It has been considered unlikely that a person in a vegetative state will regain consciousness beyond 12 months after a traumatic brain injury or 3 months after an anoxic or hemorrhagic injury.

However, ongoing improvements in both research methodology and medical intervention may be changing this way of thinking. A recent study of long-term vegetative state patients showed that 20% recovered responsiveness after 12 months, and 12% of those further progressed to regain consciousness. This recovery was associated strongly with younger age and occurred more often in traumatic brain injury, rather than anoxic or hemorrhagic.

Unfortunately, although responsiveness and consciousness can be recovered in some cases of vegetative state, it is also associated with severe functional impairments. Still, that the recovery rates were unexpectedly high in this study is an issue with ethical implications that should be addressed by medical and legal professionals.

Estraneo A, Moretta P, Loreto V, et al. Late recovery after traumatic, anoxic, or hemorrhagic long-lasting vegetative state. Neurology. (July 2010).

Children who suffer from mild traumatic brain injury are often referred back to their primary pediatrician for follow-up care. A recent study found that 89% of pediatricians felt that they were the appropriate care provider for the follow-up of mTBI, however 59% of these did not participate in continuing education to learn more about TBI and 62% did not administer neuropsychological tests.

Recent research has advanced our understanding of mTBI—so much so that health care providers need to be aware of changing guidelines and recommendations. The CDC has published a toolkit for physicians who treat mTBI, but many primary care physicians may still be unaware of it. The tool kit can be found at http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html.

The follow-up of mTBI is especially important in children, for whom complex decisions, such as return to sport, need to be carefully considered. Pediatricians who treat mTBI in their practice need to be aware of the current guidelines set out by the CDC.

Kaye AJ, Gallagher R, Callahan, JM, & Nance ML. Mild traumatic brain injury in the pediatric population: The role of the pediatrician in routine follow-up. Journal of Trauma Injury, Infection, and Critical Care. (June 2010).

On Thursday, June 24, 2010, Senate Democrats’ long effort to pass a package of tax cut extensions collapsed stopping the proposed extension of enhanced federal Medicaid funding to states in its tracks amid worries of the increased federal deficit.  Without the extension, the elevated federal Medicaid funding will expire on December 31, 2010, halfway through the fiscal year for states.

BIAA has advocated vigorously to ensure that this increased funding would be extended through June 2011, and we will continue to fight to pass this legislation.

National Intrepid Center of Excellence

This week, the National Intrepid Center of Excellence (NICoE), a privately-funded medical facility designed to treat service members suffering from traumatic brain injury (TBI) and psychological health conditions, opened its doors at the National Naval Medical Center in Bethesda, Maryland.  The 72,000-square-foot facility will provide rehabilitation care to military patients and veterans with mild to moderate brain injuries.

BIAA is encouraged by the support for the facility and will lend a hand in any way we can to ensure its success!

Health care reform at the federal level is officially on hold. Republican Scott Brown gained the Massachusetts seat vacated by the death of Edward Kennedy, thereby breaking the 60-vote majority in the Senate. Democrats met privately in the days following the Massachusetts special election but were unable to cultivate a strategy for moving forward at this time. A six‐week break is planned, and it is likely policymakers will be forced to accept a substantially scaled‐back package or abandon health care reform altogether.

The Brain Injury Association of America is deeply disappointed. Through our partnership with the Brain Injury Business & Professional Council, we made important gains in the proposed legislation. We cannot forgo this progress; we cannot quit now. We will continue to fight for access to the full continuum of brain injury treatment.

On January 24, 2010, Dateline NBC aired the compelling story of Patrick Gannon, a man who battled a severe anoxic brain injury and was then forced to wage war against his insurance company. The Dateline story accurately portrays how the health care system victimizes patients and families when they are most vulnerable.

I urge brain injury advocates everywhere to watch Patrick’s story and then write to Ann Curry, Dateline correspondent, to thank her for bringing national attention to the extraordinary challenges individuals with brain injury and their families face. I urge advocates to share their own stories with Ms. Curry and ask that she continue to educate the public about the rehabilitation needs of people with brain injury after their lives have been saved. Please address your letters to:

Ms. Ann Curry
Dateline / NBC News
30 Rockefeller Center, Studio 3B
New York, NY 10012

E-mail: Dateline@NBCUNI.com

Once you’ve written your letter (and sent copies to your legislators and BIAA), I ask that you share the Dateline story with friends and neighbors and that you encourage them to spread the story to others. With your help, we can tell the public that a brain injury can happen to anyone at anytime and that having insurance doesn’t mean you’re covered!

Very truly yours,

Susan H. Connors
President/CEO

Please send copies of your letters to your state and federal legislators and to me at BIAA’s address!

Brain Injury Association of America

1608 Spring Hill Road, Suite 110
Vienna, VA  22182

After the devastating Massachusetts special election, House and Senate leaders are expected to resume negotiations this week to attempt to finish the health care overhaul. Although a clear path is still unknown, BIAA will continue to monitor the situation closely. A big thank you to all of our grassroots advocates who answered the call last week to urge members of Congress to push forward on Health Care Reform!

State Concussion Legislation

Following the extraordinary success of BIA of Washington and BIA of Oregon in the adoption of state level sports concussion legislation, BIAA, in partnership with the Sports Legacy Institute, has become committed to encouraging, and assisting wherever possible, the enactment of sports concussion legislation in all states.

BIAA has developed a sample piece of legislation based on current laws and pending bills that exist throughout the country. This model legislation along with a sample testimony for use in state concussion hearings, distributed on January 25, 2010 to BIAA’s state affiliates, is a step foward in facilitating action in each state.

Due to the increased visibility of sports concussions within the National Football League in recent weeks, BIAA is encouraged that all states will be able to tip the scales in favor of protecting our youth athletes.

Brain Injury Awareness Day 2010

This year’s Brain Injury Awareness Day on Capitol Hill is set to take place on March, 17, 2010. BIAA will be unveiling our 2010 legislative agenda and encouraging the grassroots community along with state affiliates to participate in advocating for increased TBI Act appropriations, increased access to care, federal and state level concussion legislation, increased TBI research, military coverage of cognitive rehabilitation and caregiver assistance.

All issues mentioned will be outlined in fact sheets that advocates will receive that day and can use as reference during congressional visits and may leave behind for review by congressional staff.

Below is the schedule of events for the day:

10:00 AM – 1:00 PM - Brain Injury Awareness Fair, First Floor Foyer of the Rayburn House Office Building
2:30 PM – 4:00 PM - Briefing: “From the Playground to the Pros: A Heads-Up on Concussion”, Capitol Visitors Center – Congressional Meeting Room South
5:30 PM – 7:30 PM - Reception Celebrating Brain Injury Awareness Month, First Floor Foyer of the Rayburn House Office Building

This morning President Obama released his FY 2011 budget. Last week, the State of the Union address warned of spending freezes and tough decisions on what programs to keep and what programs to discontinue in the coming year.

BIAA is pleased to announce that the HRSA state grant program, authorized by the TBI Act, has been level funded in the President’s budget.

Although the appropriations process for 2011 is far from over, we are off to a good start.  BIAA would like to make a push for increased appropriations for this program at the 2010 Brain Injury Awareness Day on March 17th on Capitol Hill.  Please contact Sarah D’Orsie, Director of Government Affairs, BIAA at sdorsie@biausa.org if you are planning to attend.

People who lead a sedentary lifestyle are prone to cardiovascular disease, osteoporosis, colon cancer, glucose intolerance, and depression—among other disorders. People with a traumatic brain injury often lead a sedentary lifestyle because of motor impairment and cognitive dysfunction, but have an additional detriment of a decreased aerobic capacity—running on as little as 64% of normal.

Research shows that sedentary people who participate in a formal exercise intervention (rather than a simple increase in activity) will decrease their risk of developing disease. Very few studies have been performed with traumatic brain injury survivors. However, a recent research review has shown that those few studies do support an intervention of endurance training.

The following guidelines were recommended for creating a safe and effective cardiorespiratory and endurance training program for people with traumatic brain injury:

1. The exercise should be low-resistance, rhythmic, and dynamic (varied such as walking, jogging, cycling, etc).
2. The intensity of training should somewhere between 60-90% of age-predicted maximal heart rate (normally 220 minus age).
3. The duration should be no more than 20-40 minutes per session (depending on individual).
4. The frequency should be no more than 3-4 times per week.

Mossberg KA, Amonette WE, & Masel BE. Endurance training and cardiorespiratory conditioning after traumatic brain injury. Journal of Head Trauma Rehabilitation. (May 2010).

Traumatic brain injury is often thought of, and treated as, a one-time event. And yet, it is well understood that TBI is the root of many ongoing complications. Some complications can be seen immediately and continue for many years after the event: cognitive dysfunction, sleep disorders, motor impairments, or psychiatric disease. Some might not manifest until long after the event: seizures, hypopituitarism, or early onset of degenerative diseases like Parkinson’s or Alzheimer’s.

In a recent commentary published in the Journal of Neurotrauma, Drs. Masel and DeWitt of the University of Texas wrote, “Historically, individuals living with a brain injury have been referred to as brain injury ‘survivors’.” As if staying alive was the endpoint of brain injury, the same way cure is the endpoint to cancer. “However,” they continued, “annually in the United States alone, over 90,000 TBI patients become disabled,” and many face a future of “an ongoing, perhaps life-long, process” of managing critical, permanent, and expensive complications.

Perhaps, as was suggested in this commentary, TBI should be referred to as “chronic traumatic brain injury disease” because this definition will help to researchers, clinicians, and legal professionals understand that TBI may require life-long support, assessment, treatment, and funding.

Masel BE, & DeWitt DS. Traumatic brain injury: A disease process, not an event. Journal of Neurotrauma. (June 2010).

In a three-part review of acute management for traumatic brain injury, researchers recently recommended what they considered to be best practices within non-pharmacological interventions, pharmacological interventions, and interventions used to promote arousal from coma. Their findings were as follows.

Non-pharmacological interventions used to reduce secondary injury:

After the primary injury, acute care of traumatic brain injury focuses on the prevention of secondary injury, such as inflammation, hypoxia, ischemia, or edema. Non-pharmacological interventions used to prevent the intracranial pressure and reduce secondary damage include: adjusting head posture, body rotation, hyperventilation, hypothermia, hyperbaric oxygen, cerebrospinal fluid drainage, and decompressive craniectomy.

Of these seven interventions, only decompressive craniectomy, cerebrospinal fluid drainage, hypothermia, and hyperbaric oxygen provided strong evidence to be recommended as an appropriate treatment in the acute care of traumatic brain injury

Pharmacological interventions used to reduce secondary injury and improve neural recovery:

There are three types of pharmacological agents that are used to decrease intracranial pressure after brain injury. These are: 1) diuretics to draw fluid from the cranial cavity, 2) analgesics to reduce metabolic demands from injured neurons and reduce brain activity, and 3) sedatives that act in the same way as analgesics.

Of the 11 pharmacological interventions commonly used—propofol, barbiturates, opioids, midazolam, mannitol, hypertonic saline, corticosteroids, progesterone, bradykinin antagonists, dimethyl sulphoxide, and cannabinoids—all but corticosteroids (which were contraindicated) and cannabinoids (which were ineffective) showed strong evidence of providing some benefit in the acute care of traumatic brain injury.

Interventions used to promote arousal from coma:

Both pharmacological and non-pharmacological interventions were reviewed in this study. Pharmacological interventions included amantadine, bromocriptine, and levodopa. Non-pharmacological interventions included sensory stimulation, music therapy, and medial nerve electrical stimulation.

All interventions showed a trend towards promoting arousal from coma. However, only amantadine showed strong evidence of substantial benefit, and this was only reported from a single case. Further research is needed in all therapies, since there is currently a lack of thorough research.

Meyer MJ, Megyesi J, Meythaler J, et al. Acute management of acquired brain injury part I: An evidence-based review of non-pharmacological interventions. Brain Injury. (May 2010).

Meyer MJ, Megyesi J, Meythaler J, et al. Acute management of acquired brain injury part II: An evidence-based review of pharmacological interventions. Brain Injury. (May 2010).

Meyer MJ, Megyesi J, Meythaler J, et al. Acute management of acquired brain injury part III: An evidence-based review of interventions used to promote arousal from coma. Brain Injury. (May 2010).