Traumatic brain injury (TBI) in children can be difficult to diagnose, and it is even more difficult to predict an outcome. Traditionally, TBI is defined as mild, moderate, or severe by using certain indicators such as the Glasgow Coma Scale or loss of consciousness. Outcomes based on TBI severity can be unpredictable—mild TBI has been known to cause long-term deficits, and more severe TBI can sometimes result in a surprisingly good outcome.

A recent study found that force of impact was a more accurate predictor of outcome than TBI severity. Force of impact was defined as:

• Never sustained an impact with consequences worth considering
• Mild impact (e.g., knocking head against door frame)
• Moderate impact (e.g., knocked by a player’s elbow during sports)
• Strong impact (e.g., intentional punch to the head)
• Very strong impact (e.g., forceful collision with a hard surface, such as in a car
accident)

Children and parents may have a better memory for concrete examples of the injury, and may be too unfamiliar with clinical terms to accurately describe the event.

Halldorsson JG, Flekkoy KM, Arnkelsson GB, et al. The scope of early traumatic brain injury as a long-term health concern in two nationwide samples: Prevalence and prognostic factors. Brain Injury. (January 2012).

Memory and attention problems are common after a traumatic brain injury (TBI). However, both memory and attention are complex, interrelated systems that can be broken into “pieces” of a process. Research has been mixed about specifically what piece of that process is most commonly affected by TBI. One of the problems of this research is how memory and attention is analyzed during the study. In many cases, studies will only look at one piece of the whole process.

Researchers recently examined memory and attention after TBI as both an interrelated process as well as separate pieces. One interesting finding was that people with TBI made significantly more “false alarm” responses in both memory and attention tests. In other words, when having to decide if an item that was correct or incorrect, people with TBI were more likely to mistake an incorrect item as correct.

This is also called the “yes bias”—an instinct to respond “yes, this (incorrect) item is correct” rather than “no, this (correct) item is incorrect.” The yes bias is in part a result of a lack of inhibition, the inability to stop from making an incorrect choice, that is common after a TBI. The researchers suggest that this lack of inhibition may be related to the inability to sustain long periods of attention.

Slovarp L, Azuma T, & Lapointe L. The effect of traumatic brain injury on sustained attention and working memory. Brain Injury. (January 2012).

Post-concussion syndrome (PCS) is defined as a set of common symptoms that occur in the days or months after a mild traumatic brain injury (mTBI). These symptoms include fatigue, depression, headaches, dizziness, and cognitive problems. PCS has been a somewhat controversial topic because clinicians rely on the patient’s report of their symptoms, in absence of objective test results. In addition, research has shown inconsistent results for the prevalence of PCS after mTBI.

In a recent comparison of people with mTBI to people with no injury, researchers found that the rate of PCS was almost identical in both groups. PCS, therefore, describes a set of symptoms that are just as common in the general public as they are to people with mTBI.

However, when PCS symptoms were analyzed individually, the researchers did find differences between the groups. People with mTBI had significantly greater cognitive impairment than the cognitive impairment found in uninjured people. Additionally, people with mTBI reported their symptoms as more intense and disabling than the uninjured group.

The diagnostic criteria for PCS should be more specific than it is now, but further research is needed to define those criteria.

Dean PJA, O-Neill D, & Sterr A. Post-concussion syndrome: Prevalence after mild traumatic brain injury in comparison with a sample without head injury. Brain Injury. (January 2012).

A self-report of symptoms after a traumatic brain injury is an important part of the assessment process. But, how does a clinician interpret inconsistencies between self-reported symptoms and the objective neuropsychological evaluation?

One problem is that the severity of the brain injury can affect the way the patient talks about symptoms. For instance, a person with a more severe brain injury may have problems with awareness and thus deny having any symptoms. Or, they may have more problems with communication and memory that can limit their report. Conversely, a person with a mild brain injury often shows better awareness and communication about their deficits, but may also have problems such as depression, anxiety, or insomnia that can make these deficits more intense.

A recent study compared neuropsychological test results to self-reported symptoms between groups of people with mild or severe traumatic brain injuries. People with both mild and severe brain injuries reported significant memory problems, however only the severe brain injury group had test scores that showed significant memory impairment. People with both mild and severe brain injuries showed problems with attention during the neuropsychological tests, but only those with mild brain injury group were aware of and reported it.

Jamora CW, Young A, & Ruff RM. Comparison of subjective cognitive complaints with neuropsychological tests in individuals with mild vs. severe traumatic brain injuries. Brain Injury. (January 2012).

On Friday, January 13, 2012, BIAA’s government affairs director along with NASHIA’s lobbyist met with staff representing the National Disability Rights Network to discuss TBI Act reauthorization in 2012. BIAA will continue to work closely with other stakeholders as the reauthorization of the TBI Act moves forward.

AHRQ Reports Open for Public Comment

The Effective Health Care Program, Agency for Healthcare Research and Quality (AHRQ) made available to the public two draft reports that are available for comment. This review is part of a new series of reports on Closing the Quality Gap: Revisiting the State of the Science (hereafter, CQG series).

The report, Multidisciplinary Postacute Rehabilitation for Moderate to Severe Traumatic Brain Injury, is available for public comment until February 9, 2012.

The report, Closing the Quality Gap Series: QI Measurement of Outcomes for People with Disabilities, is available for public comment until February 6, 2012.

I look forward to seeing you all at the Brain Injury Awareness Day on March 21, 2012!

Schedule for March 21, 2012

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 – Congressional Briefing, Location to Be Announced

5:30 PM – 7:30 PM – Reception Celebrating Brain Injury Awareness Month, Location to be announced

Other Activities

BIAA

strongly encourages

everyone that plans to attend Brain Injury Awareness Day to make appointments with their Representatives and Senators to advocate for increased funding for the programs authorized through the TBI Act. Please see tips below:

Congressional Appointments

To find House of Representatives information:

www.house.gov, type in zip code to locate your

Representative

. Click on your member’s link for their Web site where you will find their address and phone number.

To find Senate information:

www.senate.gov, select state and view Senators’ individual Web sites for address and phone number.

When calling the main number of the Senator or Representative, ask to meet with the health legislative assistant (House) or the health policy staff (Senate).

• Make sure to let them know that you are a constituent
  • Ask them for a few minutes of their time on March 21, 2012 to discuss the need for increased resources for brain injury programs in their state.

Example:

Hello ______________ my name is ______________________. I am a constituent of yours and will be visiting Capitol Hill on Wednesday, March 21, 2012 as part of Brain Injury Awareness Day. Could I have a few minutes on that day to talk to you about (state’s) brain injury resources and how they affect the brain injury community in your district/state?

Navigating Capitol Hill

If you are coming in from out of town and require a hotel, below you will find a list of accommodations within a few miles of Capitol Hill:

Hyatt Regency, http://washingtonregency.hyatt.com/hyatt/hotels/index.jsp

Courtyard, Marriott, http://www.marriott.com/hotels/travel/wasny-courtyard-washington-capitol-hill-navy-yard

Capitol Hill Suites, http://www.capitolhillsuites.com

Hotel George, http://www.hotelgeorge.com

Marriott, Residence Inn, http://www.marriott.com/hotels/travel/wascp-residence-inn-washington-dc-capitol

A map of the key House and Senate buildings can be found below:

http://www.aoc.gov/cc/cc_map.cfm

BIAA encourages advocates to check with their state brain injury organizations to determine if others from their state will be attending and if so, to coordinate meetings.

BIAA will provide printed maps of the Senate and House buildings as well as easy to follow fact sheets outlining the issues that you will be advocating for in your meetings. Electronic versions will be distributed and posted to BIAA’s website in early March. BIAA will also provide color copies at the Brain Injury Awareness Fair. Please check back for updated information on Brain Injury Awareness Day! If you have any questions or concerns, please contact Amy Colberg at acolberg@biausa.org.

Full recovery after a sports-related concussion (i.e., mild traumatic brain injury) is critical in order to prevent cumulative damage from future concussion. Unfortunately, the pressure to return to play often outweighs the need to wait for full recovery, and athletes often return to play sooner than they should. There have been various tools proposed to measure recovery after a concussion, but these have shown inconsistent results. There is an urgent need for a more reliable measure of recovery after concussion.

Electroencephalography (EEG) measures brain activity and has been shown to be a sensitive tool for showing slight changes in brain functioning. In a recent study of high school football players, EEG was able to detect abnormalities of brain activity in those who had been concussed as compared to those who had not been injured. Using an emergency department-based algorithm, the researchers were able to show that abnormal brain activity occurred beyond the point in which traditional clinical tools had indicated full recovery.

The implication of this study is that traditional clinical tests of brain function after a concussion are not adequately measuring recovery, and players may be returning to the game too soon. EEG may be a more precise and reliable tool, and should be considered as a standard test in the future.

Barr WB, Prichep LS, Cahbot R, Powell MR, & McCrea M. Measuring brain electrical activity to track recovery from sport-related concussion. Brain Injury. (January 2012).

The rate of chronic fatigue after traumatic brain injury is more than four times higher than the general population. Chronic fatigue is a complex disorder, and research has shown that is related to sleep problems, cognitive impairment, attention deficits, depression, anxiety, and chronic pain—problems that are also common after traumatic brain injury. Hormonal insufficiencies that can occur after traumatic brain injury can also contribute to chronic fatigue.

A recent study examining both hormonal and non-hormonal causes of chronic fatigue after traumatic brain injury found that vitamin D deficiency was a surprisingly strong risk factor. Poor sleep was also a strong, but obvious, cause of fatigue. Anxiety was associated with chronic fatigue, although less so than sleep problems. Hormone deficiencies were shown to be unrelated to chronic fatigue.

The link between vitamin D deficiency and chronic fatigue is an intriguing one. Traumatic brain injury can lead to an isolated and inactive lifestyle that results in lowered sun exposure and subsequent vitamin D deficiency. Vitamin D deficiency can cause muscle pain and weakness, two symptoms that are also common in chronic fatigue. Fortunately, vitamin D replacement is a simple and inexpensive therapy that may help to reverse chronic fatigue after traumatic brain injury.

Schnieders J, Willensen D, & de Boer H. Factors contributing to chronic fatigue after traumatic brain injury. Journal of Head Trauma Rehabilitation. (February 2012).

A traumatic brain injury can result in cognitive, emotional, and physical impairments that make the patient more vulnerable to future injury. For instance, cognitive impairments may result in slow decision-making or faulty judgment that can put a person at risk while driving. Emotional impairments may lead to an increased risk of assault-related injury or self-harm. And physical impairments can increase the risk of falls.

In a recent study of veterans, researchers reported that 32% of people with a traumatic brain injury subsequently suffered from another non-fatal injury. Most of these injuries were from falls and car accidents. Assault, burns, and poisoning were less common causes of subsequent injuries.

The specific impairments that contributed the most to subsequent injury were vision loss, hearing loss, speech problems, chronic pain, and depression. Other impairments that were identified as less significant risk factors were balance problems, anxiety, anger problems, and sleep problems.

Carlson KF, Meis LA, Jensen AC, et al. Caregiver reports of subsequent injuries among veterans with traumatic brain injury after discharge from inpatient polytrauma rehabilitation program. Journal of Head Trauma Rehabilitation. (February 2012).

After discharge from the hospital or rehabilitation center, a person with traumatic brain injury (TBI) usually returns home. In most cases, one family member becomes solely responsible for the patient, creating a tremendous burden on that family member.

A recent study described the most common profile of the caregivers for TBI patients. Although the study focused on military families, the profile is likely to be similar for civilian families as well. The study found that:

• 79% of caregivers are women
• 62% are a parent of the patient
• 32% are a spouse of the patient
• 25% reported providing care for more than 40-hours per week
• 49% reported providing care for more than 80-hours per week
• 60% were the sole provider of care
• After four years, 22% of patients still needed intense care

The sole caregiver of a person with TBI is very likely doing so as an unpaid, full-time job. The financial and emotional burden of this responsibility is an often overlooked casualty of both military and civilian families.

Griffin JM, Friedmann-Sanchez G, Jensen AC, et al. The invisible side of war: Families caring for US service members with traumatic brain injuries and polytrauma. Journal of Head Trauma Rehabilitation. (February 2012).