meditation, nutrition, and sleep, there is a high likely and potential for prevention of AD, temporary relief of symptoms, and even reversal of symptomatic progression. (Fig. 3.10)
“In a way, both yoga and meditation are ‘brain exercises’ that engage different parts of the brain based on the components of practice (breathing, movement, postures, chanting, visualization, concentration), and can help the brain form new connections and recover from injuries, or as we call it, to stimulate neuroplasticity,” says Helen Lavretsky, M.D., M.S., director of the late-life mood, stress, and wellness research program at the Semel Institute for Neuroscience and Human Behavior at UCLA.
Lavretsky noted that in both of the aforementioned studies, yoga and meditation were used in combination with other approaches, such as exercise, music therapy, medications, and brushing of the teeth. However, she says yoga practice and meditation may be helpful in prevention of dementia (a general term for loss of memory and other intellectual abilities serious enough to interfere with daily life) in several ways.
“Chronic stress and related stress hormones could negatively affect brain structures important for memory and cognition, like the hippocampus. Chronic stress is also associated with inflammation in the body and in the central nervous system/brain that is linked to Alzheimer's disease and other disorders of aging. Yoga can reduce stress hormones and inflammatory factors, and teach an individual over time how to cope more effectively and protect the body from going through the stress response,” she explains, noting that the younger you are when you start practicing yoga and meditation, the better.
In patients who have concerns with memory loss and some cognitive impairment but don’t yet have Alzheimer’s disease, practices like yoga and meditation could be more beneficial in preventing cognitive decline, Lavretsky adds. In the 7 Amazing Brain Benefits of Meditation, writer Amanda Mascarelli reported that Wake Forest neurologist Rebecca Erwin Wells, MD, and her colleagues found in a 2013 pilot study that adults with mild cognitive impairment who practiced mindfulness meditation showed less atrophy in the hippocampus than those who didn't. Their research also found meditators, compared with non meditators, had greater neural connectivity in the "default mode network," an area of the brain involved in activities like daydreaming and thinking about the past and the future.
Recommended Yoga Sequence for Patients with Alzheimer’s
with Props / Assisted Yoga* / Adaptive Yoga* modifications 60 min. (Fig. 3.11)
Cue Words: “Focus”, “Concentration”, “Recall”, “Bring Attention” “Imagine”
Chair Yoga Sequence
Pranayama (Ujjayi) / Visualization “Imagine a peaceful place…” 5 min.
Arm Flow/Side Bends 4 min.
Chair Twist 4 min.
Cat/Cow Flow 4 min.
Chair Sun Salutation 5 min.
Pranayama w/ Finger Tapping (Saa Taa Naa Maa exercise) 6 min.
Leg Lifts (Bent Knee) 2 min.
Shoulder Shrugs 2 min.
Eagle Arm Hugs 2 min.
Laughter Yoga (Ha Ha Ho Ho Ho) opt. clapping/tapping 4 min.
Pranayama (Visualization “Imagine a peaceful place…” 5 min.
Viloma A / Viloma B 5 min.
Mindfulness Meditation / So Hum Meditation 6 min.
4. Brain Injuries
Traumatic brain injury (TBI) is an insult to the brain, not of a degenerative or congenital nature, but caused by external physical force that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning. (Fig. 4.1)
Traumatic brain injury, often referred to as TBI, is most often an acute event similar to other injuries. That is where the similarity between traumatic brain injury and other injuries ends. One moment the person is normal and the next moment life has abruptly changed.
In most other aspects, a traumatic brain injury is very different. Since our brain defines who we are, the consequences of a brain injury can affect all aspects of our lives, including our personality. A brain injury is different from a broken limb or punctured lung. An injury in these areas limit the use of a specific part of your body, but your personality and mental abilities remain unchanged. Most often, these body structures heal and regain their previous function.
Brain injuries do not heal like other injuries. Recovery is a functional recovery, based on mechanisms that remain uncertain. No two brain injuries are alike and the consequence of two similar injuries may be very different. Symptoms may appear right away or may not be present for days or weeks after the injury.
One of the consequences of brain injury is that the person often does not realize that a brain injury has occurred.
Most people are unaware of the scope of TBI or its overwhelming nature. TBI is a common injury and may be missed initially when the medical team is focused on saving the individual’s life. Before medical knowledge and technology advanced to control breathing with respirators and decrease intracranial pressure, which is the pressure in the fluid surrounding the brain, the death rate from traumatic brain injuries was very high. Although the medical technology has advanced significantly, the effects of TBI are significant.
TBI is classified into two categories: mild and severe.
A brain injury can be classified as mild if loss of consciousness and/or confusion and disorientation is shorter than 30 minutes. While MRI and CAT scans are often normal, the individual has cognitive problems such as headache, difficulty thinking, memory problems, attention deficits, mood swings and frustration. These injuries are commonly overlooked. Even though this type of TBI is called “mild”, the effect on the family and the injured person can be devastating. Follow this link for more information on Mild TBI.
Severe brain injury is associated with loss of consciousness for more than 30 minutes and memory loss after the injury or penetrating skull injury longer than 24 hours. The deficits range from impairment of higher level cognitive functions to comatose states. Survivors may have limited function of arms or legs, abnormal speech or language, loss of thinking ability or emotional problems. The range of injuries and degree of recovery is very variable and varies on an individual basis. Follow this link for more information on Severe TBI.
The effects of TBI can be profound. Individuals with severe injuries can be left in long-term unresponsive states. For many people with severe TBI, long-term rehabilitation is often necessary to maximize function and independence. Even with mild TBI, the consequences to a person’s life can be dramatic. Change in brain function can have a dramatic impact on family, job, social and community interaction.
What are the Causes of TBI? (Fig. 4.2)
The number of people with Traumatic Brain Injury (TBI) is difficult to assess accurately but is much larger than most people would expect. According to the CDC (United States Centers for Disease Control and Prevention), there are approximately 1.5 million people in the U.S. who suffer from a traumatic brain injury each year. 50,000 people die from TBI each year and 85,000 people suffer long term disabilities. In the U.S., more than 5.3 million people live with disabilities caused by TBI. Patients admitted to a hospital for TBI are included in this count, while those treated in an emergency room or doctor’s office are not counted.
The causes of TBI are diverse. The top three causes are: car accident, firearms and falls. Firearm injuries are often fatal: 9 out of 10 people die from their injuries. Young adults and the elderly are the age groups at highest risk for TBI. Along with a traumatic brain injury, persons are also susceptible to spinal cord injuries which is another type of traumatic injury that can result out of vehicle crashes, firearms and falls. Prevention of TBI is the best approach since there is no cure.
Mechanisms of Injury
These mechanisms are the highest causes of brain injury: Open head Injury, Closed Head Injury, Deceleration Injuries, Chemical/Toxic, Hypoxia, Tumors, Infections and Stroke.
1. Open Head Injury
Results from bullet wounds, etc.
Largely focal damage
Penetration of the skull
Effects can be just as serious as closed brain injury
2. Closed Head Injury
Resulting from a slip and fall, motor vehicle crashes, etc.
Focal damage and diffuse damage to axons
Effects tend to be broad (diffuse)
No penetration to the skull
3. Deceleration Injuries (Diffuse Axonal Injury)
The skull is hard and inflexible while the brain is soft with the consistency of gelatin. The brain is encased inside the skull. During the movement of the skull through space (acceleration) and the rapid discontinuation of this action when the skull meets a stationary object (deceleration) causes the brain to move inside the skull. The brain moves at a different rate than the skull because it is soft. Different parts of the brain move at different speeds because of their relative lightness or heaviness. The differential movement of the skull and the brain when the head is struck results in direct brain injury, due to diffuse axonal shearing, contusion and brain swelling.
Diffuse axonal shearing: when the brain is slammed back and forth inside the skull it is alternately compressed and stretched because of the gelatinous consistency. The long, fragile axons of the neurons (single nerve cells in the brain and spinal cord) are also compressed and stretched. If the impact is strong enough, axons can be stretched until they are torn. This is called axonal shearing. When this happens, the neuron dies. After a severe brain injury, there is massive axonal shearing and neuron death.
4. Chemical / Toxic
Also known as metabolic disorders
This occurs when harmful chemicals damage the neurons
Chemicals and toxins can include insecticides, solvents, carbon monoxide poisoning, lead poisoning, etc.
5. Hypoxia (Lack of Oxygen)
If the blood flow is depleted of oxygen, then irreversible brain injury can occur from anoxia (no oxygen) or hypoxia (reduced oxygen)
It may take only a few minutes for this to occur
This condition may be caused by heart attacks, respiratory failure, drops in blood pressure and a low oxygen environment
This type of brain injury can result in severe cognitive and memory deficits
6. Tumors
Tumors caused by cancer can grow on or over the brain
Tumors can cause brain injury by invading the spaces of the brain and causing direct damage
Damage can also result from pressure effects around an enlarged tumor
Surgical procedures to remove the tumor may also contribute to brain injury
7. Infections
The brain and surrounding membranes are very prone to infections if the special blood-brain protective system is breached
Viruses and bacteria can cause serious and life-threatening diseases of the brain (encephalitis) and meninges (meningitis)
8. Stroke
If blood flow is blocked through a cerebral vascular accident (stroke), cell death in the area deprived of blood will result
If there is bleeding in or over the brain (hemorrhage or hematoma) because of a tear in an artery or vein, loss of blood flow and injury to the brain tissue by the blood will also result in brain damage.
There are several ways to describe brain injuries. The brain is enclosed in the bony vault of the skull. The cerebrospinal fluid surrounds the brain and, most of the time, protects it from impact with the skull. If there is a rapid force applied to the skull or rapid deceleration of the head, the brain may strike the inside of the bony vault.
Brain tissue may stretch or tear because of the rapid movement. This can injure the nervous tissue of the brain directly. If a projectile such as a bullet enters the skull, it can directly injure the brain.
Below is a list of terms and definitions that refer to the different injuries of TBI.
Closed Head Injury– the skull is intact and there is no penetration of the skull. Direct or indirect force to the head can cause this type of injury. This may be caused by rotational and/or deceleration in the case of both direct and indirect force.
Open Head Injury– penetration of the skull with direct injury to the head.
Diffuse Axonal Injury– diffuse cellular injury to the brain from rapid rotational movement. This is often seen in motor vehicle accidents or shaking injuries. The axons are the projections of the brains nerve cells that attach to other nerve cells. They are damaged or torn by the rapid deceleration. The injury is from the shearing force disrupting the axons which compose the white matter of the brain.
Contusion– a bruise to a part of the brain. Like a bruise on the body, this is bleeding into the tissue.
Penetrating Trauma– any object that enters the brain. Causes direct injury by impact and pushing skull fragments into the brain.
Secondary Injury– swelling and release of chemicals that promote inflammation and cell injury or death. This causes swelling in the brain which may increase the intracranial pressure and prevent the cerebrospinal fluid from draining out of the skull. This causes further increase in pressure and brain damage. If this is not controlled or prevented the brain can herniate (push through) the base of the skull and cause respiratory failure and death. The only way to prevent the primary injury is to prevent the trauma. The prevention of this secondary injury is the focus of the acute medical care after injury.
Secondary Injury Includes:
Intracranial hemorrhage (bleeding inside the skull)
Brain swelling
Increased intracranial pressure (pressure inside the skull)
Brain damage associated with lack of oxygen
Infection inside the skull, common with penetrating trauma
Chemical changes leading to cell death
Increased fluid inside the skull (hydrocephalus)
Acquired Brain Injury– injuries other than congenital, birth trauma, hereditary or degenerative. This includes traumatic brain injury. In the non-traumatic types of acquired brain injury, the brain is usually diffusely injured. These injuries are usually not included in traumatic brain injury but the symptoms span the same spectrum.
Common causes are anoxia and hypoxia. These are lack of oxygen to the brain and insufficient oxygen to the brain. They can occur because of mechanical problems with breathing, with cardiac arrest or bleeding. Drugs and poisoning can also cause acquired traumatic brain injury. Carbon monoxide poisoning is an example of poisoning that may cause brain injury.
Symptoms of TBI (Fig.4.3,4.4))
Brain injuries can range in scope from mild to severe. Traumatic brain injuries (TBI) result in permanent neurobiological damage that can produce lifelong deficits to varying degrees. Moderate to severe brain injuries typically refer to injuries that have the following characteristics:
Moderate brain injury is defined as a brain injury resulting in a loss of consciousness from 20 minutes to 6 hours and a Glasgow Coma Scale of 9 to 12
Severe brain injury is defined as a brain injury resulting in a loss of consciousness of greater than 6 hours and a Glasgow Coma Scale of 3 to 8
The impact of a moderate to severe brain injury depends on the following:
Severity of initial injury
Rate/completeness of physiological recovery
Functions affected
Meaning of dysfunction to the individual
Resources available to aid recovery
Areas of function not affected by TBI
The impact of a moderate to severe brain injury can include:
Cognitive deficits including difficulties with:
Attention
Concentration
Distractibility
Memory
Speed of Processing
Confusion
Perseveration
Impulsiveness
Language Processing
“Executive functions”
Speech and Language
not understanding the spoken word (receptive aphasia)
difficulty speaking and being understood (expressive aphasia)
slurred speech
speaking very fast or very slow
problems reading
problems writing
Sensory
difficulties with interpretation of touch, temperature, movement, limb position and fine discrimination
Perceptual
the integration or patterning of sensory impressions into psychologically meaningful data
Vision
partial or total loss of vision
weakness of eye muscles and double vision (diplopia)
blurred vision
problems judging distance
involuntary eye movements (nystagmus)
intolerance of light (photophobia)
Hearing
decrease or loss of hearing
ringing in the ears (tinnitus)
increased sensitivity to sounds
Smell
loss or diminished sense of smell (anosmia)
Taste
loss or diminished sense of taste
Seizures
the convulsions associated with epilepsy that can be several types and can involve disruption in consciousness, sensory perception, or motor movements
Physical Changes
Physical paralysis/spasticity
Chronic pain
Control of bowel and bladder
Sleep disorders
Loss of stamina
Appetite changes
Regulation of body temperature
Menstrual difficulties
Social-Emotional
Dependent behaviors
Emotional ability
Lack of motivation
Irritability
Aggression
Depression
Disinhibition
Denial/lack of awareness
Ayurveda, Yoga, and Meditation for TBI
The first phase of unconsciousness serious illness as a result from TBI should first be treated in intensive care. After this phase is complete, the sooner one can begin Ayurvedic treatment the better. Applying Ayurveda and Yoga will help heal the body from the physical, cognitive, behavioral and emotional difficulties that result from TBI. Treatment is aimed at healing the damaged nerve cells, improving neuromuscular coordination.
Ayurvedic Treatment (Fig. 4.5)
Medicines like Maha-Vat-Vidhvans-Ras, Vat-Gajankush-Ras, Bruhat-Vat-Chintamani, Vish-Tinduk-Vati, Agnitundi-Vati, Kaishor-Guggulu, Trayo-Dashang-Guggulu, Abhrak-Bhasma, Trivang-Bhasma, Amalaki (Emblica officinalis), Guduchi (Tinospora cordifolia), Kuchla (Strychnos nuxvomica), Ashwagandha (Withania somnifera), Haridra (Curcuma longa), Yashtimadhuk (Glycyrrhiza glabra), Mandukparni (Centella asiatica), Bala (Sida cordifolia), Naagbala (Grewia hirsuta) and Shatavari (Asparagus racemosus) are used to normalize nerve and muscular function.
Medicines like Brahmi (Bacopa monnieri), Jatamansi (Nardostachys jatamansi), Shankhpushpi (Convolvulus pluricaulis), Vacha (Acorus calamus), Jayphal (Myristica fragrance) and Sarpagandha (Raulwofia serpentina) are used to treat cognitive, behavioral and emotional problems. Medicines like Maharasnadi-Guggulu, Nirgundi (Vitex negundo), Rasna (Pluchea lanceolata) and Tagar (Valeriana valichii) are used to control pain and muscular spasm.
The entire body is massaged using medicated oils like Maha-Narayan-Oil, Chandan-Bala-Laxadi-Oil, Bala-Oil, and Saindhav-Oil. This is followed by medicated steam fomentation using Dashmool-Qadha or Nirgundi-Qadha. These procedures are believed to strengthen muscles and stimulate the nervous system. Modified massage procedures like "Pinda-Sweda" and "Pizichil" can also be used for specific situations. Some physicians advocate the use of medicated enemas called "Basti", which are believed to regulate the Vata dosha and normalize nerve impulses.
It should be kept in mind that the response of patients to treatment can be highly unpredictable. Sometimes, patients with severe injury and an apparently major nervous system deficit make a dramatic and early recovery, whereas other patients who are comparatively not as handicapped take a longer time for improvement. Nevertheless, all patients do benefit from herbal medicines and Ayurvedic treatment procedures.
Yoga and Meditation (Fig. 4.6)
Mental distractions, such as over excitement, anxiety and other mental stressors are hallmarks of traumatic brain injury (TBI) and can interfere with the healing process. Also after a brain injury, the body and the mind struggle to function together in unison as they once did; actions our brain tells our body to do are slower and less efficient. Using mindful-based practices can help strengthen the mind-body connection while also teaching the brain how to relax and allow itself to heal.
As a therapy for both the mind and body, yoga can bring a new focus of what one can achieve, building optimism, confidence, and balance. By quieting the mind, stress and anxiety is reduced and the body can focus on building strength and flexibility not only on the physical level but the energetic and spiritual level as well.
Meditation can help mitigate the stress response and even create beneficial neuroplasticity. Attention and emotional self-regulation can be common symptoms following a TBI, which can be improved through this process of mental training.
“In the last few decades the neuroimaging research has shown evidence confirming meditation and brain plasticity. Meditation enhances cortical remapping and brain functions. Neuroimaging studies have shown the increased regional cerebral blood flow during meditation. Also the studies have indicated neural pathways and synapses changes among mediators. These results indicate that meditation is not merely an altered state of consciousness / a state of relaxation. Meditation helps to uplift mental health and causes healthy changes in the brain. Therefore mediation is one of the unique modes to improve mental health.” -Dr. Ruwan M. Jayatunge,
Meditation and Brain Plasticity
Initiates neuroplasticity
Increases cerebral blood flow
Decreases stress and anxiety
Improves attention, awareness, and emotion regulation
Leads to significant changes of gray matter in areas of learning and memory, emotion regulation, self-referential processing, and perception
New research conducted at Indiana University–Purdue University Indianapolis found that adaptive yoga—a specialized practiced tailored to the needs of a person with disabilities or chronic health conditions—is beneficial for adults who have suffered a stroke or traumatic brain injury. The study tested whether the mind-body-spirit function of yoga had more of a profound impact on its subjects than traditional rehabilitation exercises. Since mind-body disconnection is commonly diagnosed after brain injury and head trauma, scientists concluded that incorporating therapeutic yoga practices were integral to recovery.
Asana and Pranayama
Bring in simple postures to guide students towards refining awareness of body-mind.
Seated/Standing Forward Fold
Child’s Pose
Sukhasana
Savasana
Cat/Cow
Bridge Pose
Ujjayi, Nadi Shodhana, and Bhastrika can all be helpful pranayama practices, stabilizing the nervous system,increasing oxygen flow to the brain, increasing concentration, and decreasing stress. Pranayama breathing should be practiced at both the beginning and end of yoga sessions. Journaling, reflection, and a routine daily asana/pranayama/meditation practice are recommended.
Recommended Yoga Sequence for Patients with TBI w/ Props / Assisted Yoga* / Adaptive Yoga* 60min. (Fig. 4.7)
Sukhasana (ujjayi pranayama) 5 min.
Child’s pose 2 min.
Table Top and Table Top Variations 2 min.
Standing FF (blocks) 2 min.
Tadasana/ Urdhva Hastasana Flows/Side Bends 7 min.
Dristi Exercise / Eye Movement Vertical, Horizontal, Circular / Alternate Hands 5 min.
Assisted Vrksasana Pose 1 min.
Easy Navasana to Seated 1 min.
Reclined Twist 5 min.
Knees to Chest/Option for Leg Lifts w/ Bent Knees (core) 3 min.
Reclined Bound Angle (Blocks) 3 min.
Bridge Flows 2 min.
Bridge 2x (mini then medium) 3 min.
Supported Bridge 3 min.
Happy Baby 2 min.
Savasana 10 min.
Seated Meditation/Pranayama (Nadi Shodhana) 5 min.
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Google Slide available at: https://docs.google.com/presentation/d/1sFdUngHSSUTVO0dpUXL0sJoQ-Y4jT62ug44DuNl6B8M/edit?usp=sharing
