This week, BIAA joined Congressman John Adler in support of a bill that would ensure a method be in place when applying for Federal or Private student loans to designate who will make decisions on your behalf regarding all medical, financial, and legal matters in the event you are catastrophically ill, catastrophically injured, temporarily disabled, permanently disabled or deceased.

On June 17, 2004, 23 year old Christopher Bryski fell forty five feet to the ground in a recreational accident.  He sustained a severe Traumatic Brain Injury and was in a coma for approximately 4 weeks.  After emerging from the coma Christopher remained in a persistent vegetative state for almost two years before passing away on July 16, 2006.

At the time of Christopher’s accident, he was in his third year of academic study at Rutgers University and needed to supplement his federal student loans with a private alternative education loan through a private lender, in which his father was a co-signer and is still liable after his death for the amount of the loan.

The bill introduced by Congressman Adler would address this important issue for parents and caregivers in the following ways:

Any private educational lender (i.e Citibank, Wells Fargo, Chase, PNC, etc.) shall:

• Discuss with the student and the cosigner of the loan the benefits of creating a power of attorney, in the event of the death of incapacity of the student or cosigner
• Define clearly and concisely the obligations of the cosigner, including the effect of death or incapacity of the student or cosigner
• Discuss with the student and the cosigner the benefit of credit insurance in connection with the loan, however the private educational lender may not require credit insurance or deny a loan on the basis that the borrower or any cosigner has not obtained credit insurance
• Gives power to the Federal Reserve to define death or incapacity in conjunction with the Secretary of Education and institute standards regarding the borrower’s or cosigner’s obligation if the borrower or cosigner were to die or become incapacitated
• Federal PLUS Loans and Federal Consolidation Loans:
• Discuss with the prospective borrower the uses and benefits of creating a durable power of attorney in the event of the death or incapacity of the borrower or the student on whose behalf the loan is borrowed by the parent borrower
• Amends Entrance Counseling requirements for Federal Loans:
• Provide information during entrance counseling that describes the loan discharge rules in the case of death of disability, and the possibility that private loans may not be discharged upon death or disability
• Provide information with respect to creating a durable power of attorney and its benefits and uses

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).

The low tolerance for exercise that is a common complaint after traumatic brain injury is typically justified by motor impairment or secondary physical injury. However, a recent study has shown that the low tolerance may also be related to cardiac fitness.

The study measured the heart rate—at rest and after exercise—of 12 boys who had survived a severe traumatic brain injury. They found that, as compared to healthy controls, the TBI survivors had significantly higher heart rates at rest and after exercise. Although the nature of brain injury varied between the boys, it was suggested that diffuse axonal injury could contribute to impairment of the autonomic nervous system.

Additionally, prolonged bed rest and a sedentary lifestyle may contribute to the difference in heart rates. The authors of the study propose that it may be a combination of both, and that clinicians and rehabilitation professional should take the potential for lowered fitness into consideration when creating a treatment plan.

Katz-Leurer M, Rotem H, Keren O, & Meyer S. Heart rate and heart rate variability at rest and during exercise in boys who suffered a severe traumatic brain injury and typically-developed controls. Brain Injury. (February 2010).

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).

Hyperventilation (with a mechanical ventilator or a manual bag valve mask, for instance) can be a life-saving treatment in the early stages of traumatic brain injury. Although hyperventilation can reduce intracranial pressure and reduce mortality rates, improper ventilation can lead to adverse outcomes.

A recent study considered the hyperventilation guidelines from the Brain Trauma Foundation and determined how much improper use could affect in-hospital mortality. They found the following:

1. Hypocarbia/hyperventiliation and hypercarbia/hypoventilation administered after traumatic brain injury increased the risk of in-hospital mortality.
2. Normocarbia administered after traumatic brain injury decreased the risk of in-hospital mortality.

Hypo- and hypercarbia (carbon dioxide pressure that is too low or too high) that occurs early in treatment (pre-hospital trauma care) can actually induce secondary brain damage. Normocarbia (normalized carbon dioxide pressure) should therefore be the goal in early trauma management. It was suggested that, rather than indiscriminate administration of hyperventilation, only patients with signs of brainstem herniation and elevated intracranial pressure should be treated.

Dumont DM, Visioni AJ, Rughani AI, et al. Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortality. Journal of Neurotrauma. (April 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.

Because of the tight spending climate this year, with regards to programs authorized through the TBI Act, BIAA and other TBI stakeholders have opted to advocate for a five year plan in achieving the full funding of $37 million to provide grants to all states including the District of Columbia, the American Indian Consortium and territories.

Increasing the program by $1 million this year will provide funding necessary to sustain the grants for the 15 states currently receiving funding along with the three additional states added this year and to ensure funding for four additional states. Steady increases over five years for this program will provide for each state including the District of Columbia and the American Indian Consortium and territories to sustain and expand state service delivery; and to expand the use of the grant funds to pay for such services as Information & Referral (I&R), service coordination and other necessary services and supports identified by the state.

BIAA has implemented the same strategy throughout its appropriations platform by asking for incremental increases towards a long-term funding goal, specifically for TBI Act programs:

• $10 million for the Centers for Disease Control and Prevention TBI Registries and Surveillance, Brain Injury Acute Care Guidelines, Prevention and National Public Education/Awareness (an increase of $4 million)
• $8 million for the Health Resources and Services Administration (HRSA) Federal TBI State Grant Program (an increase of $1 million)
• $4 million for the HRSA Federal TBI Protection & Advocacy (P&A) Systems Grant Program (an increase of $1 million)

With respect to the TBI Model Systems, BIAA is advocating for an additional $1.5 for a total of $11 million in FY 2011, in order to add one new Collaborative Research Project. This moderate increase would go towards the five year goal of $19 million as well as “line-item” status within the broader NIDRR budget.

On January 29, 2010, BIAA and other stakeholders presented appropriations requests to the Congressional Brain Injury Task Force, who adopted the plan and is currently garnering support through its membership. BIAA also has met with both House and Senate Appropriations Committee Staff to advocate for these program funding increases.

Look for grassroots action alerts in the coming weeks as the appropriations process moves forward.

The House of Representatives is set to vote on the Senate health care reform bill at the end of this week. If the measure fails, the hope of health care reform will likely vanish for this year and maybe even for years to come.

Even though the House and Senate have both passed their versions of health care reform, the only way forward for the bill is for the House to approve the Senate version.

Your voice matters now more than ever. Call TOLL FREE 1-888-876-6242, if you don’t know who your representative is, click here.

Tell your representative that you are a constituent that is concerned about health care reform. Specifically, people that have sustained brain injuries need health care reform because:

• Millions with health insurance are now at the mercy of insurance companies that charge premiums beyond affordability. The legislation would limit these increases.
• Many with insurance find that it won’t cover them when they get sick – even after they have paid premiums for years. The legislation will ban denials based on pre-existing conditions in children and adults.
• Patients who reach their lifetime insurance cap after a catastrophic injury or illness will be able to continue treatment in order to regain functionality and have a better chance of returning to work or school. The bill will eliminate lifetime insurance limits.

AND…

Investing money now will save the government millions of dollars later when the private insurance companies are required to take responsibility for the premiums they collect instead of turning individuals facing catastrophic injury or illness away to rely on public plans and ultimately, the American taxpayers.

Some representatives in the House are debating on whether to vote for or against the bill. Regardless of how they voted in the past, many are still waying their options. This measure is vital to the brain injury community, and we need your help to ensure that people with brain injury gain access to the care that they need and deserve! CALL NOW!

On March 21, 2010 the House of Representatives passed a historic health care overhaul package that marks one of the biggest victories in the history of the Brain Injury Association and for people affected by brain injury across the country.  BIAA advocated tirelessly for more than a year to ensure that people with brain injury gain access to the care that they need.  Specifically, the measure:

Coverage

• Prohibits private health insurance exclusions for pre-existing conditions.
• Eliminates annual and lifetime caps in private insurance policies.
• Restricts the consideration of health status in setting premiums.

Benefits

• Ensures that minimum covered benefits include products and services that enable people with disabilities to maintain and improve function, such as rehabilitation and habilitation services and devices. BIAA, supported by our Business and Professional Council and assisted by Powers, Pyles, Sutter & Verville, PC was the driving force in ensuring that rehabilitation was listed as a minimum benefit in this bill.  Originally, when the bill was made public, rehabilitation was not listed as a minimum benefit.

Long Term Services and Supports

• The Community Living Assistance Services and Supports (CLASS) Act creates a national long term services insurance program which assists eligible individuals and their families to meet long term needs with a cash benefit and without forcing them into poverty to receive Medicaid benefits.
• The Community First Choice Option helps to eliminate the institutional bias by encouraging states to cover personal attendant services under the state’s optional service plan instead of through the waiver system by offering a 6% increase in the federal share of Medicaid for these services.

It is also important to note that, as part of the debate, Congressman Bill Pascrell, Jr., co-chairman of the Congressional Brain Injury Task Force submitted a statement for the record detailing his understanding of the intent of the bill with regards to coverage of the treatment continuum for people with brain injury.  BIAA thanks him for his hard work and dedication to this important issue.

Along with passing the Senate bill, House Democrats also approved a reconciliation bill that reflects negotiations reached by congressional Democrats and the White House to modify the version earlier passed by the Senate.  This would be a “fix” that would eliminate the special deals given to certain states in return for their votes as the bill was passed by the Senate in December.  On Thursday, March 25, 2010, both the Senate and the House had voted in favor of passing the corrections bill completing the package.

BIAA would like to recognize the grassroots advocates that have truly made a difference in advocating for this historic legislation.  Thank you to everyone that invested so much of their time to push this forward!

Hearing loss in head injury poses a difficult problem—patients are sometimes unaware of their hearing problems because of cognitive impairment, and others may mistake their hearing loss as a memory or communication problem. It has long been known that hearing loss is common in head injury, and yet it is not always properly diagnosed.

Direct damage can occur to the middle and inner ear, or by tearing the neuronal pathways to the auditory areas of the brain. Secondary damage can occur from bleeding and pressure, or from diffuse axonal injury. A recent study of 290 head injury patients was conducted in order to confirm the prevalence and type of hearing loss found after head injury. Patients received a broad range of audiological assessments and the results confirmed that about 30% of the patients suffered from hearing loss. In most patients, the hearing loss was mild.

Even mild hearing loss can be potentially frustrating, not only for the patient but also for family members and rehabilitation specialists. In addition, proper rehabilitation and recovery can be delayed if the hearing loss is mistaken for cognitive impairment. With the relatively high prevalence of hearing loss in head injury confirmed in this study, clinicians should consider adding hearing tests to their battery of assessments for head injury.

Munjal SK, Panda NK, & Pathak A. Audiological deficits after closed head injury. The Journal of Trauma: Injury, Infection, and Critical Care. (January 2010).