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).

The rate of chronic fatigue after traumatic brain injury is more than four times higher than the general population. Chronic fatigue is a complex disorder, and research has shown that is related to sleep problems, cognitive impairment, attention deficits, depression, anxiety, and chronic pain—problems that are also common after traumatic brain injury. Hormonal insufficiencies that can occur after traumatic brain injury can also contribute to chronic fatigue.

A recent study examining both hormonal and non-hormonal causes of chronic fatigue after traumatic brain injury found that vitamin D deficiency was a surprisingly strong risk factor. Poor sleep was also a strong, but obvious, cause of fatigue. Anxiety was associated with chronic fatigue, although less so than sleep problems. Hormone deficiencies were shown to be unrelated to chronic fatigue.

The link between vitamin D deficiency and chronic fatigue is an intriguing one. Traumatic brain injury can lead to an isolated and inactive lifestyle that results in lowered sun exposure and subsequent vitamin D deficiency. Vitamin D deficiency can cause muscle pain and weakness, two symptoms that are also common in chronic fatigue. Fortunately, vitamin D replacement is a simple and inexpensive therapy that may help to reverse chronic fatigue after traumatic brain injury.

Schnieders J, Willensen D, & de Boer H. Factors contributing to chronic fatigue after traumatic brain injury. Journal of Head Trauma Rehabilitation. (February 2012).

A traumatic brain injury can result in cognitive, emotional, and physical impairments that make the patient more vulnerable to future injury. For instance, cognitive impairments may result in slow decision-making or faulty judgment that can put a person at risk while driving. Emotional impairments may lead to an increased risk of assault-related injury or self-harm. And physical impairments can increase the risk of falls.

In a recent study of veterans, researchers reported that 32% of people with a traumatic brain injury subsequently suffered from another non-fatal injury. Most of these injuries were from falls and car accidents. Assault, burns, and poisoning were less common causes of subsequent injuries.

The specific impairments that contributed the most to subsequent injury were vision loss, hearing loss, speech problems, chronic pain, and depression. Other impairments that were identified as less significant risk factors were balance problems, anxiety, anger problems, and sleep problems.

Carlson KF, Meis LA, Jensen AC, et al. Caregiver reports of subsequent injuries among veterans with traumatic brain injury after discharge from inpatient polytrauma rehabilitation program. Journal of Head Trauma Rehabilitation. (February 2012).

In a large study of more than 72,000 traumatic brain injury patients and more than 200,000 controls, over a period of six years, researchers have recently reported an increased risk of multiple sclerosis after traumatic brain injury.

Multiple sclerosis is a disease of the central nervous system, in which the myelin sheath (white matter) is attacked, resulting in a wide range of neurological problems, including blindness and motor impairments. It has been suggested that one of the potential triggers of multiple sclerosis is a previous brain trauma, but no previous research has been able to support this. The current study suggests that traumatic brain injury, in combination with genetic and other environmental influences, may contribute to the development of multiple sclerosis.

There is a limitation to the study in that it was based in China. Other studies based in other nations have failed to find the same association between traumatic brain injury and multiple sclerosis. It is unknown if these differences are due to genetic profiles (China has a relatively low rate of multiple sclerosis) or other environmental factors.

However, another issue is that reporting measures are not consistent between nations. For instance, other studies may have included only more severe cases of brain injury. Severe cases of traumatic brain injury might “mask” symptoms of multiple sclerosis, and may have therefore led to skewed results. The current study included all cases of traumatic brain injury, and the researchers felt that their results represented an accurate view of multiple sclerosis in China.

Kang J-H, & Lin H-C. Increased risk of multiple sclerosis after traumatic brain injury: A nationwide population-based study. Journal of Neurotrauma. (December 2011).

Decompressive craniectomy is a surgical procedure that removes part of the skull to allow room for brain swelling after injury. Not long ago, researchers found that this surgery, although commonly performed, did not actually improve outcome in traumatic brain injury patients. However, that study did not specifically look at the outcomes of decompressive craniectomy in children (under age 12) with traumatic brain injury.

A child’s brain is different than an adult’s in a few ways: the size is generally smaller, the head is heavier in relation to neck muscles, and the skull may not yet be completely formed. Injury to a child’s brain in likewise different than an adult’s. Smaller brains are less vulnerable to certain acceleration injuries, but a soft skull is more vulnerable to impact. (These differences are reduced as a child gets older.)

A recent review of past research in children who underwent decompressive craniectomy after a traumatic brain injury found mixed results. Some studies showed both better outcomes, and other studies showed worse. Decompressive craniectomy may remain a controversial surgery, however, some consideration should be given to differences in brain size, development, and response to injury before deciding to proceed.

Appelboom G, Zoller SD, Piazza MA, et al. Traumatic brain injury in pediatric patients: Evidence for the effectiveness of decompressive surgery. Neurosurgical Focus. (November 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).

Online communities and social networking sites can be valuable to those with cognitive or social difficulties caused by traumatic brain injury. Virtual support systems can increase social participation and reduce isolation. Recent research shows that expressive online journaling appears to enhance quality of life and feelings of well-being for TBI patients.
So, do people with a TBI take advantage of virtual communities? A recent study found that 60% of individuals with TBI used Facebook. Age and gender were not significant factors in use of social networking tools. Several other studies show additional common online activities among people with a TBI including email, gaming, and research.
In addition, half of the TBI patients who were not Facebook users were interested in learning to use the site. Barriers for use were security concerns, cognitive defects including problems remembering passwords and navigating the site, and a preference for meeting with people in person. Costs associated with computers and internet services may also be a burden.
Identifying ways to increase social networking use may improve social outcomes in TBI patients.
Tsaousides, T, Matsuzawa, Y, and Lebowitz, M. Familiarity and prevalence of Facebook use for social networking among individuals with traumatic brain injury. Brain Injury. (November 2011).

TBI Act

On September 21, 2011, the Senate Appropriations Committee considered an FY12 Labor Health and Human Services, Education and Related Agencies (Labor/HHS) bill, which contained TBI Act funding. In the past year, more than 50 programs have been cut from the Labor/HHS budget. However, largely through BIAA and NASHIA’s advocacy, TBI Act funding has been sustained thus far.

Along with level funding, the Senate Appropriations Committee took BIAA and NASHIA’s recommendation and included language in the bill report encouraging HRSA’s work on a long-range plan for the Federal TBI Program. Specifically the report states:

“The Committee supports the efforts of HRSA to develop a long-range plan for the Traumatic Brain Injury program. The Committee encourages HRSA to collaborate with other Federal agencies during this process and to solicit broad input from consumers, States, professionals and care providers in order to ensure that the program maximizes resources related to the treatment and prevention of traumatic brain injury.”

The support the Committee has shown for HRSA’s ongoing work to elevate the Federal TBI Program lays important groundwork for TBI Act reauthorization as well as increased appropriations in future years. During meetings with Appropriations staff, BIAA has learned how much they value HRSA’s willingness to work with stakeholders as well as collaborate with other agencies.

TBI Model Systems

Funding for the TBI Model Systems of Care program (TBIMS) also resides within the FY12 Labor/HHS bill; however, the TBIMS program does not currently have a congressional budget line item to target for specific funding levels. The program is funded at the agency level by money allocated to the Department of Education’s National Institute on Disability and Rehabilitation Research (NIDRR). Therefore, although the program is vital to brain injury research, Congress cannot guarantee that it remains consistently funded.

To address this issue, BIAA and other stakeholders representing the model system at JFK Johnson Rehabilitation Institute negotiated support for inclusion of clarifying language in the Senate Appropriations report from the co-chairs of the Congressional Brain Injury Task Force and the office of Rep. Gabby Giffords, whose letters can be found on our website.

On September 23, 2011, BIAA learned that NIDRR sustained the same level of funding as FY11 and the committee included the following language in its report:

“The Committee strongly supports the Traumatic Brain Injury Model Systems [TBIMS] Centers program funded by NIDRR. Almost 500 peer-reviewed publications have resulted from TBIMS research since 1987, bringing dramatic improvements to the treatment of traumatic brain injury for both civilian and military populations. The Committee is aware that the TBIMS Centers will compete for new 5-year awards in fiscal year 2012. The Committee bill included sufficient funds to support the current size of the TBIMS Centers program and to provide adequate resources to meet the research objectives of the TBI MS program. The Committee intends that funds provided will enhance the capability of the TBIMS Centers to conduct critical multi-center investigations, expand the TBIMS Centers’ scope of intervention studies, maintain the ongoing high quality TBIMS Centers’ longitudinal research while keeping pace with the increased number of participants followed, and promote continued collaboration to improve outcomes for civilians and military populations with traumatic brain injury. The Committee also commends NIDRR for establishing collaboration between the TMIMS Centers program and the Department of Veterans Affairs and encourages continuation of these efforts.”

Although, this language is not binding on NIDRR, it clearly shows the intent of Congress to continue this program at a minimum of its current funding level.

People with traumatic brain injury often have complex problems that require multifaceted solutions. Networks, which consist of individuals, teams, and organizations that are linked together, are frequently touted as a method for addressing the difficulties these patients face in accessing resources. Networks do show promise in improving continuity of care, but some specific issues should be addressed before there is widespread implementation. To be effective, networks need to be adaptable and to have capacity.

First, expectations need to be in line with the size and scope of the network. A small committee that meets sporadically cannot handle the same tasks as a comprehensive group that meets regularly. Second, you get what you pay for. While networks may be a cost-effective way of improving services, they require economic and human resources to function. Lack of investment in design, implementation, and maintenance can be a significant problem.

Third, networks need support from stakeholders. Without buy-in from all involved, networks lack legitimacy. Finally, there must be genuine collaboration. A common language and vision must be established and maintained in order for a traumatic brain injury network to be effective.

Lamontagne, ME, Swaine, BR, Lavoie, A, and Careau, E. Analysis of the strengths, weaknesses, opportunities and threats of the network form of organization of traumatic brain injury service and delivery systems. Brain Injury. (November 2011).