Vascular injury may be more common than we think in traumatic brain injury (TBI) cases. Mild cases of TBI are often evaluated in emergency room settings and discharged to home with no further care or treatment. Yet, new research by the National Institute of Neurological Disorders and Stroke shows evidence of vascular injury with potential long-term effects even in mild TBI cases. The previously held belief that patients with no observable evidence of concussion do not need treatment or follow up should be revisited.
The THINC Study
The research was headed by Dr. Gunjan Y. Parikh, a fellow at the National Institute of Neurological Disorders and Stroke. He and several associates evaluated 256 patients enrolled in a study implemented at two hospitals: Washington (D.C.) Hospital Center and Suburban Hospital in Bethesda, Md. The study, termed the Traumatic Head Injury Neuroimaging Classification (or THINC) study, evaluated 256 patients during initial emergency room visits for head injuries and in the crucial first hours of treatment. The findings were released on March 12, 2012, just before their presentation at the American Academy of Neurology Annual Meeting (March 16 to 23 in San Diego), where the research was presented for the first time.
New Imaging Protocols
The THINC study implemented imaging protocols: an MRI within 48 hours of presentation at the hospital with acute head injury, followed by visits at 4, 30, and 90 days—even if patients didn’t receive a positive diagnosis for concussion. Protocols at follow-up visits were intensive: diffusion-weighted imaging (DWI), T2-weighted MRI, fluid-attenuated inversion recovery (FLAIR), and three-dimensional tracking imaging (3-DTI).
Of the 256 patients, 104 had evidence of hemorrhage in the brain. These patients received more detailed brain scans (using advanced MRI technologies) within an average of 17 hours after injury. 20 percent of those 104 patients showed imaging evidence of microbleed lesions, while 33 percent had linear lesions that suggest vascular injury. These linear lesions, new evidence of vascular injury in TBI, were associated with injury to surrounding or adjacent brain tissues. Microbleed lesions, on the other hand, were distributed throughout the brain after mild TBI.
Putting Research Into Practice
The team’s research findings have multiple implications for treatment of TBI. Dr. Parikh and his team found evidence of trauma indicative of mild TBI and long-term impacts even in patients that would have been sent home untreated using traditional diagnostic protocols.
The results also have implications for doctors who see diffuse axonal injury (DAI) on a regular basis. In cases of diffuse axonal injuries, which often happen due to the shearing forces in auto accidents or falls, trauma to the brain is widespread rather than in a narrow location as with focal brain injury due to direct impact. DAI has been thought to be one of the most common causes of coma or persistent vegetative state after TBI. However, as Dr. Parikh told Doug Brunk of ACEP News, “Not everything that we’re calling diffuse axonal injury is diffuse axonal injury.” In many cases, targeting therapies to vascular injury rather than to assumed DAI may drastically improve patient outcomes.
Dr. Parikh is quick to point out that this research is preliminary and difficult to replicate due to the exigencies of working with TBI in clinical settings. Still, the research findings are important to the successful treatment of both mild and severe TBI, so further research along these lines should be forthcoming in future years.
At Paradigm, we work to keep abreast of the latest traumatic brain injury research and other relevant medical topics. Connect with us on LinkedIn and Facebook to stay up to date on the latest workers’ compensation and complex care management news.
In our last post in a three part series exploring the intersection of catastrophic care management and the military, we highlight new research into the exciting possibility of quickly diagnosing damaged brain cells.
Traumatic brain injuries (TBIs) can be life threatening or cause lifelong damage and can be difficult to detect in the field. New military research may be closing in on a test that Army medics could use to detect brain injuries on location.
Diagnosing Brain Injuries
Traumatic brain injuries at the cellular level can be almost impossible to detect. The Army’s news service reported Col. Dallas Hack, Director of Combat Casualty Care in Fort Detrick, Md., said it’s difficult to know whether an individual has damage to brain cells or tissues. In assessing a patient’s condition, doctors or medics ask questions, perform balance tests, or ask him or her to follow a moving object with their eyes. That means the patient must be awake and active to participate, and the field circumstances must be conducive for adequate testing. This is not always possible.
The Future of Diagnosis for Traumatic Brain Injuries
Researchers at Hack’s facility are investigating ways to detect damage to brain cells that are similar to current methods used for testing blood sugar levels. “We have some articles that have now been published in peer reviewed literature that show a really good sensitivity and specificity,” said Hack.
The Army plans to file for Food and Drug Administration approval of the test once the current clinical trials are complete, which should be by the end of 2013, Hack said.
Military and Industry Leaders Working Together
The current clinical trials are a combined endeavor between the U.S. Army and private interests. The team collaboration was designed through the Military Health System Research Symposium, where researchers from the University of Florida and members of the Walter Reed Army Institute of Research first met in 2001 to discuss the project.
Benefits for Private Sector Treatment in Brain Injury Cases
Private research personnel and funding are already being channeled into this enterprise. Such a test could enable quick, efficient hospital care and immediate treatment for brain injuries. First responders or even law enforcement officers could administer the test at accident scenes, leading to early identification of TBI and maximizing patient outcomes by allowing hospital staff to concentrate on appropriate patient care during the crucial first minutes after admission.
Neural imaging technology is used to study cases of brain injury with some surprising results. Researchers at the Center for Cognitive Brain Imaging at Carnegie Mellon University used a new combination of neural imaging techniques to determine how the brain adapts in cases of traumatic brain injury. The results of their study were recently published in Cerebral Cortex.
Back-Up Brain Systems
Robert Mason, senior research psychologist at CMU, and Chantel Prat, assistant professor of psychology at the University of Washington, designed the research study to increase understanding of the brain’s function during periods of injury. They used cutting-edge functional resonance imaging (fMRI) techniques to understand how 16 healthy adults adapted to injury in the region of the brain that governs language comprehension, known as the Wernicke area.
According to the study, when one area of the human brain is injured and unable to function normally, secondary brain areas become “back-ups,” replacing the functions of the injured area and closely-related parts. This adaptability means that the brain has the ability to rebound from serious injury.
Changes in Brain Activity after Brain Injury
The researchers used Transcranial Magnetic Stimulation, or TMS, during the fMRI scans to temporarily disable the Wernicke area of the study subjects’ brains. The method simulates brain injury without causing any lasting damage.
Mason, the lead author on the study, told News Medical that the impaired brain region and “partners” that work with it slowly regained their normal range of activity as the TMS wore off; during that time, a back-up team of brain areas was still working to coordinate activity. “This means,” he said, “that for some period of time, there were two cortical teams operating simultaneously.”
According to Mason, the results explain why a person’s performance is sometimes improved by exposure to TMS. When back-up brain areas come online, they coordinate areas close to the site of the injury and spots that are a mirror image of the injured location (called contra-lateral areas), with a frontal area in charge of organizing and giving commands.
The involvement of a “frontal executive area” to identify and coordinate back-up areas is a critical component in the brain’s ability to adapt to injury. Understanding the ways the human brain adapts has implications for therapy, pointing to ways people can train their brains to facilitate easier and quicker recovery times.
At Paradigm, we work to keep abreast of the latest traumatic brain injury research and other relevant medical topics. Connect with us on LinkedIn and Facebook to stay up to date on the latest workers’ compensation and complex care management news.
Traumatic brain injury rehabilitation must take into account more than basic motor function. These types of injuries can have major implications for mood and depression—both during and after treatment. Professional football players are an excellent example of a patient population with an increased risk of depression that can occur as a person ages after even minimal brain damage.
Multiple studies have indicated that people who suffer sports-related concussions are more prone to developing depression as they age than the general population—no matter how well or how quickly traumatic brain injury rehabilitation occurred. Since 1.6 to 3.8 million sports concussions occur each year (according to the Centers for Disease Control and Prevention), this is a problem that needs to be recognized and addressed by the medical community at large.
Connective white matter in the brain is damaged in the event of a concussion, and that damage has also been seen in studies of depressive cases. In a neurological study presented by lead author Kyle Womack at the 2013 American Academy of Neurology annual meeting, analysis of white matter damage in a particular region of the brain could predict depression after traumatic brain injury with 100 percent sensitivity and 95 percent specificity. Examples like this offer a measurable link between the injury and the psychological repercussions.
Another study, authored by Nyaz Didehbani, Ph.D., was presented at the same meeting and is not yet published. Thirty-four retired NFL athletes with a history of concussion and 29 people of the same age from the general population (and without a history of concussion) were tested for depression using the Beck Depression Inventory. The results indicated a strong correlation between the number of concussions NFL players sustained in early adulthood and the presence of depression later in life. Didehbani was quoted in a press release as saying, “It is important… that medical professionals appropriately include depression screening in their follow-up assessment [after a concussive incident]. Depression is a treatable condition if the proper and necessary steps are taken.”
Together, these two studies indicate with a high degree of likelihood that players who suffer multiple concussions will have to deal with depression as they age.
The good news is that researchers and physicians are becoming more aware of the lingering problems that concussions may present for their patients, and more adept at treating those problems. Future NFL players and non-athletes alike require help navigating a recovery from concussions that addresses biological, psychological, and social needs. Especially since the injury repercussions may present years after the original injury.
A recent study of the relationship between caregiver/family functioning and traumatic brain injury (TBI) rehabilitation found that higher degrees of caregiver emotional health and stability translated to better patient outcomes.
The study, available online as of March 2012 in the Archives of Physical Medicine and Rehabilitation, took place at the Brain Injury Research Center in Houston. Researchers adjusted their findings for age, education, gender, ethnicity and other potentially confounding factors.
Even with careful adjustments, they found a significant relationship between the emotional functioning of caregivers and greater social and occupational integration of traumatic brain injury patients. This relationship held as long as the individual with traumatic brain injury entered rehabilitative care within six months of the injury. TBI patients who entered rehabilitation programs more than six months after injury experienced no impact with regard to caregiver emotional function.
Researchers evaluated 136 patients with medically confirmed traumatic brain injury (57 percent of cases were classified as severe, 12 percent moderate, and 31 percent mild) along with their caregivers. Each patient was involved in one of three post-acute rehabilitation programs.
Participants were physically examined and questioned as part of the study. Those responses were integrated using accepted indices for measuring degree of disability and emotional/family functioning, including the Community Integration Questionnaire, the Craig Handicap Assessment and Reporting Technique (CHART), the Brief Symptom Inventory-Global Severity Index (BSI-GSI), and the Family Assessment Device-General Functioning Scale (FAD-GFS).
For those cases where the primary caregiver is a family member, employers and carriers may want to consider an integrated program that helps alleviate monetary and personal stress for the caregiver. This may help expedite the injured person’s return to work and minimize the long term workers’ compensation costs.
For information about how Paradigm successfully manages traumatic brain injury cases, contact us via our website or call 888-621-6602. We also invite you to join our social communities on LinkedIn, Twitter, Facebook and YouTube.
Did you know, over two hundred thousand people are hospitalized for traumatic brain injuries every year, with many injuries occurring in the workplace? And even worse, at least five million Americans currently have a long-term or life-long need for assistance as a result of a traumatic brain injury that can cause behavioral, mood, and cognitive disorders. Fortunately, appropriately managed care in workers’compensation can significantly improve the quality of life for those injured.
Traumatic brain injury (sometimes referred to as “TBI Injury”) is one of the most complex and perplexing medical conditions facing medical professionals and the public. These injuries can result from falls, auto accidents, combat situations, and sporting accidents. When they occur, the patient, their family and loved ones face devastating circumstances. This type of injury often results in long-term or lifelong medical complications that make it difficult or impossible for patients to return to work and the normal activities of daily living. However, studies show that high quality, systematically managed care throughout the recovery process often leads to more promising traumatic brain injury treatment outcomes for patients.
Traumatic brain injury cases involve a multitude of services administered by a variety of providers, including medical specialists, clinical therapists, acute rehabilitation facilities, etc. These services need to be coordinated by a single entity from the onset of treatment. In these cases, outcomes are improved when there is expert coordination of care. The key to traumatic brain injury management is surveillance and quick attention to the neuropsychiatric issues that can develop and perpetuate problems with recovery. Understanding how to manage those issues is paramount. This not only helps ensure the patient receives the best care, but it also reduces the risk of complications such as multiple contractures, spasticity, movement disorders, peripheral nerve injuries, and a variety of others. Medical costs in these cases are high, but if complications arise, costs can be astronomical.
Positive outcomes for severe brain injuries are best accomplished by an organized, systematic approach to case management. While there is some expert consensus on managing the care of these patients, practices vary. Therefore, having top medical professionals collaborate and explore all treatment options in a structured manner helps improve the chances for the best possible recovery.
Recent news from the annual meeting of the American Neuropsychiatric Association suggested that civilian physicians can expect to encounter cases of blast-related traumatic brain injury (TBI). More than half of the returning military personnel use civilian medical services rather than the Veterans Affairs health care system. This makes the recognition of the clinical manifestations of TBI a critical skill for medical staff and claims professionals. While we have discussed many aspects of TBI in previous blogs, this situation is unique for the entire clinical system.
TBI occur by the powerful shock wave of high pressure that radiates from an improvised explosive device (IED). The shock waves reverberate through the skull and on the brain itself to cause axonal injuries. More than 150,000 troops in Iraq and Afghanistan have experienced traumatic brain injury since the start of conflict. In 2009, 79% of the nearly 28,000 traumatic brain injuries sustained by U.S. military personnel in those two countries were mild.
Dr. David X. Cifu, National Director of the Veterans Affairs (VA) Physical Medicine and Rehabilitation Office and an expert in TBI, has advocated for these returning military personnel to utilize the resources and experience of the VA system to seek medical help. The soldiers are entitled to free healthcare through the VA system for 5 years after coming home.
Military sustaining polytrauma, individuals with TBI and another physical injury or psychological trauma, have a greater need for careful following and treatment. The VA TBI program has a 4-question screen that may lead to a more comprehensive TBI evaluation from multiple disciplines, including a physical medicine and rehabilitation physician, a psychologist, a speech and language pathologist, and occupational, physical, and recreational therapists. The VA screened 470,000 veterans for mild TBI from April 2007 through September 2010 as part of its mandatory program and roughly 20% answered all four questions affirmatively. Additional evaluation of those with a positive screen demonstrated that 39% (or 8% of all returning personnel) had symptomatic evidence of TBI at the time of screening.
Dr. Cifu recommends that both military and non-military physicians refer to the comprehensive clinical practice guideline on the management of mild TBI that he coauthored. In addition, Dr. Cifu has reported that the polytrauma TBI individuals have only an 80% recovery within a year, compared to 97% for sports concussion injuries.
If 150,000 of our military personnel have sustained a TBI and 8% may have ongoing manifestations of TBI, then that suggests there may be 12,000 people with residual effects of TBI. Confusion, aggression and PTSD can all be manifestations of TBI in this group of individuals with training in combat. If a combat trained military personnel experiences confusion and aggression with family and friends present, the adverse consequences could be harmful to all. Families, friends and medical staff should be vigilant and proactive when observing anyone who has experienced a TBI, particularly, returning military personnel. The aim is to get them to medical centers where they can be evaluated and treated appropriately. Find guidelines and more information related to TBI in military personnel at the Department of Defense Deployment Health Clinical Center.
Enjoy Dr. Cope’s last piece on traumatic brain injuries. Please be sure to read part 1 and part 2 if you missed them. – Dr. Holt
As recovery from a TBI progresses, more specific, non-psychopharmacologic measures to deal with the confusion and agitation are appropriate. These measures are best applied in a formal rehabilitation setting where the environment can be structured to minimize likelihood of injury. This typically begins within an acute rehabilitation hospital but then, with prolonged delirium, may extend to post-acute rehabilitation residential settings. Occasionally, the agitation dimension has a degree of aggressiveness (e.g. biting, hitting) that requires a specific setting commonly referred to as a “neurobehavioral” program. These are highly specialized, locked environments where the staff is trained in behavioral contingent management techniques and in appropriate physical control methods. Such programs are essential in safely dealing with the assaultive patient until this period resolves with progressive recovery. In a very few cases, however, this aggressiveness never resolves and a permanent placement in a locked facility is indicated.
Cognitive Disturbance and Cognitive Therapy
Cognitive disturbance is the most common significant deficit following TBI. This encompasses many dimensions, including impairment of attention and concentration, increased distractibility, reduced speed of information processing, memory issues, difficulty with logical thinking or problem solving, and so on.
Usually, a variety of these aspects is affected in a unique profile and a comprehensive neuropsychological test battery is needed to measure the extent of each. Most can be expected to significantly improve with time following injury. It is believed that this process of recovery continues for 18 to 24 months. Though it is likely that improvement progresses beyond this period, it becomes progressively so minor as to be ultimately clinically trivial.
The most common approach to these deficits is “cognitive therapy,” which is a collection of rehabilitation techniques intended to guide a recovering TBI survivor through graded cognitive “exercises.” It is believed that these will guide the recovering brain to better function. This basic theory is one which has numerous supporters and detractors. The evidence for its efficacy is not overwhelmingly convincing. Nevertheless, cognitive therapy is generally accepted as, at worst, it teaches compensatory methods to the patient, and at best, it potentially actually advances recovery.
Current clinical standards dictate these treatments be provided for up to the period of “active” recovery, which is the 18 to 24 month period mentioned above. The utility of these approaches should be periodically reevaluated throughout this process. A lack of progress in cognitive ability generally indicates a lack of efficacy for that patient. In such cases, the effort should be discontinued.
However, it is important to recognize that the lack of effect may be because the intervention was attempted too soon after injury (during the period of delirium), or that some co-morbidity (e.g. depression or pain) has interfered with the process. Under these circumstances, a later re-engagement in the effort may be appropriate.
The issue of psychotherapeutic counseling (as distinct from cognitive remediation) arises often in TBI. For minor injuries, this is undoubtedly useful in many cases. For the cases of moderate and severe TBI, there is a question of the efficacy of these psychodynamic approaches when the basic underlying functions of attention, judgment, memory and insight may be significantly impaired. There is clearly some level of severity above which such efforts are futile, yet there are some patients who appear to clearly benefit.
Unfortunately, it is difficult to be prescriptive about when or when not to attempt psychodynamic treatments. The judgment of experienced clinicians should be relied upon in each case.
A more open-minded approach should be kept regarding other aspects of counseling that address more compensatory techniques. Examples include the use of memory notebooks, “time out” responses to emotionally difficult situations, and specific community survival procedures such as public transportation use or emergency responses like dialing 911. Interventions that involve couple or family counseling are also quite beneficial in helping the patient’s social support system adapt to the changes following TBI.
Job coaching and vocational counseling, when appropriate, are also effective ways to aid a survivor to regain some meaningful work opportunity which additionally can do a great deal to help with the emotional distress following TBI. Group therapy with peer survivors has often been reported useful for all types of counseling following TBI.
Wrapping it all up
It is perhaps most important to realize that the neuropsychiatric deficits following TBI are both the most “hidden” to casual observation, but are at the same time the most universally present, and that the neuropsychiatric deficits overall become the most disabling. While there are limitations to the degree to which these can be reduced by current techniques, there are many approaches which have been shown generally effective to some degree and which, for some patients, can have dramatic and “life-saving” impact. In planning for management of the TBI survivor and his or her family, this aspect of care should never be overlooked.
We are happy to share the second post in a series of three from our founder and Senior Medical Officer, Dr. Nathan Cope. Be sure to read part 1 if you missed it. – Dr. Holt
In my post last week, I discussed the general neuropsychiatric overview of TBI as well as the approach to the cognitive and emotional impairments following mild TBI injuries. This week I will discuss the consequences of more severe TBIs and address the role of psychopharmacology in the treatment of such injuries.
Recall that these moderate and severe injuries make up less than 15% of the total incidence of TBI in the United States, but produce the vast majority of long-term, TBI-related disability. Millions of Americans are living with the long-term deficits resulting from these more serious injuries. For many of these survivors, various psychiatric issues emerge. These issues can be addressed via environmental and psychotherapeutic approaches, as well as psychopharmacological approaches.
Consequences of Moderate and Severe TBI
As with any TBI, there is an immediate period of disorder or loss of consciousness. Additionally, with moderate and severe TBI, there is a wide spectrum of syndromes which can occur. For example, for injuries that involve the lower brain areas (brainstem), multiple hard neurologic deficits are commonly seen: difficulty with temperature and blood pressure regulation, reduced function of vital processes such as respiratory drive, difficulty with arousal, reduced autonomic functioning, severe paralysis (locked-in syndrome) and so forth.
With such cases, it can be difficult to ascertain whether beneath the “unresponsive” patient there is an individual who is aware but unable to move or communicate. This is a difficult clinical issue–how do we ever really know that there is not awareness that we as physicians cannot observe? There are also cases where significant error has been made and patients do have awareness that is not appreciated. Moreover, if the patient is sedated with drugs or is significantly ill from another cause (e.g. infection or metabolic disturbance) then an error can be made about the ultimate potential for recovery and awareness. It is important to ensure a sufficient period of expert clinical observation and trial to observe for any sign of awareness.
During this period, the principle psychiatric task is to accurately understand the neurologic damage and prognosis and communicate this to the family of the patient. There is a tremendous psychological “crisis” in this acute injury period which can lead families to form erroneous or maladaptive beliefs leading to much needless treatment and distress. Early efforts to fully educate and counsel families in this early period will be multiple times more effective than similar efforts delayed.
Return to Consciousness and Psychopharmacology
In most cases, even with the most severe TBI, responsiveness eventually returns. Initially, there is usually a period of acute agitation and confusion (delirium). As noted last week, psychoactive medication is rarely needed during this period and treatment should include simple measures to protect the patient from self injury. Only in special circumstances, such as if there are medical I.V. lines or other measures which require a quieter patient, would it be appropriate to use a simple sedative or narcotic to produce calm, and these should be discontinued as soon as medically possible.
In general, pharmacologic treatment is felt to be a later (if not last) resort intervention; to be ventured after inadequate response to more general rehabilitation efforts involving traditional physical, occupation, speech and psychological therapies. No drugs have been validated with large-scale prospective, randomized, blind studies, despite a variety of pharmacologic approaches that have been reported effective to some degree. Nevertheless, the most common classes of drugs indicted as useful following TBI include almost the entire range of psychotherapeutic agents: neuroleptics (antipsychotics), anticonvulsants, mood stabilizers, stimulants, antidepressants and antianxiety agents.
Only under some circumstances is pharmacologic treatment appropriate. For example, it may be important to gain immediate behavioral control of a manically excited or aggressive patient, or it may be felt that a combination of stimulant and traditional therapies is a more efficient way to benefit from limited rehabilitation resources (i.e. limited acute rehabilitation hospital days).
In any case, it is essential when using drugs that good single-case design be followed:
make good baseline measurements of the specific behavior or mood to be effected
trial a specific drug at both an adequate dose and for an adequate duration
follow the rule of “start low and go slow”
keep specific periodic measures of response to demonstrate change (or lack thereof)
conduct a drug withdrawal phase to see if the target behavior recurs
reinstitute the drug when efficacy has been demonstrated by the above procedure
design a follow-up plan to periodically reevaluate the necessity of the medication
I’d like to emphasize the importance of that last point. Too often, when a drug is found to be therapeutic in the short term (and unfortunately often even when it is not), the drug regimen is continued on “automatic pilot” without reestablishing the need or benefit. All psychoactive drugs have significant side effects and toxicities, including elevated mortality, which have generally been shown to be more a risk with patients with organic conditions of the brain (e.g. TBI).
It is best for a physician with specific training and experience in the treatment of TBI (usually a psychiatrist, behavioral neurologist or a rehabilitation specialist) to manage the psychopharmacologic approach to TBI.
Continued Recovery, Cognitive Disturbance, and Psychotherapeutic Counseling
As a TBI patient continues to recover, more specific, non-psychopharmacologic strategies may be appropriate. I’ll discuss this in more detail in my third and final post next week.