On Friday, March 11, 2011, the House Appropriations Committee will unveil a three-week continuing resolution (CR) that will extend FY10 funding through April 8, 2011. The current CR is set to expire on March 18, 2011. The bill would make some relatively non-controversial spending cuts, totaling about $6 billion dollars in savings.

BIAA is monitoring the situation closely and working with the Congressional Brain Injury Task Force to make sure that FY2011 appropriations will look favorably on brain injury programs. BIAA is also engaging with both Senate and House Appropriations Committees in preparation for FY2012 appropriations work.

This year, brain injury awareness day on Capitol Hill will be held on Wednesday, March 16, 2011. BIAA and other stakeholders are working with the Congressional Brain Injury Task Force to develop a schedule for the day and a theme for this year’s briefing.

Look for more details in future editions of Policy Corner, including BIAA’s 2011 legislative agenda and a full schedule and other advocacy materials for the March 16^th event.

On January 13, 2011, The Congressional Brain Injury Task Force, with help from BIAA, Ohio State University and JFK-Johnson Rehabilitation Institute, issued a letter to the Office of Management and Budget (OMB) encouraging line-item status and increased funding for the TBI Model Systems of Care program within the soon-to-be released President’s budget.

As of now, the budget is set to be released during the week of February 14, 2011. At that time, BIAA will analyze funding levels and alert grassroots advocates when appropriations action becomes necessary.

Leisure activities—such as reading, sports, outdoor activities, or other hobbies—are an important part of our day-to-day lives. Leisure activities can also contribute greatly to a recovery after TBI. Not only do such activities add opportunities for social interaction and physical health, they can also enhance a sense of independence and personal accomplishment for returning to an activity that was enjoyed before the injury.

A recent study looked at three aspects of leisure activities after TBI. One, how does participation in leisure activities change from before injury to one year after injury? Two, how do age and gender affect participation in leisure activities? Three, are people with TBI bothered about how well they can participate in leisure activities?

Their results found that, one year after injury, 81% of people with TBI were not participating in leisure activities at the same level they did before injury. The most popular new leisure activity after injury was watching television. These changes contributed to a more sedentary, less social life—which dissatisfied most participants. Although decreasing some leisure activities, such as partying or drug and alcohol use, were considered to be positive changes, participants felt there were few new activities that could replace the lost ones.

Wise EK, Mathews-Dalton C, Dikmen S, et al. Impact of traumatic brain injury on participation in leisure activities. Archives of Physical and Medical Rehabilitation. (September 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).

On May 5, 2010, The Senate Veterans Affairs Committee held a hearing examining the efforts of the Department of Veterans Affairs in responding to the rehabilitation needs of veterans with TBI since the passage of the TBI-related provisions as part of the National Defense Authorization Act of 2008.  BIAA passed its slot to testify to the Brain Injury Association of Michigan (BIAMI) because of their in-depth involvement with the veteran population in Michigan.

Mike Dabbs, President of BIAMI, testified about the need for an increased public/private partnership between the VA and private health care providers in order to insure that veterans can access the best care possible.  For further reading, the full testimony is available on BIAMI’s Web site.

As many of you know, this hearing comes after the Veterans’ Health Care Authorization Act that was cleared last month.  Because of the specific language in the bill regarding veterans with brain injury and access to non-VA providers, in which BIAA and the Wounded Warrior Project advocated for tirelessly, BIAA is hopeful that the provisions in the bill as well as the outcomes of the May 5^th hearing will serve to dramatically increase access to care for the veteran population across the country.

Skimboarding is a popular water sport that involves “skimming” a wave from shore to ocean. As it has become more competitive and extreme, the risk of injury has increased. Past medical research has shown an increase in fractures and sprains, but a recent study has shown that there is also a significant risk of spinal cord injury.

In a series of case studies from Emory University in Georgia, medical researchers presented three cases of skimboarding accidents that resulted in spinal cord injury. In each case, the patient had flipped his board in shallow water so that his head made contact with the ocean floor. The resulting injuries affected areas C3-C5 and resulted in partial to complete paralysis.

As compared to similar sports, such as traditional surfing, there is a significant risk of spinal cord injury in skimboarding due to the potential for landing head first in shallow water. Skimboarders, their families, and clinicians should be aware of this increased risk.

Collier TR, Jones ML, & Murray HH. Skimboarding: A new cause of water sport spinal cord injury. Spinal Cord. (2010).

On Thursday, April 22, 2010, the Senate cleared an omnibus veterans’ health care measure that provides important assistance to both veterans and caregivers.  S. 1963, as modified by the House, includes nearly $1.6 billion in authorizations for programs designed to aid caregivers of eligible veterans.

The measure, which now goes to the White House for President Obama’s signature, is intended to strengthen the health care support system for veterans and to expand services in rural areas. The measure will also expand caregiver programs, making them eligible for training and education assistance.

The bill also authorizes VA hospitals to contract with non-VA providers, as stated in the bill:

“The Secretary may contract with appropriate entities to provide specialized residential care and rehabilitation services to a veteran of Operation Enduring Freedom or Operation Iraqi Freedom who the Secretary determines suffers from a traumatic brain injury…”

Both BIAA and the Wounded Warrior Project have long advocated for approval of this measure and yesterday’s final passage signified a great victory for service members who suffer from TBI and their families.

Health Care Reform Update

After several weeks of delving into the final text of the health care reform bill, our partners at Powers,  Pyles, Sutter & Verville, PC, sponsored by BIAA’s Business and Professional Council, have prepared an analysis of the major provisions that impact our community.

BIAA will continue to work to identify and advocate for favorable regulations to ensure access to brain injury care as the process moves forward.

STATEMENT OF THE PROBLEM

Brain injury constitutes a major public health threat in California. The number of people who sustain brain injury each year in California is estimated to exceed 222,000 per year . These numbers do not include between 144,000 to 342,000 sports-related concussions estimated to occur in California each year . Approximately 52,250 children in California sustain a brain injury and/or are hospitalized with a brain injury each year. These estimates derive from data collected at a National level . Brain injuries arise from a large variety of causes such as falls, motor vehicle accidents, being struck by or against an object, gunshots, stroke, heart attack, viral or bacterial infections, neoplasms, anoxia, toxic exposure and metabolic causes2. The CDC estimates that between 396,000 and 740,000 Californians are living with long-term disability as the result of traumatic brain injury (TBI) .

The statistics of this population are staggering in two regards. The first is that the numbers appear to be so high. The second is that this “silent epidemic” as it has been called for many years remains poorly understood in its scope and size. Epidemiologic studies are complex and difficult and established medical surveillance processes were not designed in anticipation of the myriad of complex issues that brain injury presents.

The event of brain injury begins lifelong disease processes. Disease management for brain injury includes emergency care, intensive care, hospital-based rehabilitation, non-hospital based rehabilitation, and vocational rehabilitation . Recovery from brain injury arising from concussion can be expected for approximately 80 to 95% of all individuals. Of the remainder, 20% will have persistence of at least one symptom for at least one year, while 5% will have five or more symptoms for at least one year . Brain injury is cumulative and repeated injuries constitute a major concern in the form of repeated concussions or more severe injuries .

Access to disease management, medical rehabilitation and vocational rehabilitation has deteriorated drastically since 1990. Length of stay for hospital based treatment in 1990 averaged 77 days, progressed to 48 days in 1999 and stands now between 11 and 46 days according to differing data sets. Hospital-based medical rehabilitation charges changed from $1532 per day in 1990 to $1356 in 1999 and are reported now at as low as $1000. This is equivalent to $618 in 1990 dollars using a 3% annual CPI.

Coverage for disease management, medical rehabilitation and vocational rehabilitation is severely restricted and is being systematically lessened by public and private payers alike resulting in unnecessarily heightened levels of disability, long term cost, job loss, financial impoverishment, and medical indigence . “Subprime” health insurance currently privatizes profit and socialized financial risk by systematically restricting or denying access to medical treatment for the disease of brain injury on par with other diagnoses. The disease of brain injury can cause other disease progression or acceleration. Medical treatment, medical rehabilitation and vocational rehabilitation are known to mitigate disease progression and complication and reduce long term cost of care and societal economic burden9-15.

No Californian has adequate access to appropriate disease management, medical rehabilitation or vocational rehabilitation for brain injury due to payer restrictions and access is sharply and rapidly diminishing. The economic burden associated with non-treatment is systematically shifted to the public sector as insurers disallow access to continued treatment resulting in very high levels of medical acuity and disability. Individuals cannot return to work and they and their families lose their income and health insurance altogether.

The nationally annualized direct and indirect costs of TBI have been estimated to range between $51.2 and $60 billion in the United States while the annual costs for stroke are estimated at $68.9 billion. The true extent of the economic impact to the state cannot be realized because the State has no epidemiology and surveillance program that thoroughly tracks brain injury16. Consequently, the State cannot know the exact economic burden resulting from brain injury. The likely inflated cost of untreated or improperly treated brain injury is distributed at least among California’s Departments of Education, Corrections, Health, Rehabilitation, Developmental Disabilities and Medi-Cal programs17,18.

Cost of care for a single disabled person with brain injury over a lifetime can range from $1 to $30 million. Disease management, medical rehabilitation and vocational rehabilitation can save millions of dollars per life when expertly and expediently applied10,12-14,19.

Ample evidence from the private sector points to the clinical and cost effectiveness of intensive, expert multidisciplinary medical rehabilitation and disease management for brain injury of appropriate duration along a continuum of treatment that has evolved over the last thirty years. Workers’ compensation systems at the State and national levels have managed billions of dollars in claims through these systems. The most effective management has resulted in marked reduction in disability for individuals with brain injury and marshaled excellent cost-effectiveness for the responsible financial parties. The best practices of these approaches should inform a systematic approach to medical treatment and disease management for all people who suffer a brain injury and the disease processes that follow.

These approaches have definitively demonstrated that medical rehabilitation stands as the single most effective treatment for brain injury in achieving maximized reductions in disability, improvements in independence, improvements in net health outcomes and quality of life, and lifetime cost savings. We know how to better return people to productive lives of independence, work and school, yet we are systematically preventing the majority of individuals who experience brain injury from realizing their best outcomes.

Veterans returning to California after serving in Operation Iraqi Freedom or Operation Enduring Freedom who have suffered brain injury can be expected to be under-counted statistically for many reasons. Whatever the reasons, these individuals and their families will come to know the same difficulties in accessing proper diagnosis and treatment for their neurologic conditions and they will experience similar lifelong disease processes including epilepsy, accelerated onsets of Alzheimer’s and other neurodegenerative diseases, neuroendocrine disease, depression, suicide, and an incredible collection of other disease entities. They will fail economically, socially, vocationally, educationally and within their families. They will join the homeless, the medically indigent, the jobless, the institutionalized, the incarcerated and the socially isolated civilians with brain injury who suffer the indignities of brain injury untreated and uncared for. None who understand what military service requires would accept that this is the finest that our country can offer to its finest. While the Veterans’ Administration and the Department of Defense struggle valiantly to define and meet the needs of these returning military service men and women, it remains significantly challenged and over-burdened. Claims backlogs alone cause substantial delays in accessing treatment and can range between months and years. Delayed treatment is recovery denied, whether for veterans or civilians, and while the inhumanity and impropriety of such an approach is obvious, the financial ramifications are less so. Simply put, failure to expertly and promptly diagnose and treat costs the Californian taxpayer huge sums of money per patient that are unrivaled by nearly any other medical diagnosis.

The facts about brain injury are compelling. The solutions are elegantly simple and, properly crafted, can provide “win-win” scenarios for all parties. Listed below is a partial list of recommendations:

RECOMMENDED SOLUTIONS

1. Require public and private health plans to cover medically necessary medical rehabilitation for the treatment of brain injury consistent with Medical Treatment Guidelines for Traumatic Brain Injury of the Department of Labor, Division of Workers’ Compensation of the State of Colorado across the entire established continuum of treatment. Disallow arbitrary timeframes that constrain treatment to periods of 30 to 100 days and are based rather on patient status and condition.
2. Support the Department of Health in establishing a statewide traumatic brain injury registry system and to collect data relating to brain injuries.
3. Support the Department of Health in establishing a process for identification of persons with brain injury currently being served by the Departments of Health, Education, Rehabilitation, Corrections, Developmental Disabilities and Medi-Cal programs.
4. Increase DMV penalty fund fines commensurate with other States’ penalty fund and allocations to provide at least $30 million in novel funding to be distributed between the University of California Brain Injury Research sites ($15 million), Department of Health ($10 million) and the Traumatic Brain Injury Services of California sites ($5 million).
5. Require mandatory training of school athletic coaches, trainers, PE teachers, team physicians, and students in brain injury prevention. Require adoption of the CDC Guideline for Concussion by all organized athletic groups and activities. Require the purchase of catastrophic injury protections insurance for all student athletes that provides $5 million coverage for brain injury, spinal cord injury and/or catastrophic amputation and allow for equivalent recovery relief for school districts that purchase such coverage for students.
6. Promote adherence to medical treatment standards via MediCal reimbursement policy that provides reimbursement at preferred rates for facilities that choose to adopt and comply with medical treatment standards for brain injury.
7. Promote prompt and expert diagnosis and treatment of brain injury and related disease management for veterans and civilians. Establish a clearinghouse of State and Federal resource availability through a single source to enable all with brain injury and/or their families to gain rapid access to services such as housing, transportation, food assistance, return to work, return to school, respite care, and ongoing medical treatment and access.
8. Promote injury prevention efforts to reduce the overall incidence of brain injury from falls, sports activities, motor vehicle and other cause.

Bibliography
Cassidy J, Carroll, LJ., Peloso, PM., Borg, J., van Holst, H., Holm, L., Krauss, J., Coronado, VG.. Incidence, risk factors and prevention of mild traumatic brain injury: Results of the WHO collaborating centre task force on mild traumatic brain injury. J Rehab Medicine 2004;Supp. 43:28-60.
Langlois JA, Rutland-Brown-W, Wald MM. The Epidemiology and Impact of Traumatic Brain Injury. Journal of Head Trauma Rehabilitation 2006;21(5):375-8.
Langlois JA, Rutland Brown W, Thomas KE. The Incidence of Traumatic Brain Injury Among Children in the United States. Journal of Head Trauma Rehabilitation 2005;20(3):229-38.
Zaloshnja E, Miller T, LAnglois JA, Selassie AW. Prevalence of long-term disability from traumatic brain injury in the civilian population of the United States, 2005. Journal of Head Trauma Rehabilitation 2008;23(6):394-400.
Traumatic brain injury medical treatment guidelines. In: Department of Labor and Employment, editor.:Division of Workers’ Compensation, Sate of Colorado; 2005.
Auerbach SH. The postconcussive syndrome: formulating the problem. Hospital Practice (Office Ed) 1987;22(10A):9-12.
Carlsson GS, Svardsudd K, Welin L. Long-term effects of head injuries sustained during life in three male populations. Journal of Neurosurgery 1987;67(2):197-205.
Hollingsworth W, Relyea-Chew A, Comstock BA, Overstreet KA, Jarvik JG. The risk of bankruptcy before and after brain or spinal cord injury. Medical Care 2007;45(8):702-11.
9  Turner-Stokes L. The evidence for the cost-effectiveness of rehabilitation following acquired brain injury. Clinical Medicine, Journal of the Royal College of Physicians 2004;4:10-2.
10  Wood RL, McCrea JD, Wood LM, Merriman RN. Clinical and cost effectiveness of post-acute neurobehavioural rehabilitation. Brain Injury 1999;13(2):69-88.
11  Worthington AD, Matthews S, Melia Y, Oddy M. Cost-benefits associated with social outcome from neurobehavioural rehabilitation. Brain Injury 2006;20(9)947:-57.
12 Ashley MJ, Krych DK. Cost/benefit analysis for post-acute rehabilitation of the traumatically brain injured patient. Journal of Insurance Medicine 1990;22(2):156-61.
13 Ahsley MJ, Schultz JD, Bryan BL, Krych DK, Hays DR. Justification of postacute traumatic brain injury rehabilitation using net present value techniques: A case study. Journal of Rehabilitation Outcomes Measurement 1997;1(5)33-41.
14 Faul MP, Wald MMMLSMPH, Rutland-Brown WMPH, Sullivent EEMD, Sattin RWMD. Using a Cost-Benefit Analysis to Estimate Outcomes of Clinical Treatment Guideline: Testing the Brain Trauma Foundation Guidelines for the Treatment of Severe Traumatic Brain Injury. Journal of Trauma-Injury Infection & Critical Care 2007;63(6):1271-8
15 Turner-Stokes L. Cost-efficiency of longer-stay rehabilitation programmes: Can they provide value for money? Brain Injury 2007;21(1):1015-21.
16 Langlois JA, Rutland-Brown W. Traumatic brain injury in the United States: The future of registries and data systems. In:Control CfDCaPNCflPa, editor.;2005.
17 Morrell RF, Merbitz CT, Jain S, Jain S. Traumatic brain injury in prisoners. Journal of Offender Rehabilitation 1998;27(3-4):1-8.
18 Slaughter B, Fann JR, Ehde D. Traumatic brain injury in a county jail population: prevelance, neuropsychological functioning and psychiatric disorders. Brain Injury 2003;17(9):731-41.
19 Finklestein E, Coros P, Miller T. The Incidence and Economic Burden of Injury in the United States. New York: Oxford University Press; 2006.

Diffuse axonal injury (DAI) describes damage to the axon of a neuron. Axons are covered in white, fatty matter that helps to quickly relay messages back and forth, and the major region of the brain that is dense with this white matter is called the corpus callosum. As such, the corpus callosum is the most vulnerable to damage from DAI.

Recently, a team of UCLA researchers studied the long-term effects of injury to the corpus callosum in pediatric brain injury patients, as well as the correlation of injury to cognitive functioning. They found that there were structural and metabolic differences in the corpus callosum between the acute and chronic stages of injury. These metabolic changes could be related to the energy used during neural repair, or from changes due to permanent cell death. Furthermore, metabolic dysfunction and structural damage seen in the corpus callosum after DAI was associated with declines in cognitive functioning.

The preliminary results of this study contribute to the understanding of how metabolic and structural changes might develop long-term in cases of pediatric traumatic brain injury. Although future studies may pinpoint the exact time course of these changes, it is important to acknowledge that degeneration of the corpus callosum may continue long after the initial injury.

Babikian T, Marion SD, Copeland S, Alger JR, et al. Metabolic levels in the corpus callosum and their structural and behavioral correlates after moderate to severe pediatric TBI. Journal of Neurotrauma. (March 2010).