Traumatic brain injury, head injury, and concussion are all terms that can be used interchangeably when describing the now accepted clinical diagnosis “mild traumatic brain injury.” The clinical definition of mild traumatic brain injury has only recently been accepted, and clinicians and researchers still seem to struggle with the term. Understandably, the public is now very confused.

Researchers who polled random people from the community found that the public incorrectly evaluated 20% of basic statements made about traumatic brain injury. In addition, when different terminology was used, the public attributed more a negative association to “brain injury” than to “head injury.” Half of the participants who had experienced a concussion did not acknowledge to having had a brain or head injury.

One reason for this confusion is inconsistent information from the Internet. When a person experiences a concussion (mild traumatic brain injury), a decision has to be made whether or not to pursue medical attention. Confusion, inaccurate knowledge, and inconsistent information can mean that many people who require medical attention could be slipping through the cracks.

McKinlay A, Bishop A, & McLellan T. Public knowledge of “concussion” and the different terminology used to communicate about mild traumatic brain injury (MTBI). Brain Injury. (July 2011).

A recent study was conducted to determine the age at which people are at greatest risk for a fatal head injury after a car accident. They found that an increase in mortality occurred in people over the age of 60. Despite an association with decreased crash severity, and no difference in Injury Severity Score as compared to people under the age of 60, people over the age of 60 were more likely to have had higher crash speeds, more frequent rollover accidents, and increased alcohol involvement.

In addition, mortality after head injury in people over the age of 60 was related to contact with the airbag, door, or seat of the car. People under the age of 60 were more likely to have sustained a head injury from contact to the roof of the car. This suggests that future vehicle design could consider safety features that address the higher risks for older adults.

Richmond R, Aldaghlas TA, Burke C, et al. Age: Is it all in the head? Factors influencing mortality in elderly patients with head injuries. The Journal of Trauma, Injury, Infection, and Critical Care. (March 2011).

During the August recess, as a follow up to a meeting held on June 15, 2010, representatives from HRSA and various TBI stakeholders held a teleconference to plan work on a long-term plan for the Federal TBI Program and also to discuss possible changes to the TBI Act come reauthorization in 2012.

HRSA, BIAA and the National Association of State Head Injury Administrators (NASHIA) have begun to assemble an advisory board to work on the long-term plan and to also manage and incorporate public comment and transparency. BIAA is encouraged by the partnership forged between TBI stakeholders and HRSA and is looking forward to elevating the Federal TBI Program within HRSA and to advocating for increased funding for the program by leveraging agency cooperation in program improvement and efficiency on Capitol Hill.

Head injury accounts for more than half of bicycle-related deaths and nearly half of bicycle-related hospital visits in children aged 5-14. Helmets can prevent these injuries, and yet a recent study has shown that more than half of children aged 5-14 do not always wear their helmets.

Changes in state legislation over the last 15 years have significantly increased the number of children who always wear a helmet. However, children who are older, live in lower income areas, or live in an area with no state-wide law are still less likely to wear a helmet while riding their bicycles.

Because of the substantial risk for bicycle-related head injuries in children, the task of communities and legislative leaders is to promote education and support for helmet use among children.

Dellinger AM, & Kresnow M. Bicycle helmet use among children in the United States: The effects of legislation, personal and household factors. Journal of Safety Research. (September 2010).

Dianna Bolen
A life can change dramatically in a flash and sometimes for the best. On September 16, 2004, I, Dianna Bolen, was on my way to a bike fest in Las Vegas, NV on my 1993 Harley Davidson Sportster with 3 other bikers. For some unknown reason, and not even the highway patrol knows why, I went off the freeway, flew 100 feet, went over a barb wire fence, and landed in the desert ground with my bike on top of me. This accident happened in Arizona where wearing a helmet is optional. I was SMART and was wearing mine. I was airlifted to a Phoenix Hospital where I was taken immediately into surgery. While on the operating table the doctors called Code Blue three times. They had to put a titanium rod into my left leg and my ankle is held together by screws. As a result of my TBI, I was in a coma for 2 months. After awakening from my “sleep”, I realized that my memory disappeared, all the way till “who knows when”. After being released, I also realized that I lost my smell and taste. Overall, after going through a lot, I ended up in Fresno. I got hooked up to a TBI support group in Fresno. At the time I was not looking for anyone – just a support group. At a meeting, we were told about the first annual Walk For Thought that was going to be held in Bakersfield in March of 2008. The support group agreed to meet at the center in Fresno and carpool to Bakersfield. I ended up in the car of a funny man, named Michael Taylor, who would end up being my fiancé.

Michael Taylor
On Sunday, April 8, 1989, my day started off as normal as a day can start off for a Sheriff. I was advised of a burglar alarm that was going off at a market in Madera. I proceeded to the market when I was involved in my accident. A Bronco towing a boat, traveling 55 mph, smashed into my patrol car on the driver’s side. I was flown to a hospital in Fresno where I was in a coma for 10 days. After awakening from my coma, I was released to my mom’s care. I was then enrolled into Neurological Retraining Center (N.R.C.). I was with N.R.C. until December 1989. Then I started putting my life together again. I started attending CORC meeting in Fresno. I was very active with CORC. Then February, 2008 I attended the 1st Annual Walk For Thought in Bakersfield. Since I had a good car and was able to drive with no problems, I volunteered to drive down to the Walk with 4 others in my car. That was the day I met Dianna Bolen and her service dog, Sierra. Little did I know, she was the answer to a prayer I made to God shortly after my new life with TBI started.

Now Dianna and Sierra are a big part of my life. All the way down and all the way back home, I kept looking in my rear view mirror at her, (and she has said to me that she never knew I was looking at her). After seeing each other for a few weeks, I volunteered my service (along with another TBI friend) and we built a redwood deck in the back of her condo. From that day on, we have never been separated. After a few months, I got down on my knees and proposed to her. She has told me several times that if Sierra didn’t approve of me, she would have to decline. Needless to say, Sierra is just as much a part of my life than she is to Dianna.

Michael & Dianna
We feel that if it wasn’t for the Walk For Thought in Bakersfield, we would have never gotten to know each other. We help each other to overcome the many obstacles we have to deal with since our accidents. We thank the California Brain Injury Association for organizing that awesome Walk that put us together and we will always have a special place in our “head” for that great Walk!

Concussions, whether from an accident, sporting event, or combat, can lead to permanent loss of higher level mental processes. Scientists have debated for centuries whether concussions involve structural damage to brain tissue or whether physiological changes that merely impair the way brain cells function, explain this loss. Now, for the first time, researchers at Albert Einstein College of Medicine of Yeshiva University have linked areas of brain injury to specific altered mental processes caused by concussions.

The research, described in the August 26 edition of Radiology, provides compelling evidence that concussions involve brain damage. The findings suggest that diffusion tensor imaging (DTI), the brain scanning method used by the Einstein scientists, could help in diagnosing concussions and in assessing the effectiveness of treatments.

“DTI has been used to look at other brain disorders, but this is the first study to focus on concussions,” said Michael Lipton, M.D., Ph.D., associate director of the Gruss Magnetic Resonance Research Center (MRRC) and associate professor of radiology, of psychiatry and behavioral sciences, and of neuroscience at Einstein and lead author of the study. “It proved to be a powerful tool for detecting the subtle brain damage that we found to be associated with concussions.”

Each year, more than one million Americans sustain a concussion (technically referred to as mild traumatic brain injury). Concussions in adults result mainly from motor vehicle accidents or falls. While most people recover from concussions with no lasting ill effects, as many as 30 percent suffer permanent impairment — undergoing a personality change or being unable to plan an event. A 2003 federal study called concussions “a serious public health problem” that costs the U.S. an estimated $80 billion a year.

At present, diagnosis of concussions is based primarily on the patient’s accident history and on clinical examinations that check for common concussion symptoms including headache, dizziness and behavioral abnormalities. There is no way of knowing from these exams who will suffer the most severe consequences and who will recover quickly. The results of the Einstein study indicate DTI scanning could provide a more objective way to diagnose concussions, determine whether brain injury has actually occurred following trauma, and possibly predict the lasting loss of executive function. Executive function refers to the ability to make decisions, organize, set priorities and manage time.

The Einstein research involved 20 people known to have suffered concussions (18 from motor vehicle accidents and two from falls) and 20 healthy control subjects. The patients were recruited from one hospital emergency room; two of them had lost consciousness, but only for a few minutes. Both the patients and control subjects underwent conventional brain imaging with magnetic resonance (MR) and computed tomography (CT) scanning, plus a battery of neuropsychological tests to assess executive function, which is often impaired after a concussion. All concussion patients underwent brain imaging and testing within two weeks of their accidents.

Experienced reviewers who evaluated the conventional MR and CT images of patients and controls found no abnormalities in either group. However, the neuropsychological results showed that the patients performed significantly worse than the controls on tests of executive function.

Patients and controls also underwent diffusion tensor imaging (DTI), a recently developed MRI-based imaging technique that can detect subtle changes in the brain by measuring the diffusion of water in the brain’s white matter. DTI revealed abnormal brain regions in 15 of the concussion patients, while no abnormal regions were found in controls. Most importantly, the presence of major areas of structural damage in concussion patients (as shown by large alterations in normal water diffusion using DTI) predicted low scores on their executive-function tests. These damaged areas were located mainly in the brain’s prefrontal cortex, which is essential for normal executive function and is susceptible to injury in concussion.

Dr. Lipton notes that use of DTI could prompt doctors to begin treatment early, when it’s likely to be most useful. “The problems in functioning caused by concussions often don’t become evident until weeks or months after the injury, suggesting that the brain pathology may actually expand over time,” he notes. “By detecting brain injury early with DTI and then initiating cognitive rehabilitation therapies for those patients, we may be able to limit the effects of concussions.”

“We are really excited by these findings,” indicates Craig Branch, Ph.D., a co-author of the study and director of the Gruss MRRC. “For the first time we appear to be able to identify the subtle pathology sometimes caused by concussion, providing researchers a ‘pathology target’ for the development of therapies to reduce or eliminate the damage identified by this novel imaging method.” Dr. Lipton adds that DTI could help in evaluating the effectiveness of existing therapies for concussion.

As reported in a previous edition of Policy Corner, the Senate version of this year’s National Defense Authorization bill includes an amendment that authorizes the Secretary of Defense to carry out a pilot program for providing cognitive rehabilitation therapy services under TRICARE.

As the House and Senate meet to debate the differences in the two versions in order to craft a final bill, BIAA has increased awareness among House members serving on the Armed Services Committee of the amendment and its importance to returning service members sufferring from TBI.

This week, Congressman Bill Pascrell, Jr. and Congressman Todd Platts, co-chairs of the Congressional Brain Injury Task Force, sent a letter to members of both the House and Senate Armed Services Committee members urging their support in preserving this amendment in the final bill. A copy of the letter can be viewed on our web site, or by clicking the link below:

http://www.biausa.org/elements/policy/cognitive_rehabilitation_ndaa_letter.pdf

This week the Senate finance committee wrapped up debate on its version of a health care reform package. The committee now has finished debating the more than one hundred amendments offered to the bill. A final vote is possible next week, although the finance committee cautiously waits to hear the cost estimate of the measure from the congressional budget office.

BIAA will continue to monitor the situation as the legislation progresses.

This week, the House Committee on Energy and Commerce Subcommittee on Health held its first hearing of the year focused on the critical importance of Medicaid as a source of health care, including long-term care, for Americans with disabilities.

A good deal of the hearing focused on Bush Administration proposed regulations which effectively hold states back from making progress towards transitioning individuals with disabilities back into their communities.

For more information on testimony at this hearing, please visit http://energycommerce.house.gov/cmte_mtgs/110-he-hrg.011608.MedicaidDisabilities.shtml.

SENATE PASSES TBI ACT REAUTHORIZATION BILL

Earlier today (Tuesday, December 11, 2007), the Senate passed by voice vote S. 793, legislation to reauthorize the TBI Act. The reauthorization includes provisions to continue and hopefully expand TBI Act programs, such as the HRSA State Grant and CDC surveillance programs.

This is a big victory, as the authorization for TBI Act programs officially lapsed in 2005 and advocacy efforts to renew this authority have been vigorous. Stay tuned to BIAA for further information and analysis as developments progress.

APPROPRIATIONS HANG-UP

Unfortunately, as of press time on Tuesday, December 11, 2007, Congressional leadership had still not made a final decision regarding floor consideration of a “split-the-difference” omnibus appropriations bill, and thus, a conference report for this bill has not been filed. Stay tuned to BIAA for the latest updates on this situation.

DEFENSE AUTHORIZATION BILL – INCLUDING TBI CARE PROVISIONS – SET FOR PASSAGE

Congress is expected to pass the National Defense Authorization Act for Fiscal Year 2008 – including key wounded warrior provisions related to TBI care – this week. The House of Representatives is expected to adopt the conference report tomorrow (Wednesday) or Thursday, followed by predicted swift passage in the Senate.

According to CQ Today (Dec. 11, 2007), “Several dozen House members might vote against the bill because of its war authorization, but they are likely to prove only a bump in an otherwise smooth road to adoption. And despite the conferees’ differences with the White House on a wide range of issues including military pay and overseeing contractors, they have sufficiently modified provisions to avert a veto threatened by the administration, members and aides predict.”

BIAA has lobbied actively this year on many of the TBI care provisions contained in the final version of the bill, and grassroots activity on the part of TBI advocates helped ensure that these TBI provisions were included in the conference report.

Below is a summary of the key TBI provisions included in the bill:

Major TBI Provisions in the National Defense Authorization Act for Fiscal Year 2008 (H.R. 1585)

? Overlap of DoD/VA benefits: Allows severely ill or injured service members and veterans to access their health care – including TBI care – based on their medical condition, rather than on their status as active duty or medically retired. For example, if implemented, this overlap of benefits would allow medically retired veterans to access TBI care at private/civilian facilities that are eligible TRICARE providers. Currently, this access is limited to service members who have active duty status. Note: Some civilian TRICARE facilities provide cognitive rehabilitation therapy. This provisions sunsets in 2012. (Sec. 1631)

? DoD Comprehensive Plan To Address TBI: Requires DoD to submit within 180 days of enactment, in consultation with the VA, a comprehensive plan for programs and activities of the Department of Defense to prevent, diagnose, mitigate, treat, research and otherwise respond to TBI and PTSD. Plans are directed to include provisions for making injured service members aware of options for different treatments. (Sec. 1618)

o This plan is required to include a proposal for the development and deployment of evidence-based means of assessing traumatic brain injury, PTSD, and other mental health conditions in members of the Armed Forces, including a system of pre-deployment and post-deployment screenings of cognitive ability in members for the detection of cognitive impairment. (Sec. 1618)

o This plan is also required to include a proposal on the development and deployment of an education and awareness training initiative designed to reduce the negative stigma associated with TBI and PTSD, and a plan for the provisions of education and outreach to families of members of the Armed Forces with TBI, PTSD, or other mental health conditions. (Sec. 1618)

? VA Individualized TBI Rehabilitation Plans/Use of Civilian Facilities for TBI Care: Requires the VA Secretary to develop an individualized plan for rehabilitation and reintegration into the community for each veteran or service member who receives inpatient or outpatient care at the VA for TBI (Sec. 1702).

o Note: Unfortunately, the final version of this defense authorization bill/conference report does NOT include the provision in the Senate version of the bill which would have required the Secretary of the VA to provide care in non-VA (civilian) facilities if the Secretary determines that the VA is unable to provide care at the frequency or duration prescribed in the individualized plan, for rehabilitation and reintegration, or if the Secretary determines it is optimal for the veteran to receive care in a non-VA facility.

o Similar – but weaker – language, was included, stating that, in implementing and carrying out the individualized plans, the Secretary of the VA “may provide hospital care and medical services through cooperative agreements with appropriate public or private entities that have established long-term neurobehavioral rehabilitation and recovery programs.” (Sec. 1703)

? Procedures for Referrals to VA and Civilian Health Care Services: Requires a comprehensive policy on improvements to care, management, and transition of recovering service members to “provide for uniform policies, procedures, and criteria among the military departments on the referral of recovering service members to the Department of Veterans Affairs and other private and public entities (including universities and rehabilitation hospitals, centers, and clinics) in order to secure the most appropriate care for recovering service members, which policies, procedures, and criteria shall take into account, but not be limited to, the medical needs of recovering service members and the geographic location of available necessary recovery care services.” (Sec. 1611)

? DoD TBI Center of Excellence: Requires the establishment of a Center of Excellence in the Prevention, Diagnosis, Mitigation, Treatment, and Rehabilitation of Traumatic Brain Injury, including mild, moderate, and severe TBI. The Secretary of Defense is directed to enter into partnerships, to the maximum extent practicable, with the VA, institutions of higher education, and other appropriate public and private entities, to further the research efforts of the centers. This DoD TBI Center of Excellence is responsible for implementing the DoD’s comprehensive plan to address TBI – as required by Sec. 1618 – once this plan is developed. (Sec. 1621)

? Collaboration Required in New VA TBI Research Efforts: Requires new VA TBI research efforts to collaborate with facilities that conduct research on rehabilitation for individuals with TBI and receive grants for such research from the National Institute on Disability and Rehabilitation Research of the Department of Education (for example, the TBI Model Systems of Care program). (Sec. 1704)

? National Academy of Sciences DoD/VA TBI Study: Requires DoD, in consultation with the VA, to contract with the National Academy of Sciences to study the physical and mental health – specifically including the neurological, psychiatric, and psychological effects of TBI – of members and former members of the Armed Forces who are deployed in OEF or OIF, and their families as a result of such deployment. Specifically, a comprehensive assessment is required – not later than three years after the date of legislative enactment – of “the full scope of the neurological, psychiatric, and psychological effects of traumatic brain injury on members of the Armed Forces, including the effects of such effects on the family members of such members and former members, and an assessment of the efficacy of current treatment approaches for traumatic brain injury in the United States and the efficacy of screenings and treatment approaches for traumatic brain injury within the Department of Defense and the Department of Veterans Affairs. (Sec. 1661)

? Comprehensive Long-Term TBI Rehabilitation Program in VA: Requires the Secretary of the VA to develop and carry out a comprehensive program of long-term care for post-acute traumatic brain injury rehabilitation that includes residential, community, and home-based components utilizing interdisciplinary treatment teams. This program is to be developed and located in Department of VA polytrauma rehabilitation centers. Eligibility is restricted to veterans diagnosed as suffering from “moderate to severe” traumatic brain injury (excludes mild) who are unable to manage routine activities of daily living without supervision or assistance, as determined by the Secretary. (Sec. 1702)

? Pilot Program on Assisted Living Services for Veterans with TBI: Requires the Secretary of the VA, in collaboration with the Defense and Veterans Brain Injury Center of the Department of Defense, to carry out a five-year pilot program to assess the effectiveness of providing assisted living services to eligible veterans with traumatic brain injury to enhance the rehabilitation, quality of life, and community integration of such veterans (Sec. 1705)

? Report on TBI Classfications: Requires the Secretary of Defense and the Secretary of Veterans Affairs to jointly submit a report – not later than 90 days after the date of legislative enactment – describing the changes undertaken within the Department of Defense and the Department of Veterans Affairs to ensure that traumatic brain injury victims receive a medical designation concomitant with their injury rather than a medical designation that assigns a generic classification (such as “organic psychiatric disorder.”) (Sec. 1664)

TBI Registry in VA: Requires the Secretary of the VA to establish and maintain a registry of names of each individual who: 1) served as a member of the Armed Forces in Operation Enduring Freedom or Operation Iraqi Freedom; 2) exhibits symptoms association with TBI; 3) applies for care and services from the Department of Veterans Affairs or files a claim for compensation for disability associated with such service; and 4) grants permission to the Secretary to include such information in the registry. (Sec. 1704)

Source: http://www.calbia.org/