Degenerative Disc Disease at L4-L5 and L5-S1

Maine Mass Killer Robert Card Likely Had Traumatic Brain Injury From His Time As Army Grenade Instructor: Family

The mass-shooting Army Reservist who gunned down 18 people and injured more than a dozen others in Maine last year likely suffered from a traumatic brain injury stemming from his time as a military hand grenade instructor, according to his family.

Tissue analysis on the remains of Robert Card III revealed that he "had evidence of a traumatic brain injury," according to the findings released Wednesday by his family in conjunction with the Boston University Concussion Legacy Foundation. 

"In the white matter, the nerve fibers that allow for communication between different areas of the brain, there was significant degeneration, axonal and myelin loss, inflammation, and small blood vessel injury," Dr. Ann McKee wrote in the statement.

Robert Card killed 18 people in Lewiston, Maine, on Oct. 25. AP Robert Card opened fire at a bowling alley and a bar in the small Maine town. AP

Card's brain tissue showed no evidence of chronic traumatic encephalopathy, McKee said.

"These findings align with our previous studies on the effects of blast injury in humans and experimental models," the physician explained.

"While I cannot say with certainty that these pathological findings underlie Mr. Card's behavioral changes in the last 10 months of life, based on our previous work, brain injury likely played a role in his symptoms," she concluded.

Card, 40, was a longtime instructor at an Army hand grenade range, where he was exposed to "thousands" of low-level blasts, the Concussion Legacy Foundation noted. 

Robert Card was hospitalized a few months before the shooting. AP

The father of one killed 18 people and wounded 13 others in the devastating Oct. 25 mass shooting at a bowling alley and bar in downtown Lewiston.

He was found dead from a self-inflicted gunshot wound inside a trailer after a two-day manhunt.

Authorities later revealed that Card — who was briefly hospitalized last summer due to concerns over his wellbeing — was alive until eight to 12 hours before his body was discovered.

The Maine Chief Medical Examiner's Office requested a post-mortem study of Card's brain in the wake of the horrific mass shooting.

Card's family expressed their sympathies for the victims and their families. AP

"We want to begin by saying how deeply sorry and heartbroken we are for all the victims, survivors, and their loved ones, and to everyone in Maine and beyond who was affected and traumatized by this tragedy," Card's family said in the Concussion Legacy Center's press release.

"We are hurting for you and with you, and it is hard to put into words how badly we wish we could undo what happened," the loved ones added, noting that "while we cannot go back, we are releasing the findings of Robert's brain study with the goal of supporting ongoing efforts to learn from this tragedy to ensure it never happens again."

"By releasing these findings, we hope to raise awareness of traumatic brain injury among military service members, and we encourage more research and support for military service members with traumatic brain injuries," the family said.

The shooting was the deadliest in Maine state history. AP

Card's brain will continue to be studied, according to the Concussion Legacy Center.

Army personnel are also set to testify on Thursday before the state commission investigating the shooting, which was the deadliest in Maine's history, the Portland Press-Herald reported.

Fasciitis Is As Unpleasant As It Sounds (it Means Inflamed Tissue)

FASCIITIS is not a particularly nice word. Aside from the fact that it is rather awkward to type, it just doesn't sound very pleasant.

Of course it might be its association with the condition known as necrotising fasciitis that makes me think along those lines.

Necrotising fasciitis is the horrible intractable infective process that almost literally eats away at your flesh and is quite often fatal.

Necrotising in this sense means cell death and fasciitis means the cells which are dying are those from the connective tissue known as the fascia.

Mention of this word may cause DIY and roof enthusiasts to think about the bands that run along roof edges at this point.

While architectural fascia is safe from the types of fasciitis I will be talking about, one can see how it got its name — fascia is a Latin word meaning band, bundle or swathe.

In the medical sense, it is a fitting name therefore for the bundles and bands of fibrous connective tissue that surround muscle, connect or separate internal organs and hold a degree of structure within layers of skin.

Because of this rather large remit, you can expect to find fascia in one form or another all over the body.

If you stick an "itis" (the medical suffix denoting inflammation) on the end of fascia, you get fasciitis. In other words, an inflammation of fascia.

Aside from necrotising fasciitis, the condition known as plantar fasciitis tends to be the celebrity of the fasciitis world.

Fortunately, its consequences are a distinct condition, making the terminology, although technically accurate, a little misleading.

As alarming as plantar fasciitis might initially sound, it is certainly not life-threatening. A good thing, too, as it is really quite common.

With a prevalence of about four per cent in the general population, plantar fasciitis occurs in the soles of the feet in what is known as the plantar fascia and is described by the National Institute for Health and Care Excellence as "persistent pain associated with degeneration of the plantar fascia as a result of repetitive microtears in the contracted fascia".

Not as bad as a flesh-eating bacterial infection then, but that's not to say it isn't undesirable in its own right. In fact, plantar fasciitis can be downright debilitating.

The plantar fascia is a tight band of fibrous connective tissue that runs all along the bottom of the foot from the heel to the toes, a region anatomically known as the plantar region (think plantar warts, otherwise known as verrucae).

When it becomes inflamed, sufferers may experience pain and tenderness in the soles of the feet.

The absolute classic symptom is the immediate pain in the heel during the first steps after waking up in the morning.

As the day goes by and the foot flexes and loosens up a bit, the pain tends to ease off but the longer one spends walking or standing in one spot, the more likely it is for the pain to creep back in.

Due to the plantar fascia's close relationship with the Achilles tendon at the back of the heel and, by extension, the calf muscles, any inflammation that occurs often does so because of tightness in the muscles.

A tighter contracted fascia is more prone to the injuries and microtears that characterise a fasciitis.

That means those who run regularly have an increased prevalence of plantar fasciitis (around eight to ten per cent) compared to the general population, as do those who are overweight or who walk around bare-footed a lot.

Women also seem to be a bit more affected, possibly due to their tendency to wear tighter footwear and high heels which provide poor cushioning for the sole (or plantar aspect) of the foot.

While a mild case of plantar fasciitis can pass in a matter of weeks, it has the potential to continue for up to a year.

If you think you might be developing a touch of this, therefore, it would be wise to have a look at some of the measures used to treat or avoid the condition.

Firstly, lose some weight, ease yourself into running if you are thinking of taking it up and ensure that you are wearing sufficiently cushioned running shoes. These should ideally be changed every few months if you run a lot.

You could try using some insoles of heel pads in your everyday shoes to provide a bit of cushioning but the really key thing here is stretching.

Even better, switching to a low impact form of exercise would be better, such as swimming or cycling. Stretching the calf muscles and hamstrings every day will significantly lower your risk of it developing in the first place but is also a really good way to aid recovery.

Likewise, regular massage of the plantar fascia can loosen the tissue and reduce any tension to the area.

You could do this with your hands, a tennis or squash ball, or any number of pummelling massage machines out there these days. Rolling your foot over a ball on the floor or even a baked bean tin will also do it.

On occasion, even if someone is doing all of this, the pain continues and in such cases simple anti-inflammatories such as ibuprofen can be used.

One bone of contention is the use of steroid injections to the sole of the foot.

While the introduction of a steroid via this route can theoretically provide some relief due to its anti-inflammatory properties, I tend to advise against it.

This is due to its potential to weaken or rupture the plantar fascia altogether as well as causing something called fat pad atrophy which is a potential complication that results in a loss of the natural fat pad cushioning of the foot, leading to longer term issues far more difficult to remedy.

I have on occasion heard of people concerned about the presence of heel spurs, a bit of bone sticking out from the bottom of the heel bone (calcaneous), in relation to plantar fasciitis. Often, if someone finds they have a heel spur, they are understandably keen to have it removed as the potential source of their pain.

In fact, heel spurs are most likely caused by the plantar fasciitis and are an outcome rather than a cause of the condition, making removal unnecessary.

Beyond this, if nothing is working, you will almost certainly come across some private options such as extracorporeal shockwave therapy.

While non-invasive and therefore relatively safe, the results are not always consistent.

The really intractable cases of plantar fasciitis may therefore end up going to a foot surgeon for consideration of some sort of surgical release.

This is to be avoided if at all possible and I have never even come across a patient who has had to resort to this.

Thankfully, plantar fasciitis is a condition which, with some dedicated daily self-guided therapy, can be entirely managed by the sufferer.

We do see a lot of it in general practice but you don't need initially to see a GP to diagnose and start treating it.

Just use the measures I've mentioned and, with a bit of dedication and time, you'll get there.

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Ask The National Institue On Drug Abuse Expert

In my last blog, I discussed that methamphetamine (or cocaine), in concert with fentanyl, is often a factor in overdose deaths in the United States. In this interview, I spoke with Jean Lud Cadet, MD, chief of the Molecular Neuropsychiatry Branch at the National Institute on Drug Abuse (NIDA) in Baltimore, Maryland. He completed training as a neurologist at Mt. Sinai in New York City. He also completed a psychiatry residency at Columbia University College of Physicians and Surgeons, where he was a medical student. Dr. Cadet has been the leading researcher and national expert on methamphetamine for nearly forty years. His research has been cited by researchers around the world over 31,000 times, and consequently, he is uniquely qualified to talk about past and current issues with "meth" and other drugs.

Racial Disparities in Substance Use Disorders Are Real But Usually Ignored

Jean Lud Cadet, MD

Source: Susan Calkins, MD

Gold: What have been the most important insights you have learned about methamphetamine and other substance use disorders?

Cadet: I have learned substance use disorders (SUDs) are very difficult to treat because of stigmas. I have also learned there are many racial disparities in the diagnosis and treatment of patients suffering from substance use disorders. Yet many clinicians refuse to deal with those facts, which is unhelpful to patients.

Gold: Many people think this is a black/white issue after watching the hit television show "Breaking Bad." However according to the Substance Abuse and Mental Health Services Administration (SAMHSA), when it comes to people ages 12 years and older who used methamphetamine in the past year, American Indians/Alaska Natives had the highest abuse rate (2.4%), followed by Native Hawaiians or Other Pacific Islanders (1.1%). SAMHSA also reported an abuse rate of 0.7% for whites and only 0.2% for Blacks. Of course, abuse rates vary depending on the substance. In most cases of abused substances, neither whites nor Blacks have the highest abuse rates.

The question then becomes, why do so many doctors ignore research on racial disparities? It seems important.

Cadet: It is important. Racial disparities exist in the assessment, diagnosis, treatment, and follow-up of patients presenting with substance use disorders. Many patients are also negatively impacted by attitudinal biases health care providers might abhor subconsciously or consciously. Yet despite literature documenting the existence of racial disparities, SUD professionals are reticent to read that literature or, if they have read these papers, they tend to ignore their contents and suggestions for change.

If health professionals admitted the existence of racial disparities, they would have to acknowledge their lack of cultural awareness and make individual changes in their approaches to SUD patients. More importantly, they would have to address issues relevant to structural racism in medicine. Most physicians and others caring for SUD patients do not appear ready to make substantial alterations in their modus operandi within very conservative structures.

Amount of Methamphetamine Abuse May Cause Brain Injury and Damage

Gold: Do you think methamphetamine-induced psychosis is more like traumatic brain injury (TBI) than a naturally occurring psychosis?

Cadet: The issue is complicated. Not all patients have identical causes for psychosis; any more than patients diagnosed with acute schizophrenic psychosis or acute manic psychosis have identical neurobiological etiologies for their psychotic symptoms. Also, the similarities of methamphetamine-induced psychosis to traumatic brain injury depend on the amount of methamphetamine patients were exposed to. This is manifested by the clinical course of methamphetamine-induced psychosis. Some patients have remitting and relapsing courses with negligible evidence of cognitive deficits, while others have progressive cognitive disabilities, and still others show profound cognitive deterioration. A case could be made that patients in the progressive cognitive disabilities group might have taken enough of the drug to develop neuropathological changes in the brain, somewhat akin to TBI. This is partly supported by studies of patients exposed to methamphetamine showing significant abnormalities in their neuroimaging findings. In addition, post-mortem studies have identified neuropathological changes in various regions of the brains of users of large doses of methamphetamine.

My colleagues and I have reviewed the literature on neuropathological changes associated with methamphetamine and other drugs. Methamphetamine users have evidence of structural abnormalities in their brains. They also have a smaller hippocampal volume and exhibit altered white matter tissue integrity in the frontal cortex, corpus callosum, and perforant pathway. These findings implicate brain dysfunctions that must be taken seriously when evaluating patients and making treatment recommendations.

For example, a person with methamphetamine psychosis should not be treated with older antipsychotics like haloperidol because these patients are more at risk for motor abnormalities triggered by older antipsychotics. The risk is lower with newer antipsychotics.

Psychedelics, Including Psilocybin, May Be a Future Treatment for Methamphetamine Use Disorder

Gold: What do you think about psilocybin ("magic mushrooms") for treating methamphetamine use disorder?

Cadet: Psilocybin is a non-addictive psychedelic agent shown to provide beneficial effects in cases of depression, anxiety, and alcohol and nicotine use disorders. Given there is no FDA-approved medication for methamphetamine use disorder, it is important to support trials of psilocybin-assisted therapy for this brain disorder.

Addiction Essential Reads

Future Discoveries

Gold: What do you think will be the most significant discovery in addiction science in the next few years?

Cadet: I feel the biggest discoveries will be in epigenetics, which explains how behaviors and the environment may cause changes affecting how genes work. Epigenetics will provide a paradigm for understanding what triggers or affects the elevation from occasional use in some patients to continuous abuse. The All of Us research program is one major mechanism that could be used to help attain these goals.

Gold: I consider you a genius. But how has your family impacted your career and current level of success?

Cadet: I have always wanted to be a physician as far back as I can remember. This is probably because my mother worked as head of a pharmacy in a hospital in Limbe, Haiti. The hospital was a missionary hospital that cared for everyone regardless of their ability to pay. My parents, especially my mother, supported my goal and supported my education by enrolling me in the best secondary school, College Notre Dame du Perpetuel Secours in Cap-Haitien on the northern side of Haiti. My mother always said hard work pays off and provided the example I have followed.

Cadet's Most Important Research Papers

Gold: What are your most important papers MDs, researchers, and parents and family members should read?

Cadet: I view SUDs as brain disorders with a significant underlying inclination to look for their neurological impact on all patients. I suggest reading these classic papers:

Cadet JL, Bisagno V, Milroy CM. Neuropathology of substance use disorders. Acta Neuropathol. 2014 Jan;127(1):91-107.

Jayanthi S, McCoy MT, Cadet JL. Epigenetic Regulatory Dynamics in Models of Methamphetamine-Use Disorder. Genes (Basel). 2021 Oct 14;12(10):1614. Doi: 10.3390/genes12101614.

IN Krasnova, JL Cadet Methamphetamine toxicity and messengers of death. Brain research reviews 60 (2), 379-407.

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