The Los Angeles Times wrote that “the trifecta of alcohol abuse, cigarette smoking and a high body may be linked with alcohol-related brain injuries.”  

 http://www.latimes.com/health/boostershots/la-heb-brain-20100907,0,7994320.story

That story was based on a study described in the journal Alcoholism: Clinical & Experimental Research.

http://onlinelibrary.wiley.com/doi/10.1111/j.1530-0277.2010.01305.x/abstract

 That study analyzed data from 54 male veterans, from 28 to 66 years old, who “were dependent on alcohol and were in treatment  and had not been drinking for about a month,” The Times wrote.

Researchers looked at several aspects of the men’s health, including their body mass index, or BMI. They also did brain magnetic resonance imaging on the men, as well as checking blood flow and the level of metabolites, byproducts of metabolism, in their brains.

The study found that those with a higher BMI often had low concentrations if N-acetylaspartate, a metabolite, in their central nervous systems. Lower levels of NAA can signal brain dysfunction, according to The Times.

“Excessive weight is not only a risk factor for cardiovascular disease or diabetes, but it is also a risk factor for deveoping dementia,” Stefan Gazdzinski, a researcher at Jagiellonian University in Poland and the lead on the study, said in a press release. “Knowing that individuals in develioped counries who overuse alcohol are usually heavier than individuals enjoying alcohol in moderation — because of the caloric intake — we wanted to investigate if excess weight accounts for some of the brain injury usually observed in alcoholics.”   

Turner, who retired from pro football when he was 31 in 2000, has been diagnosed as having ALS, so-called Lou Gehrig’s  disease.

http://www.myfoxphilly.com/dpp/sports/nfl/eagles/Kevin_Turner_ALS_Lou_Gehrigs_Disease_082310

Turner left football because of problems he had with his spinal column.  When Turner retired his doctors told him that he had the spinal column of a 65-year-old — at age 31!

But now Turner faces another health issue, the problem that the National Football League has been called on the carpet to address: permanent brain injury and disease that players sustain from repeated concussions.  

In terms of developing ALS, Turner has a lot of company. He is the 14th former National Football League player found to have ALS since 1960,  according to The Boston Globe, which is a higher rate than the disease occurs in most men.

Retired NFL players have also been developing Alzheimer’s disease and other forms of dementia at far higher rates than the general population. There is research going on right now on the issue, studies that include autopsies being performed on the bodies of ex-NFL players.

In light of a recent study, I wonder if  Turner was diagnosed correctly. Research released last week found that athletes that have been diagnosed as having Lou Gehrig’s disease, including Lou Gehrig, may actually have had a condition that is very similar to that malady but is in fact different. 

http://www.subtlebraininjury.com/blog/2010/08/study-links-brain-injury-to-condition-that-apes-lou-gehrigs-disease.html?preview=true&preview_id=521&preview_nonce=567261fa9a

In any event, Turner has serious brain-related problems, whether they are actually Lou Gehrig’s disease or something similar.

http://discovermagazine.com/2010/jul-aug/18-brain-what-happens-to-a-linebackers-neurons

The piece opens by describing the new battery of cognitive tests that the National Football League gives to players in the college draft, brainteasers such as trying to remember where different “Xs” and “Os” were positioned a page. 

The idea is to have a baseline to compare to a player’s answers after they sustain a head injury. If a player gets a concussion in a future game, he can be retested to compare his pre-concussion answers to his post-concussion ones, to gauge how badly his brain was injured. 

As our brains float around in the cerebrospinal fluid in our skulls, they get knocked around quite a bit. So how do our brains usually escape getting damaged?   

Discover Magazine illustrates that by citing research by Douglas Smith, director of the Center for Brain Injury and Repair at the University of Pennsylvania. We won’t go into all the detail, but Smith set up rat neurons on a stretchable membrane, and they developed axons, appendages that connect one neuron to another, transmitting electric signals.

When Smith directed a “controlled puff of air’” at  his “brain,” the axons were elastic and stretched, then went back to their old position.  But if he subjected his “brain” to a quick, big shot of air, the axons developed “kinks,” according to Discover Magazine. They wind up permanently damaged.

This type of damage can lead to diffuse axonal injury, which is when proteins “pile up”  on an axon, and can even burst it, Discover Magazine said. Diffuse axonal injury happens when a person’s brain is suddenly acclerated, as when someone gets whiplash.

This is apparently what happened to New York Mets outfielder Jason Bay recently. He crashed into a wall to catch a fly ball, and hurt his back and legs. He never hit his head, so a concussion was ruled out. But two days later Bay came down with a nagging headache. Team doctors now believe that Bay sustained a concussion from whiplash, from his head snapping back when he hit the wall. 

The type of mild brain injury that football players sustain again and again over the years has a cumulative effect, and the repeated stretching that axons undergo can essentially kill them “like a shorted-out circuit,” according to Discover Magazine.

There is some hope of finding drugs that can stop brain damage on the molecular level.

But at the present time, “Once a person does sustain a brain injury, there is not a lot doctors can do,” the magazine article says.  And that is the sad truth at the moment.  

The research essentially links brain injuries — concussions and brain trauma — to a disease than can be mistaken for Alzheimer’s, Parkinson’s and amyotrophic lateral sclerosis, which is commonly known as Lou Gehrig’s Disease.

The report by the Journal of Neuropatholgy and Experimental Neurology  got widespread press coverage Wednesday, including a lengthy Page One story, ”Study Says Brain Trauma Can Mimic ALS,” in The New York Times and an article in The Wall Street Journal.

http://www.nytimes.com/2010/08/18/sports/18gehrig.html?src=me&ref=general

http://online.wsj.com/article/SB10001424052748704554104575435850832715586.html?mod=WSJ_WSJ_US_News_5

According to The Times, physicians at the Veterans Affairs Medical Center in Massachusetts and the Boston University School of Medicine doing autopsies on athletes found that two football players and a boxer who’d been diagnosed with ALS didn’t actually have it.

Exams on the three men’s brains and spinal cords determined that they had a fatal malady similar to ALS, “caused by concussionlike trauma, that erodes the central nervous system in similar ways,” The Times reported.

New York Yankee Lou Gehrig solidified his standing as a sports legend when he declared himself  “the luckiest man on the face of the earth,” even though he’d been diagnosed with the fatal disease that would come to have his name. ALS causes a person to lose muscle control, and for their muscle tissue to atrophy.

Gehrig sustained many concussions over the years, according to The Times, and he insisted on playing when he had them. That could have cumulatively added to the initial brain damage casued by his concussion, and resulted in the condition that ended his life.

The study released this week could, and I think it should, lead to more careful diagnosis of both athletes and soldiers who suffer head trauma. As The Times points out, athletes and the military could be more effectively treated if they were diagnosed correctly, let’s say as suffering from a motor-neuron disease rather than ALS.

The new study offers firm some evidence that brain injury causes motor-neuron degeneration, and that this can lead to a disease that is not ALS. Rather, the disorder that resulted is marked by two proteins, tau and TDP-43, in the spinal cord that negatively affect nerve function.       

http://www.army.mil/-news/2010/07/28/42934-army-health-promotion-risk-reduction-and-suicide-prevention-report/index.html

The startling report found that increased drug and alcohol abuse among soldiers is contributing to a skyrocketing suicide rate for service members, as well as leading to accidental deaths caused by risky behavior by the drunk and stoned.

http://www.aolnews.com/nation/article/army-report-finds-alarming-rise-in-suicides-risky-behavior/19573590

In fact, the report says that more soldiers die from their own actions rather than being killed by the enemy in combat.

“Simply stated, we are often more dangerous to ourselves than the enemy,” according to the Health Promotion, Risk Reduction and Suicide Prevention Report.

The report found that during the last fiscal year, 239 soldiers committed suicide, with more than 1,700 attempting to take their lives during that same period.  So-called high-risk behavior, like drinking and drug abuse, are contributing to the increased suicide numbers. 

But the report also said that a breakdown in leadership, in oversight over soldiers, can also be blamed for the deaths.

The report is based on a 15-month study, prompted by the rise in soldier suicides. At one time, the military had a lower suicide rate than the overall U.S. population. But that trend started to change in 2004, according to the report, and in 2008 the Army’s suicide rate was higher than Americans overall.

I have written about the mental and physical impact of repeated deployments of our troops in Iraq and Afganistan. I have written  how the military seems to be putting its head in the sand about the brain injury that these soldiers sustain, by not doing the mandated testing when soldiers have completed their tours.

Brain injury, mild or severe, often leads to depression. And clinical depression, if not treated properly, often leads to self-medication, with illegal drugs or alchohol. And clinical depression can lead to suicide. That is part of the big picture here.

Ike Skelton, D-Mo., is chairman of the House Armed Service Committee. He issued a statement about the Army’s report — or should be.

“It’s clear that the Army feels the same heartache that all Americans feel when even one service member takes his or her life, and the Army deserves praise for its honest and comprehensive study on suicide prevention,” Skelton said.

The military had its own comment, from Army Chief of Staff Gen. George Casey, in its press release on the report.

http://www.defense.gov/releases/release.aspx?releaseid=13756

“This comprehensive review exposes gaps in how we identify, engage and mitigate high-risk behavior among our soldiers,” Casey said. “After nearly a decade of war, we must keep pace with the expanding needs of our strained Army, and continuously identify and address the gaps that exist in our policies, programs and services.”

Now let’s see what the Army does about it.

But at a conference Wednesday, the new co-chairmen of the National Football League’s head, neck and spine medical committee said they are looking for ways to change that attitude, so players are honest and report head injuries.  http://www.nytimes.com/aponline/2010/06/02/sports/AP-FBN-NFL-Concussions.html?_r=1&ref=sports

Dr. Richard Ellenborgen and Dr. Hunt Batjer, the committee chairmen, were at a conference on brain injury held in  Washington by Johns Hopkins Universiry. Representatives of all the NFL teams were present.

The committee is kicking around the idea of offering players financial  incentives to report concussions, according to Ellenborgen. The NFL is also considering guaranteeing that players won’t lose their place in their teams’ lineups or rosters if they have to sit out some games due to a concussion.

The other idea being tossed around is putting a transmitter in each players’ helmet, to track every blow — small or big — that players sustain.

There are other options beyond those, such as trimming off-season practice time, making helmets safer and teaching players not to tackle headfirst.

But the bottom line at the conference was this: New studies are needed on football and brain injury.      

The teams’ medical officials were in town for a medical forum on the diagnosis and treatment of brain injuries that was conducted by John Hopkins University.

 http://www.washingtonpost.com/wp-dyn/content/article/2010/06/01/AR2010060103682.html

NFL Commissioner Roger Goodell was among the speakers, reportedly addressing an audience of about 300 people at the forum.  http://www.sbnation.com/2010/6/2/1497910/nfl-seminar-concussion-player-safety-roger-goodell

Dr. Richard Ellenbogen and Dr. Hunt Batjer, the new co-chaiman of the NFL’s medical committee on head, neck and spine injuries, were also among those attending the conference.

The confab’s participants were slated to discuss the existing medical evidence on traumatic brain injury and make suggestions about what tack future research on diagnosis and treatmetn should take, according to The Washington Post. 

Ellenbogen told The Post that the NFL didn’t have any imput in the conference and don’t know what recommendations will be made.

He did say that he and Batjer will be open to using outside research to help the NFL craft new policies regarding players who get concussions.

The NFL was blasted during Congressional hearings last year because of skepticism league officials expressed about the long-term impact of concussions on players.

Goodell’s letter, according to the Associated Press, was expected to be mentioned by Dr. Richard Ellenborgen during a concussion forum that Congressman John Conyers, D-Mich., is holding today, Monday, in Manhattan.

The NFL put its head in the sand for many years in terms of acknowledging the long-term impact of brain injury. Now, the league and Goodell are actively promoting the institution of proper guidelines for those who suffer concussions while playing sports.

“The NFL has taken a much more aggressive approach in recent years in identifying and treating concussions among our own players,” Goodell wrote in his letter. “We have implemented an awareness campaign to make certain that everyone in the league, including players and coaches, is better equipped to identify concussion symptoms. Our primary rule is: The medical staffs determine when a player is ready to return, not the coach nor the player himself.”

http://www.nfl.com/news/story?id=09000d5d81847223&template=with-video-with-comments&confirm=true

The NFL is urging the 44 states without student-brain injury guides to use the Lystedt Law in Washington as their model. That legislation is named after Zackery Lystedt, a high school player who went back into a game in 2008 after sustaineing a concussion, and then had to be hospitalized and nearly died.   

Dr. Ellenborgen was Lystedt’s surgeon. The NFL’s Head, Neck and Spine Committee is chaired by Dr. Ellenborgen and Dr. Hunt Batjer, who testified at today’s hearing.

 ”The Center for Disease Control estimates that there may be as many as 3.8 million sports and recreation-related concussions in the United States each year,” Goodell wrote in his letter. “These injuries are sustained by both boys and girls in numerous contact sports.”

He continued, “Given our experience at the professional level, we believe a similar approach is appropriate when dealing with concussions in all youth sports. That is why the NFL and its clubs urge you to support legislation that would better protect your state’s young athletes by mandating a more formal and aggressive approach to treatment of concussions.”

The Lystedt law’s has three major components: Athletes, parents and coaches must be educated about the dangers of concussions each year; if a young athlete is suspected of having a concussion, he/she must be removed from a game or practice and not be permitted to return to play; and a licensed health care professional must clear the young athlete to return to play in the subsequent days or weeks.

“We would urge that similar legislation be adopted in your state,” Goodell wrote. “We believe that sports and political leaders can help raise awareness of these dangerous injuries and better ensure that they are treated in the proper and most effective way. Young athletes, as well as parents, coaches and school officials in your state, will thank you for taking a stand on this important issue.”

If you think it isn’t important, read the statistics on the correlation between head injury and crime, from a comprehensive scholarly article on the issue, published in 2009 in the Archives of Clinical Neuropsychology, available online at http://acn.oxfordjournals.org/cgi/reprint/25/1/1

Finally, a history of head trauma and TBI has been linked to violent aggression and criminal behavior, and the prevalence of TBI among violent offenders has consistently been documented as higher than that of the general population. In a sample of 279 veterans who had sustained penetrating brain injuries during military service in Vietnam, Grafman and colleagues (1996) found that veterans with ventromedial frontal lobe lesions had an increased risk of aggressive and violent behavior, relative to veterans with nonfrontal brain lesions and normal controls. However, research on the prevalence of closed head trauma among criminals is often based on the self-report of inmates in correctional facilities (e.g., Schofield et al., 2006). Such studies have documented extremely high rates of self-reported incidents of closed head trauma, including 86% of prison inmates in New Zealand (Barnfield & Leathem, 1998) and 87% of county jail inmates in Washington (Slaughter, Fann, & Ehde, 2003). In a sample of 15 convicted murderers sentenced to death, Lewis and colleagues (1986) found that 100% of this death row sample had a history of severe head injury.

Source: From Archives of Clinical Neuropsychology 25 (2010) 1–13 Neuropsychological Features of Indigent Murder Defendants and Death Row Inmates in Relation to Homicidal Aspects of Their Crimes Robert E. Hanlon, Leah H. Rubin, Marie Jensen, Sarah Daousta

Yes, that study said 100% of a sample of death row inmates had a history of “severe brain injury.” That isn’t concussion, that is the kind of brain injury that involves extended coma. (You don’t guess that someone had a severe brain injury. You reach that conclusion because the medical records and history make it clear that such person was severely injured.) What that means for us is that any time someone suffers significant brain damage there is not just greatly increased risk, but an outright probability that they will have difficulty conforming conduct to the law.

Should society thus excuse everyone with frontal lobe damage from criminal punishment? Of course not. We can’t set all of our criminals free, regardless of what explanation there may be for behavior that threatens society. I am an advocate for the brain injured, but I am not a fool. Yet justice does require a further incorporation of what we know about brain damage into our criminal law. We must define diminished responsibility into categories more than “sane versus insane”. Brain damage can dramatically change the capacity of an individual to behave like an adult. We do not punish children like we do adults. We should not punish the brain injured like adults either. See my comment on brain injury rehabilitation at http://www.subtlebraininjury.com/blog/2010/04/no-twelve-step-program-for-brain-injury-rehabilitation.html

But a modification of the application of the concept of criminal intent isn’t the critical issue here. What is important is that society appreciate the magnitude and nature of abnormal neurobehavior. The first step is of course appreciating the nature of the problem. That is a task that this blog can undertake. The bigger problem of how to make radical change in what treatment and services are provided for brain injured individuals requires a commitment from government, doctors and the entire medical establishment. We must fully understand that if we continue to fail in this objective, that the problem isn’t Roethlisberger type conduct but a staggering level of violence and crime throughout our society. Could we fix all brain damage, we would eliminate far more violent crime than we could by stopping all drugs and crooks at the border.

To understand crime in the brain injury population, we must first understand the frontal lobes, and the role they play in law and order. The frontal lobes not only control what is called executive functioning, but virtually all reasoned behavior. Further they play a large role in modulating emotions, depression, anxiety and stress. The biggest difference between human beings and other mammals is the size of the frontal lobes and how long they take to fully develop. As stated earlier this week: “We learn to become adults in our frontal lobes.” Tragically, it is our frontal lobes and their axonal connections that are most vulnerable to brain injury, especially the type of forces in motor vehicle wrecks and falls. The result of such accidents (even at times concussions that may not appear to involve serious injury to the brain) can be a dramatically changed person and behavior. It can be as if the injured person suddenly reverted to the maturity of a 10 year old.

I ended yesterday’s blog with a quote from the excellent online source written by Inés Monguió, Ph.D. a neuropsychologist from California and I will include further references to her material below. That article can be found at http://www.uninet.edu/union99/congress/confs/hi/03Monguio.html That source is written specifically to the issue of criminal conduct, but in my experience what she says about criminal conduct applies to all neurobehavioral abnormalities, regardless of whether the conduct is criminal. To make that point, Roethlisberger is again useful.

The District Attorney in the Georgia case determined that no crime (at least that he could satisfactorily prove) had been committed. Yet, even if not criminal, the conduct was inappropriate. We learn before we start kindergarten that boys don’t go into the girl’s restroom. We learn somewhere between 15 and 22 to be polite in our courting of members of the opposite sex, especially in public. Perhaps the admitted aspects of this bar incident were not criminal, but they showed staggering immaturity. That immaturity was the basis of the NFL’s suspension and Roethlisberger’s subsequent apology. Neurobehavioral abnormalities not only put the brain injured person at risk for criminal sanctions, they also will wind up with discipline or dismissal in the work place and wreak havoc on interpersonal relations. So as we use Dr. Monguio’s work as a resource, keep in mind that less severe manifestations of the same deficits can still have dire consequences, short of criminal prosecution.

Dr. Monguio begins her treatment of the frontal lobe issues by addressing the issue of whether a criminal defendant has the capacity to understand the charges against him. This can pertain to something called a receptive aphasia, often common in Alzheimer’s disease where the individual is simply unaware that the conduct is illegal. Another problem which impacts whether a defendant can be tried for the conduct is something called “Anosognosia, or the inability to perceive ones own deficits or illness.” This is common, to some degree. after TBI and is one of the reasons that the injured persons themselves may often underreport what is wrong with them.

The article then goes on to address the specific frontal lobe deficits that make the determination of whether there was sufficient “free will” to find “criminal intent.’

Once the defendant has been found competent to stand trial the issue of criminal intent becomes crucial in the presentation of the case to the judge or jury. It is in this area that the issue of free will and therefore responsibility is at its most central.

The criminal defendant must have been able to know and appreciate the nature and consequences of actions for him or her to have formed criminal intent. Brain injury, particularly to the frontal lobes or to the connecting circuits of frontal areas to other brain centers, can affect the ability to form criminal intent. Deficits in executive function result in poor self monitoring, planning, judgment, and forethought. The rigidity or impulsivity often seen in traumatic brain injuries make the formation of criminal intent quite a challenge for the individual. Following are general areas to consider when evaluating a criminal defendant to provide information during the trial. The question of legal insanity will be explored in more detail as neuropsychological data may provide information to the courts regarding a defendant’s state of mind at the time of the commission of the crime.

Dr, Monguio then isolates the following areas of concern: Planning and Executing a Plan; Sequencing and Organizing Ideas and actions; The ability to appreciate the consequences of actions; Prefrontal Damage, i.e. the brain’s operating system; Language Regulation; Impulsivity, Poor Empathy and Socialization. Follow through; and Improper Interpretation of emotions in Oneself and in Others.

All of the deficits interrelate, and while it is useful to isolate them for purposes of describing them, in Dr. Monguio’s own words:

It is rare when neuropsychology can isolate damage to one or another area of the frontal lobes. Barring non-invasive tumors and certain strokes, most causes of damage to the frontal lobe do not isolate one area over another. In general, any cause of possible damage to the frontal lobes needs to be assessed as potentially affecting any or all areas identified above.

The challenge in understanding abnormal behavior post a TBI is that in smaller doses, all of these behaviors are recognizable as normal variants of human behavior. Jocks tend to get drunk and interact inappropriately with women when they do it. See for example this comment published in yesterday’s NFL Fan House: http://nfl.fanhouse.com/2010/04/28/stop-excuses-before-i-lose-my-mind/?icid=main|netscape|dl8|link3|http%3A%2F%2Fnfl.fanhouse.com%2F2010%2F04%2F28%2Fstop-excuses-before-i-lose-my-mind%2F

I just have a hard time believing they made Roethlisberger seemingly want to sleep with every woman he meets. Years of observing brains of athletes make me conclude other factors played a much larger role.

Arrogance, coddling, groupies, immaturity, booze, a sense of entitlement, a lack of responsibility, the moral code of a hyena. That explains how an NFL quarterback ends up hitting the town in a “Drink Like a Champion” T-shirt a lot more than a few blows to the head.

So then how do we distinguish inappropriate behavior from abnormal neurobehavior? It requires a qualitative assessment by professionals, who because of their years of training and experience can tell the difference between rude and pathology. But the key to understanding frontal lobe deficits is not the administration of a particular neuropsychological test, but the evaluation of the behavior of the individual in the real world laboratory of life. Is there a bright line of demarcation? No. Can certain technological based studies assist in making that determination? Sometimes.

MRI technology improves by significant leaps every five years or so, and we are just coming to the end of such a cycle, with the increased resolution of 3 Tesla scanners and the broad implementation of FMRI, DTI and SWI imaging techniques. It is hoped that what was learned during this huge bubble of imaging research can soon be routinely applied to clinical diagnosis. For more on imaging advances, see my blogs on the topic here:

http://www.tbilaw.com/blog/2010/01/congressional-nfl-hearings-dr-ronald-benson-testifies-about-neuroimaging-advances.html

http://www.tbilaw.com/blog/2010/01/congressional-nfl-hearings-dr-ronald-benson-testifies-about-neuroimaging-advances-diffusion-tensor-imaging.html

http://www.tbilaw.com/blog/2010/01/congressional-nfl-hearings-dr-ronald-benson-testifies-about-neuroimaging-advances-susceptibility-weighted-imaging.html

I actually have even more hope for a break through in EEG technology. I believe that the ability to create super powerful portable computers as small as an Iphone could renew the development of a tool to distinguish abnormalities in the brain’s electrical waves, in real time. The problem is that standard EEG machines aren’t portable (and thus give us no real world data) and the portable EEG machines aren’t very good.  Further, the fundamental technology upon which EEG is based is more than 50 years old.  The brain in operation creates immense force fields that if we applied the kind of technology to it we use in submarines and radio telescopes, we should be able to create intricate patterns of normal versus abnormal.  The key is better listening devices and more computer processing.  We certainly can handle the computer problems now portably.  We just need to get all the fields of science together to reinvent the tool.

Still today and probably for centuries, the ultimate call of “brain damage” is a subjective one that a doctor with years of work with brain injured people can make. We must have more of such people and then respect their subjective call, not insist on some thingamometer to replace the proper diagnosis.

I end this segment by renewing my call for Roethlisberger to get a full state of the art assessment for brain damage, which would include not only DTI and SWI imaging, but also a neuropsychological assessment that would fully consider his behavior. The NFL has taken a true leadership role on sport concussion in the last year and the Roethlisberger case could further focus the public and the medical establishment’s vision with respect on the full neurobehavioral implications of TBI. If we can prove the magnitude of the problem, then treatment should become a priority. Never forget the implications of this study:

In a sample of 15 convicted murderers sentenced to death, Lewis and colleagues (1986) found that 100% of this death row sample had a history of severe head injury.

“Houston, Commissioner Goodell, Congress, I think we have a problem.”

There is no magic cure for brain injury, no tried and true system that consistently corrects neurobehavior issues, there is no 12 step program. Part of the problem is – depending on how severe the injury or how vulnerable the brain that was injured – there may be brain damage that cannot be repaired. While the old rule that neurons (the operative brain and nerve cell) don’t regrow has notable exceptions, the reality is that once neural connections have been severed, the brain will work differently. When the damage is in the emotional or inhibitory sectors of the brain, that damage materially changes behavior and may leave the injured person with little or no ability to conform his behavior to standards for adult conduct.

The other problem in applying classic addiction therapy to neurobehavior problems is that when rehab does improve function after brain damage, it is a very slow process. A long time friend and the brain injury lawyer I have admired the longest, Dianne Weaver of Florida, says this: “We learn to become adults in our frontal lobes.”

The important part of that statement is not that our manners, our socialization, our adulthood resides in our frontal lobes, but that it takes us from the time we are children, until we are college graduation age, to “learn to become adults.” If we can improve neurobehavior problems, we can’t do it by a six week stay in the Betty Ford clinic.

Here is the reality about brain injury rehabilitation. Some things can’t be fixed. Those that can require long term, hands on guidance, like raising a child. Like with a child, the brain injured survivor may need a human guide to keep them out of trouble, until they relearn the manners, the gray areas of the rules, the judgment to know right from wrong. Unfortunately, normal human maturing is very difficult to duplicate process when it is an adult who must relearn to be an adult.

We grew up under the tutelage of mom and dad, a dozen teachers and numerous friends, each working in concert to make us better persons. Telescoping that generation long process into a finite “in patient” stay is a terribly difficult thing to accomplish.

If Roethlisberger’s behavior problems stem from brain damage, there is one element to his treatment that must be adhered to: no more brain injuries. The effects of brain injury are cumulative and if brain damage has already impacted his ability to inhibit his behavior to this extent, any more damage may wind up with him in a far more unfriendly rehab environment: prison.