It has been considered unlikely that a person in a vegetative state will regain consciousness beyond 12 months after a traumatic brain injury or 3 months after an anoxic or hemorrhagic injury.

However, ongoing improvements in both research methodology and medical intervention may be changing this way of thinking. A recent study of long-term vegetative state patients showed that 20% recovered responsiveness after 12 months, and 12% of those further progressed to regain consciousness. This recovery was associated strongly with younger age and occurred more often in traumatic brain injury, rather than anoxic or hemorrhagic.

Unfortunately, although responsiveness and consciousness can be recovered in some cases of vegetative state, it is also associated with severe functional impairments. Still, that the recovery rates were unexpectedly high in this study is an issue with ethical implications that should be addressed by medical and legal professionals.

Estraneo A, Moretta P, Loreto V, et al. Late recovery after traumatic, anoxic, or hemorrhagic long-lasting vegetative state. Neurology. (July 2010).

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

Among the multiple skills required to drive safely is the ability to visually scan one’s surroundings in order to adapt and respond to unexpected situations. In a study that compared traumatic brain injury patient to controls, subjects were connected to an eye-tracking device that mapped their visual field while completing a driving simulation.

The study found that people with traumatic brain injuries did not explore as many visual areas as the controls. Additionally, these deficits were associated with reduced scores on neuropsychological tests of attention. The study therefore provided an excellent model of how cognitive impairment translates to practical life. When making a decision to return to driving after a traumatic brain injury, neuropsychological tests of attention may be a useful tool.

Milleville-Pennel I, Pothier J, Hoc J-M, & Mathe J-F. Consequences of cognitive impairments following traumatic brain injury: Pilot study on visual exploration while driving. Brain Injury. (April 2010).

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
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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.
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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
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It is estimated that nearly one-quarter of deployed service members have sustained a traumatic brain injury, with mild brain injury being the most diagnosed severity. A short screening assessment that is given to service members after deployment has been used to identify the presence of mild traumatic brain injury, and has helped to identify many injured individuals. However, it has not been effective at singling out symptoms from brain injury when there is a potential for post-traumatic stress, pre-existing psychological conditions such as depression, or other co-morbid symptoms such as insomnia or pain. And this has become a challenge for military researchers and clinicians.

The challenges of screening for mild traumatic brain injury in the military are similar to the challenges found in the civilian population. Dr. Grant Iverson, a member of the Defense Health Board, recently recommended some changes to the military screening assessment. Some of his recommendations are also applicable to the civilian population.

For example, loss of consciousness is impossible to verify or quantify unless there was a witness to the event. Another screening item that asks whether an individual was “dazed or confused,” is problematic because it fails to determine if the confusion came from a concussion, stress, or other physical injury.

With many millions of dollars currently being spent on military-related traumatic brain injury research, it would be wise for civilian researchers, clinicians, and other professionals to follow and adapt to any updates in military screening and diagnostic practices.

Iverson GL. Clinical and methodological challenges with assessing mild traumatic brain injury in the military. Journal of Head Trauma Rehabilitation. (April 2010).

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).

Approximately the size and shape of a big egg, the thalamus is located deep and somewhat center in the brain. Thick projections of white matter connect the thalamus to other areas of the brain, which is why the thalamus to often referred to as a “relay system” of the brain, or in simpler terms, “Grand Central Station.”

Therefore, when the thalamus or its many connections are damaged through direct injury or diffuse axonal injury (where the white matter tracts are stretched or severed), it may be concluded that the connected areas of the brain are also affected. In other words, if Grand Central Station is down, so are its incoming and outgoing destinations. Damage to the thalamus or its connections can result in widespread functional impairment.

The frontal lobe is heavily connected to the thalamus. It is also associated with cognitive abilities such as memory or executive functioning. In cases of traumatic brain injury, however, the relationship between damage to the white matter connections from the frontal lobe and cognitive impairment has generally been weak.

Medical researchers from Chicago recently hypothesized that damage to these incoming and outgoing connections could lead to cognitive impairment. They used diffusion tensor imaging to verify that lesions in projections into the thalamus were indeed significantly associated with cognitive impairment—the greater the lesions, the greater the impairment. This research provides further support that cognitive impairment related to the frontal lobe need not have originated from direct frontal lobe damage.

Little DM, Kraus MF, Joseph J, et al. Thalamic integrity underlies executive dysfunction in traumatic brain injury. Neurology. (February 2010).

Even when the head is not in direct contact with an electrical power source, head injuries can occur by means of an electrical surge to the peripheral nervous system (from contact to an extremity such as arm or leg). Electrical injury survivors often show mental deficits and slowed motor skills as a result of the secondary head injury.

Although the effect of electrical injury on cognitive dysfunction has been well established by research, studies that attempt to pinpoint the specific changes in the brain have been few. In a recent study by medical researchers in Chicago, electrical injury survivors (who did not experience direct electrical contact to the head) performed cognitive and sensorimotor tasks while being assessed for brain activation using functional MRI (fMRI).

When the electrical injury survivors performed these tasks, the fMRI images of their brain showed abnormal activation as compared to healthy participants. The study therefore provided the first evidence of functional and physical changes in the brain corresponding to cognitive and sensorimotor deficits after electrical injury.

Ramati A, Pliskin NH, Keedy S, et al. Alteration in functional brain systems after electrical injury. Journal of Neurotrauma. (October 2009).

As part of the Coalition for Regenerative Stem Cell Medicine, BIAA enthusiastically endorses two important pieces of legislation aimed at advancing the therapeutic potential of newborn stem cells, the unique stem cells that can be collected immediately following birth from umbilical cord blood and the cord itself, as well as helping to advance the use of one’s own newborn stem cells in regenerative medicine.

HR 1718 – The “Family Cord Blood Banking Act” amends Section 213(d) of the IRS Code to add cord blood banking services as a qualified medical expense. This change will allow individuals and couples to use tax advantaged dollars to pay for umbilical cord blood banking services through flexible spending accounts (FSAs), health savings accounts (HSAs) health reimbursement arrangements (HRAs) or the medical expenses tax deduction.

The “Family Cord Blood Banking Act” will make cord blood banking more affordable for American families and provides incentives to ensure that this valuable health resource is never thrown away.

HR. 2107 – The “Cord Blood Education and Awareness Act of 2009″ will provide expectant mothers with straightforward, accurate and easy to understand information about the value of their child’s umbilical cord blood stem cells. It will offer a government stamp of approval on all available cord blood banking options and will give expectant parents confidence in the information they are reviewing.

This week House Democratic leaders vowed to pass a comprehensive overhaul of the nation’s health care system before the Congressional recess in August. Speaker Nancy Pelosi, Majority Leader Steny Hoyer, and the chairmen of three committees with jurisdiction over this issue made the pledge following a morning meeting with President Obama. The President restated the importance of the effort as a necessary step for containing long-term budget deficits.

BIAA will continue to monitor any health care reform related progress. If you have not yet taken action and emailed your Senators and Representatives regarding the brain injury guiding principles, you may still do so by clicking the following link: http://capwiz.com/