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).

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).

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).

A health care insurance plan may not deny coverage for medical or rehabilitation treatment for an acquired brain injury (ABI) at a licensed facility at which appropriate services may be provided, including, but not limited to, a hospital; an acute rehabilitation hospital; a long-term acute care hospital (LTACH); a congregate living health facility; an adult residential facility or postacute residential transitional rehabilitation facility or home and community rehabilitation program accredited by the Commission on Accreditation of Rehabilitation Facilities as a specialty brain injury rehabilitation program, such as an interdisciplinary outpatient medical rehabilitation program, a brain injury program, or a residential rehabilitation program; a medical office; or another analogous facility at which the most appropriate level of services may be provided.

A health care insurance plan may not impose time, cost or other benefit limitations in provision of treatment of Acquired Brain Injury (ABI) that are different from benefit limitations for other major medical conditions.

Acquired brain injury treatment includes items or services provided from a continuum of accredited programs and treatment settings used to restore functional capacity, minimize limitations on physical and/or cognitive functioning, and prevent deterioration of functioning as a result of an illness, injury, disorder or other health condition. Treatment settings include a hospital; an acute rehabilitation hospital; a long-term acute care hospital (LTACH); a congregate living health facility; an adult residential facility or postacute residential transitional rehabilitation facility or home and community rehabilitation program accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) as a specialty brain injury rehabilitation program, such as an interdisciplinary outpatient medical rehabilitation program, a brain injury program, or a residential rehabilitation program; a medical office; or another analogous facility at which the most appropriate services may be provided.

An acquired brain injury is a catastrophic injury to the brain which occurs after birth that disrupts the normal function of the brain and can arise from an external force applied to the brain, stroke, heart attack, near-drowning, brain tumor, infectious disease, prolonged high temperature, decrease or loss of oxygen to the brain, metabolic disorders, surgery, or toxic exposure. Acquired brain injury can result in impairments in one or more areas such as cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor abilities; psycho-social behavior; psychological functions; physical functions; information processing; and speech.

The Brain Injury Association of California (BIACAL) is pleased to sponsor Senate Bill 253, The Brain Injury Access To Treatment Act. SB 253 will enable access to treatment for acquired brain injury across an established continuum of licensed treatment settings specifically designed to provide the most clinically effective and cost efficient specialized treatment for acquired brain injury and to ensure that acquired brain injury as a catastrophic health condition is treated on par with other major medical conditions which have no time limitations. Current rehabilitation provisions are time limited and are intended for orthopedic conditions, rather than neurologic injury. Arbitrary time or cost limitations on neurological rehabilitation are inappropriate and passage of SB 253 will provide opportunities for recovery as observed in individuals like ABC reporter Bob Woodruff and Congresswoman Gabrielle Giffords, who have demonstrated what is possible with proper access to specialized treatment of appropriate timing, duration and intensity.

The Brain Injury Association of California would like to ask for your support by way of writing letters and attending the Senate Health Committee Hearing in Sacramento on Wednesday, January 11, 2012, in State Capitol Room 4203 at 1:30 pm.

Please address letters of support to Senator Michael Rubio at the following address:

Senator Michael Rubio

State Capitol, Room 2066

Sacramento, CA 95814

These support letters are needed by Friday, December 30, 2011. To expedite the receipt of these letters, we ask that you either email or fax the letters to the attention of Mr. Martin Radosevich at martin.radosevich@sen.ca.gov or fax to Mr. Radosevich’s attention at (916) 327-5989. We also request that you send copies of all support letters to Paula Daoutis, Administrative Director of BIACAL via email to pdaoutis@biacal.org or by fax to (661) 873-2508.

Sample support letters can be accessed from BIACAL’s website by clicking on the link to the left. Please edit as appropriate and all Hospitals, Rehab Facilities, Other Treating Facilities, and Organizations should submit letters of support on company letterhead. Individuals are encouraged to insert a paragraph that will highlight struggles to receive appropriate levels of rehabilitation due to the denials of the insurance carriers.

BIACAL wants to stress the importance and urgency of sending these letters of support and with the approaching Holidays, we ask that you send these support letters right away to avoid missing the opportunity to support this legislation.

Please direct any questions to Paula Daoutis at pdaoutis@biacal.org

Mild traumatic brain injury (mTBI) makes up approximately 80% of all TBI cases. It is associated with a range of physical, mood, and cognitive symptoms such as headaches, depression, and memory problems. While these symptoms usually dissipate within three months after injury, some patients experience long-term symptoms. In clinical and research settings, the long-term symptoms of mTBI is called post-concussion syndrome (PCS).

However, the syndrome can be difficult to diagnose. The International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders use different diagnostic criteria. The symptoms of PCS often overlap each other (eg, depression, insomnia, and headaches may all lead to fatigue or memory impairment). And, under the current guidelines, patients without a history of brain injury may be as likely to fit the criteria as patients with mTBI.

These difficulties in diagnosis call for the development of less ambiguous criteria that take the most recent mTBI research under consideration. The current definitions of PCS may otherwise lead to misdiagnosis and missed treatment opportunities.

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).

Neonatal encephalopathy, or disturbed neurological functioning in a term infant, affects between 1 and 7 babies out of 1000 live births. It causes permanent disability in terms of cognitive and motor development in 15-20% of affected newborns. An MRI scan can help predict outcomes for infants with brain injury, with increasing levels of accuracy.

A recent study found that:

• The presence of brainstem lesions is predictive of mortality. Close to half of infants with these lesions die within the first three years of life.
• Mesencephalic and pontine lesions, alone or in combination, are also associated with high rates of mortality.
• The severity of damage to basal ganglia and thalamus (BGT) is predictive of motor impairment, with 89% accuracy.
• BGT is closely associated with cerebral palsy (CP)—the worse the BGT injury, the higher the risk of CP. Infants with severe BGT injuries have near universal rates of CP.
• Damage to the white matter, cortex, and brainstem is not associated with motor impairment.

Further study of these associations shows promise in improving outcomes.

Inder, TE. Predicting outcomes after perinatal brain injury. Nature. (October 2011).

Organization, attention, and strategic planning are frequently problematic after traumatic brain injury. These issues reflect failures of executive function, a set of processes necessary for goal-directed behavior. Lack of executive control can complicate the recovery process for people with a traumatic brain injury; therefore, executive function should be specifically targeted for rehabilitation.

A recent study found that people with a traumatic brain injury who received goals training showed improvement in completing complex tasks. The training appeared especially strong on the protection of working memory from distractions, possibly due to the effectiveness of the mindfulness-based attention regulation techniques.

Participants reported that they were able to maintain the “Stop-Relax-Refocus” exercises in daily life. Other elements of training included goal selection, breaking down tasks into smaller subtasks, establishing a timeline, execution, error correction and adjustments, and progress review.

These findings are supported by recent research on attention and problem solving training for people with a traumatic brain injury who show improvements on functional measures and caregiver ratings.

Novakovic-Agopian, T, Chen, AJW, Rome, S, et al. Rehabilitation of executive functioning with training in attention regulation applied to individually defined goals: A pilot study bridging theory, assessment, and treatment. Journal of Head Trauma Rehabilitation. (October 2011).

With improvements in medicine, more patients survive severe traumatic brain injuries, even in cases where the brain injury led to a minimally conscious or vegetative state. An increase in survival means that there is a chance that the brain injury patient can emerge from unconsciousness.  Subsequently, this has led to an increase in opportunities to observe the effects of such injuries.

One of the effects noted in patients who emerge from a brain injury-related minimally conscious or vegetative state is a unique speech disturbance known as mixed speech apraxia and dysarthria syndrome.

Patients with this speech disturbance can typically comprehend verbally, read silently, and write words using a word board or talking aid implement. However, these patients suffer from facio-oral apraxia— a diminished ability to purposefully control the muscles in their faces and mouths. They also typically have difficulty swallowing (dysphagia), other motor control issues, and cognitive and emotional impairments.

Researchers found that brain injury patients with this speech disturbance showed damage to the arcuate fasciculus (AF) and to fibers in the white matter related to dysarthria. Additionally, diffuse damage to the cingulum, fornix, white matter, and basal ganglia may be related.

Toyoshima, Y, Asano, Y, Shinoda, J, et al. A speech expression disorder in patients with severe diffuse brain injury who emerged from a vegetative or minimally conscious state. Brain Injury. (November 2011).