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).

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).

Children who suffer from mild traumatic brain injury are often referred back to their primary pediatrician for follow-up care. A recent study found that 89% of pediatricians felt that they were the appropriate care provider for the follow-up of mTBI, however 59% of these did not participate in continuing education to learn more about TBI and 62% did not administer neuropsychological tests.

Recent research has advanced our understanding of mTBI—so much so that health care providers need to be aware of changing guidelines and recommendations. The CDC has published a toolkit for physicians who treat mTBI, but many primary care physicians may still be unaware of it. The tool kit can be found at http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html.

The follow-up of mTBI is especially important in children, for whom complex decisions, such as return to sport, need to be carefully considered. Pediatricians who treat mTBI in their practice need to be aware of the current guidelines set out by the CDC.

Kaye AJ, Gallagher R, Callahan, JM, & Nance ML. Mild traumatic brain injury in the pediatric population: The role of the pediatrician in routine follow-up. Journal of Trauma Injury, Infection, and Critical Care. (June 2010).

Dear Advocates,

As many of you know, the House of Representatives passed a historic health care overhaul package late Sunday 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 insurance limits or “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 brain injury to maintain and improve function, such as rehabilitation and habilitative services and devices. BIAA, along with 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 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 Senate votes as the bill was passed by the Senate in December.

The Senate is expected to take up the bill as early as Tuesday under special budget reconciliation rules that will shield it from filibusters.  BIAA will continue to monitor the situation closely as consideration concludes.

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

Last week, the Health and Human Services (HHS) department asked for public comments regarding their draft strategic framework on multiple chronic conditions (MCC).  The framework addresses approaches to improving the health of individuals with concurrent MCC by providing options for HHS to strengthen coordination of its efforts internally and collaboration with stakeholders externally.

BIAA submitted a document detailing the concern that the draft framework does not include TBI in the list of conditions that constitute concurrent multiple chronic conditions.  BIAA argued that because brain injury has been linked to epilepsy, Parkinson’s and Alzheimer’s disease and that  individuals with brain injury manifest neurologic, neuroendocrine and psychiatric disorders as well as cardiovascular, musculoskeletal, gastrointestinal, urologic and sexual dysfunction it absolutely should be addressed in the framework.

BIAA will continue to advocate for its inclusion and will update grassroots advocates on our progress.

On June 15, 2010, BIAA and other TBI stakeholders met with Mary Wakefield, the Administrator of Health and Human Service’s (HHS) Health Resources and Services Administration (HRSA) to discuss the future of the federal TBI program, one of the programs funded through the TBI Act. The federal TBI program provides grants to states to improve access to care for people with brain injury.

The meeting was very positive and both the TBI stakeholders and HRSA are committed to working together to bring the attention needed to the program in order to grow the program and receive more funding for the TBI population in each state. HRSA has committed to working with stakeholders going forward to craft a strategic plan for the program and solicit public comment from appropriate entities such as BIAA state affiliates and state lead agencies in order to ensure that elevation of the program is successful.

BIAA is encouraged by the partnership forged between TBI stakeholders and HRSA and will continue to pass on important information as efforts progress.