A common problem of more severe traumatic brain injuries (TBI) is a complete denial of symptoms. This can significantly complicate treatment, as people with a TBI may be unwilling to accept therapies or interventions for problems they do not believe they have.

A recent case study described a TBI patient who exhibited combativeness, significant cognitive and motor impairments, as well as reduced awareness of his symptoms. He would not comply with treatment, and his recovery was suffering. The treatment team decided to use deception. The patient, who very much wanted to be able to work and contribute to his family, was told that he had been “hired” at the rehabilitation center. His specific job responsibilities were to participate in various therapies, take prescribed medications, and maintain behavioral standards. The patient accepted therapy and improved to the point that he could be transitioned to a day care facility.

Although the trust and autonomy are important ethical considerations between provider and patient, deception may be considered acceptable in extremely special circumstances, such as this case study. Other examples of deception under special circumstance are valid clinical situations such as paradoxical therapy or the use of placebos. While it should perhaps be a last resort, deception can have some efficacy in managing patients with TBI.

Matthes J & Caples H. Ethical issues in using deception to facilitate rehabilitation for a patient with severe traumatic brain injury. Journal of Head Trauma Rehabilitation. (January 2012).

This week, House Budget Chairman Paul Ryan released a fiscal 2011 budget allocation that would cap spending at $1.055 trillion and slice $32 billion from current government spending levels this year. As many of you know, fiscal year 2011 spending is currently running on FY2010 levels through March 4, 2011.

The allocation by Ryan represents a $58 billion reduction below President Obama’s proposed fiscal 2011 budget request of $478 billion for non-security programs. As defined by Republican leaders, non-security spending includes all discretionary spending not for defense, homeland security, veterans and military construction.

Programs that fall into this category, such as TBI Act programs and the TBI Model Systems are at risk for budget cuts and BIAA is committed to advocating in their favor. As Congress draws near the March 4, 2011 appropriations deadline, the grassroots community should be poised to take action when BIAA alerts are distributed.

After a brain injury, there is a serious concern for secondary damage caused by intracranial hypertension and pressure. This hypertension is usually monitored using surgical means, which can be invasive and dangerous when conditions are critical.

Recently, a study on severe pediatric brain injury found that the non-invasive Transcranial Doppler is as effective at detecting dangerous signs of intracranial hypertension as traditional surgical methods. Additionally, the Transcranial Doppler can be used within minutes of the injury, which may provide an opportunity to treat more quickly and avoid further damage.

Melo JRT, Di Rocco F, Blanot S, et al. Transcranial Doppler can predict intracranial hypertension in children with severe traumatic brain injuries. Child’s Nervous System. (January 2011).

Memory is a difficult concept to define. To remember something requires the complex processing of information such as time, place, emotions, or sensory input (sight, smell, sound, touch), in order have the ability to re-create that information at a later time. Scientists have long tried to define memory by using models to describe this process, but some of the most useful memory models have been derived from studies of impaired memory with brain injury patients.

One important theory of memory that has come (at least partially) from brain injury studies, is the model for explicit versus implicit memory. Explicit memory refers to the memories that we can explicitly remember taking part in. For instance, we may have a strong memory of attending a child’s graduation. We not only know intellectually that the child has graduated, we can pull up the specific emotions, sights, smells, sounds, time, and place that color that memory.

Implicit memory refers to a much more subtle process—one that is difficult to observe outside a psychology lab. Implicit memory implies that a person has encoded some information in his brain, but without consciously knowing how. The information has gotten in under the radar, in other words. For instance, a psychology lab can flash words very quickly in front of a subject—too quickly for the subject to even perceive—and the subject will be surprised to learn that he can correctly guess the word, even when he has no memory of even seeing it.

In the traumatic brain injury patient, depending on what part of the brain was injured, explicit memory can be impaired. Amnesia—either the loss of memories from the past or the lost ability to learn new information—can occur because of an impaired explicit memory system. Without a specific recollection of memory detail such as sight, sound, smell, emotion, time, or place, the patient has no context to help anchor a memory into reality.

Strangely enough, however, implicit memories are very often intact in brain injury patients. These patients can perform just as well as healthy people at the quickly flashing words experiment described above. The implication of this is that rehabilitation professionals (and family members) can use the intact implicit memory system to help get new information through to the brain injury patient. By repeating a piece of specific information over and over (ie, “The coffee cups are in the right cupboard.”), the patient may implicitly remember the information, even if he has no conscious memory of learning it.

Baddeley A. Human Memory, Theory and Practice. Psychology Press Ltd. (2002).

A high level quality of life is considered the ultimate goal in rehabilitation efforts for spinal cord injury patients. But, quality of life can be difficult to determine because of its subjective nature. A recent review of quality of life assessment tools found that the World Health Organization Quality of Life (WHOQOL-BREF) assessment was the most consistently promising tool for predicting quality of life in spinal cord patients.

The following questions are examples from the WHOQOL-BREF. Subjects answer on a scale of 1-5, with 1 being the most negative answer and 5 being the most positive answer.

1. How would you rate your quality of life?
2. How satisfied are you with your health?
3. To what extent do you feel that physical pain prevents you from doing what you need to do?
4. How much do you need any medical treatment to function in your daily life?
5. How much to you enjoy life?
6. To what extent do you feel your life to be meaningful?
7. How well are you able to concentrate?
8. Do you have enough energy for everyday life?
9. Are you able to accept your bodily appearance?
10. Have you enough money to meet your needs?
11. How available to you is the information you need in your day-to-day life?
12. To what extent do you have the opportunity for leisure activities?
13. How well are you able to get around?
14. How satisfied are you with your sleep?
15. How satisfied are you with your ability to perform your daily living activities?
16. How satisfied are you with your capacity for work?
17. How satisfied are you with yourself?
18. How satisfied are you with your personal relationships?
19. How satisfied are you with your access to health services?
20. How often do you have negative feelings such as blue mood, despair, anxiety, depression?

Hill MR, Noonan VK, Sakakibara, et al. Quality of life instruments and definitions in individuals with spinal cord injury: A systematic review. Spinal Cord. (June 2010).

Coping with the negative effects of traumatic brain injury is an important aspect of a person’s ability to rehabilitate, as well as adapt to a changed lifestyle. There are different coping strategies that a patient can use. One is to actively confront a challenge by gathering information, cultivating skills, or changing a situation in order to adapt. Another, more passive, coping strategy is to regulate one’s emotional response to a challenge by suppressing negative thinking, distracting one’s thoughts, or learning to accept a negative situation.

A recent study found that people who used a passive coping strategy had a greater number of subjective complaints, and were less likely to seek social support to help with their challenges. People whose injury had occurred a long time before were more likely to use a passive coping strategy, suggesting that, over time, people may stop actively trying to change their situation and instead enter a more passive, emotion-based frame of mind.

Additionally, people with higher education more readily used active coping strategies in order to directly deal with their challenges, and people with lower levels of education tended to use passive coping strategies. Since passive coping strategies tend not to be as effective as active coping strategies, rehabilitation professionals might consider guiding their patients towards more active participation.

Wolters G, Stapert S, Brands I, & van Heugten C. Coping following acquired brain injury: Predictors and correlates. Journal of Head Trauma Rehabilitation. (July 2010).

One of the more disturbing results of traumatic brain injury is that secondary damage can often occur after the initial trauma. Such secondary damage can lower oxygen levels in the brain—making tissue oxygenation through hyperbaric oxygen therapy a potentially promising therapy for traumatic brain injury.

A recent animal study confirmed that a single treatment of hyperbaric oxygen therapy does indeed reduce secondary brain damage after injury. However, the benefit occurred only if the single treatment was administered within 6 hours of the initial injury. The benefit was considerably lessened if therapy was administered 12 hours after injury, and no benefit was seen if therapy was delayed even longer.

Although the best time for a single treatment of hyperbaric oxygen treatment was within 6 hours after injury, multiple treatments applied later (up to 2 days after injury) could also reduce injury and recover function. The most significant benefit, however, was a single treatment within 6 hours of injury.

Hyperbaric oxygen therapy is therefore a potentially useful treatment for traumatic brain injury, but only within limited time frames.

Wang G-H, Zhang X-G, Jiang Z-L, et al. Neuroprotective effects of hyperbaric oxygen treatment of traumatic brain injury of rat. Journal of Neurotrauma. (June 2010).

We are now beginning to understand that traumatic brain injury may often include damage to the pituitary gland—a small, pea-sized area of the brain that can easily be sheared or obstructed by the bony cradle it sits in. The result of pituitary gland damage can be hypopituitarism (a condition in which the pituitary gland doesn’t produce sufficient amount of hormones), more specifically, a growth hormone deficiency.

Clinical studies are now underway to determine the various effects of growth hormone replacement therapy on traumatic brain injury. One such study has found that growth hormone replacement therapy for a year can reverse some of the cognitive deficits common to TBI. As compared to the placebo group, patients who received growth hormone replacement therapy showed improvements in memory, information processing speed, motor speed, and executive functioning tests.

Patients did not report negative side effects of growth hormone replacement therapy, even after a year of continued therapy. It may therefore be a viable addition to rehabilitation efforts in the future.

High WM, Briones-Galang M, Clark JA, et al. Effect of growth hormone replacement therapy on cognition after traumatic brain injury. Journal of Neurotrauma. (June 2010).

It is common perception that alcohol intoxication lowers the Glasgow Coma Scale (GCS) rating in cases of traumatic brain injury, and is therefore not a reliable rating for intoxicated patients.

In a large study of nearly 500 TBI patients, however, no association was found between alcohol intoxication and GCS score. Only when controlling for injury severity did very high intoxication levels and positive intracranial CT scans correlate with lower GCS scores.

The implication of this research is that GCS scores should be taken at face value when evaluating a patient’s injury severity. The perception that GCS scores are lowered by alcohol intoxication is very likely a false one, and may hinder critical and acute care management decisions for TBI patients.

Lange RT, Iverson GL, Brunacher JR, & Franzen MD. Effect of blood alcohol level on Glasgow Coma Scale scores following traumatic brain injury. Brain Injury. (July 2010).

It is commonly thought that children show rapid improvement after a traumatic brain injury because of either increased neuroplasticity or the ability for young brains to re-organize after injury. However, research that supports this notion has often been limited to cognitive and motor skills.

A recent study took a broader view of recovery after pediatric TBI. They found that when TBI occurs in younger (under age 4) preschoolers, they have social impairments that persist until at least age 8. These impairments are greater than if the TBI occurred between ages 4-6, implying that a critical time for social development is being disrupted in the younger preschoolers.

The long-term implications of this research have yet to be fully investigated, but parents and clinicians should be aware that children who suffer from TBI as a younger preschooler may have poorer social outcomes in later years.

Sonnenberg LK, Dupuis A, & Rumney PG. Pre-school traumatic brain injury and its impact on social development at 8 years of age. Brain Injury. (July 2010).