Traumatic Brain Injury: A Public Health Epidemic?

The day after the July 7 London bombings, George Zitnay, PhD, an expert on TBI, spent the morning on the phone with callers from London who needed to tap his expertise. Zitnay, founder and president of Virginia NeuroCare Inc, a rehabilitative facility in Charlottesville, VA, and a core member of the Defense and Veterans Brain Injury Center (DVBIC), refers to brain injury as a "silent" public health epidemic.

In the United States alone, more than 3 million cases of TBI are reported annually, according to Jonathan Silver, MD, Thomas McAllister, MD, and Stuart Yudofsky, MD.¹ In the preface to their Textbook of Traumatic Brain Injury, they note, "Unfortunately, the psychiatric impairments caused by TBI often are unrecognized because of the deficiency of appropriate education in this area for psychiatrists and other mental health professionals. Most clinicians lack experience in treating and evaluating patients with TBI and are, therefore, unaware of the many subtle but disabling symptoms."¹

As pointed out by Jess Kraus, MPH, PhD, and Lawrence Chu, MPH, PhD, in the textbook's chapter on epidemiology,² the incidence rates of TBI are, at best, an estimate. Numbers of fatal brain injuries may be miscounted because the diagnosis given on a death certificate may not indicate the specific area of the body that suffered trauma. Numbers of nonfatal brain injuries may be confounded by self-reporting of concussion and by whether a patient was treated in an emergency room or a non-emergency facility.

But even if we use Zitnay's conservative estimate that 1.5 million TBIs occur annually in the United States, we see that the annual incidence of TBI is greater than that of all cancers, estimated by the American Cancer Society to be at 1.37 million in year 2005.³

EMERGENCY ROOM PROTOCOLS

Specific protocols exist for handling a patient in the emergency room who is known or suspected to be suffering from a TBI.^4-7 These patients include anyone who has fallen, especially someone older than 64 years; a person who has been in a motor vehicle accident; someone with a gunshot wound or violence-related injury; or an adolescent or young adult who has a sports-related injury. Men are more likely to suffer TBIs than are women, and the 2 highest risk groups are young people aged 15 to 24 years and the elderly.²

Initial neurologic examination of patients older than 4 years includes evaluation using the Glasgow Coma Scale (GCS),⁴ which assigns points for eye opening, verbal response, and motor response. A score of 13 to 15 indicates a mild TBI, a score of 9 to 12 indicates moderate TBI, and a score of 8 or lower indicates severe TBI.² In a civilian hospital in the United States, 80% of patients admitted for TBI will have a score in the mild range, while 10% each will have moderate or severe injury.² The Brain Trauma Foundation guidelines note that 20% of those with the lowest GCS scores (worst injury) will survive, and about half of those patients "will have a functional survival."⁶

Diagnostic imaging is an important modality in determining the location and extent of brain trauma and is helpful in determining possible sequelae.

OPPORTUNITIES TO STUDY

Studies of TBI have used different parameters for determining the seriousness of the injury. "Just as in other areas of medicine, where we wish we had a bigger evidence base, the gold standard is randomized trials," noted Deborah Warden, MD, of Walter Reed Army Medical Center in Washington, DC. Clinical trials would determine which methods of treatment work best for a particular level of TBI, but there have been few randomized trials on the effects of pharmaceuticals in patients with brain injury.

In fact, by setting up the DVBIC, the US military has taken a lead role in treating and monitoring military personnel who suffer TBIs, and it is creating the database necessary to determine which clinical treatments work best for different levels of injury.

Zitnay points out that even during peacetime, approximately 10,000 head injuries occur each year among members of the US armed forces as a result of vehicular and other accidents, including falls. During times of war, this number increases, and the types of injury change. About 23% to 24% of all the soldiers returning to Walter Reed Army Medical Center, have had a TBI, said Warden, the director of the DVBIC. From January 2003 through early July 2005, the center has seen about 520 soldiers returning from Iraq or Afghanistan who have suffered a TBI, she said. People who are at a high risk for TBI include those who have been injured in a blast, have fallen, have been in a motor vehicle accident, or have sustained a gunshot wound to the neck or the head, said Warden.

MORE HEAD WOUNDS IN CURRENT WAR ERA

The wars in Iraq and Afghanistan differ from previous wars in that a larger percentage of injured soldiers have TBIs. According to a recent article in The New England Journal of Medicine by Susan Okie, MD, one reason for this is that the improved body armor and Kevlar helmets better protect soldiers, increasing survival rates.⁸ Thus, the types of body injuries that would have killed soldiers in past wars are not occurring. But one of the weapons of choice for insurgents in this war is the improvised explosive device.

Even if a person near the site of a blast is not hit by shrapnel or large objects that were thrown by the force of the explosion, the change in air pressure from the explosion can damage the brain--a phenomenon that may have affected some of the survivors of the London Underground and double-decker bus bomb blasts.

Regardless of whether fractured bone or foreign objects puncture the brain, a blast or an injury that causes a sharp acceleration in the movement of a person's head can damage the axons.^9,10 Diffuse axonal injury is seen in patients who die as a result of brain injury and in patients who survive several hours after injury.¹⁰ In mild to moderate TBI, some of this neuronal damage may occur as much as 72 hours after the injury.¹⁰

MILD TBI

Most brain injuries are mild and, in most mild brain injuries, the patient does not lose consciousness, has transient loss of consciousness, or is unconscious for less than 5 minutes. Indeed, in most cases of mild TBI, the patient loses consciousness for less than 60 minutes.² However, no consensus definition exists for mild TBI, and the scientific literature is too sparse to conclusively determine its negative effects.²

Walter Reed's Warden pointed out that length of loss of consciousness is only one of the criteria that define mild TBI. Physicians also are looking for post- concussive symptoms. Somatic symptoms include:

• Headache.

• Dizziness.

• Irritability.

• Tinnitus.

• Sensitivity to light and/or noise.

• Difficulty in paying attention.

• Difficulty with recent memory.

Neuropsychiatric symptoms can include:

• Lack of judgment.

• Inability to plan for the future.

• Inappropriate social behavior.

• Difficulty in controlling anger.

Warden, who is the military's expert on TBI, explained that the vast majority of patients who have a mild TBI improve over time; however, a subset will decline. Patients at risk for a worse outcome include those older than 40 years and those who have had a previous head injury, said Warden. Patient education is important to recovery. "If you explain to peo- ple what post-concussive symptoms are and that they get better over time, [this] decreases the length of time they will have the symptoms."

According to Constance Mil- ler, MA, managing director and founder of the Brain Injury Resource Center (www.headinjury. com), a patient who is made aware of the secondary psychological consequences of head injury may be able to take steps to avoid them. Thus, the US military has adapted the book Traumatic Brain Injury: Rehabilitation for Everyday Adaptive Living¹¹ for use in its rehabilitative program.

The patient may have behavioral issues. Define what they are first, Warden advised. The physician should understand the severity of the patient's depression, anxiety, or anger. Are these issues of concern to the patient and the patient's family? After a TBI, Warden said, patients who may have been "holding it together" may be sent home from the hospital only to display more depression, anxiety, or irritability than when they were inpatients. She explained that it is important to "evaluate safety in the home. [For example,] does someone want to smack his kids around?" Is there concern among family members that the patient is displaying rage?

Evaluate whether the patient's questionable behavior manifested after the trauma or was a pattern before the trauma occurred. If it was prevalent before the trauma occurred, establish whether the patient received treatment for it and in what form. "You also want to make sure they're not doing things that make it harder for them to maintain control," explained Warden. Patients should have a routine, get a lot of sleep, and avoid caffeinated drinks and alcohol.

Warden advises that when a patient walks into a physician's office and talks about these behaviors, the physician should ask:

• When did the behavior start?

• Is it getting better or worse?

• Have you suffered any trauma?

• Have you hit your head?

Zitnay points out that many people with brain injuries are misdiagnosed. "People think they're basically depressed or they're crazy." That's not the case. Asking the right questions of the patient may elicit responses that will indicate a history of TBI.

A patient experiencing the after effects of TBI should be referred to a specialized center for evaluation, explained Eduardo Lopez, MD, a specialist in TBI and neurorehabilitation, who is medical director in the Department of Physical Medicine and Rehabilitation at Jamai- ca Hospital Medical Center in Queens, NY. The hospital is home to the Brady Institute, which is dedicated to the treatment of brain injury.

These patients, said Lopez, require evaluation and screening by a neuropsychologist and may require psychometric testing to determine whether they have deficits in functioning at higher levels. He noted that it is not always easy to determine whether a patient who has had a TBI has deficits without the use of specialized testing. "Some of these patients [have] socially appropriate [behavior] and they're oriented temporally, and they're very familiar with their biographical information," said Lopez. "It's really at the higher level of executive functioning that there are deficits." A patient with more obvious deficits, such as physiologic functional problems, should be referred to a specialist in physical medicine or a physician specializing in rehabilitation.

COMMUNITY REHAB

A small number of soldiers and civilians are participating in a 24/7 community-based rehabilitation program run by Virginia NeuroCare. Zitnay, who developed the program and runs it, believes that "neurorehabilitation needs to take place in the real world." The live-in program has room for 10 patients at most. "It really takes 6 to 9 months for the brain itself to get out of that depressed state from the initial injury," said Zitnay. "It's important to recognize the subtle signs and symptoms that we see can often dissipate and we don't need to overmedicate.

"All our rehabilitation is to get the person to function in the community," said Zitnay. "So often in neurorehabilitation, when you have executive problems, other forms of frontal lobe injury, it's hard enough to learn." According to him, it is important for patients to relearn how to interact in social environments. That is, for a patient to go to a bank and reaccustom himself to what goes on there. "We'll take people right into the restaurants where they order off the menu; they'll pay the bill. Our program is geared to get people back to the community as quickly as possible."

Sometimes, it is difficult for persons with normal brain function to understand what a person with a TBI is experiencing. For example, said Warden, her patients have related that they wait to go to the cafeteria to eat until just before it closes to avoid crowds. "If they go when it's very crowded, they're bombarded with stimuli. Someone reaches in front of them, they're caught off guard and afraid they'll lash out."

Sometimes, said Zitnay, "they can't do the simplest things." Sally (name changed to protect the person's identity), a scientist who suffered a TBI when her car was hit head-on by a panel truck, remarked, "I remember having to relearn to stop pouring boiling water into a cup when the cup got full. The first time I made tea, I kept pouring till I burned my hand, then stopped. I am very hypervigilant when I pour because I've over-poured a couple of other times." She also recalls having difficulty with subtraction and having to relearn arithmetic.

DIFFERENT THERAPY

The operation of a used-book store is part of Virginia NeuroCare's inpatient program. The store is located in the downtown mall in Charlottesville. "Instead of sitting down working with pegs, working with abstract things that are ridiculous for people," noted Zitnay, comparing the Virginia NeuroCare therapy to standard occupational therapy, "we're working with books." The patients must look at the book title, subject matter, and cover type to decide where it should be shelved. Because the bookstore sells to customers who walk in, along with selling on the Internet, patients who work there have to greet the customers. "It's a fabulous cognitive exercise," said Zitnay. "It's a wonderful social exercise."

Many of the soldiers suffer from post-traumatic stress disorder as a result of their blast injuries. At Virginia NeuroCare, soldiers receive group and individual counseling. They use neurofeedback--on a biofeedback machine--to help them deal with impulses and control. They practice tai chi for motor control and receive hippotherapy (therapeutic horseback riding). The soldiers learn how to control and care for the horses. "All of our clients every day go to a full day of therapy. No one stays in their beds. Everyone is engaged," said Zitnay. Language skills are an important focus, for which notebooks, computers, iPods, and assisted memory devices are used.

"What we have found works the best is getting people involved with other human beings, a sense of purpose, a sense they have something to give," added Zitnay. Inpatients also are required to do volunteer work at places such as the Society for the Prevention of Cruelty to Animals, the local soup kitchen, or the children's museum.

Thirty-five percent of the head-injured soldiers who complete the Virginia NeuroCare program return to active duty. The rest go home. When they return home, they are given a package of information for the local physician who will be caring for them.

OUTPATIENT CARE

Virginia NeuroCare provides a day program for about 40 civilian patients from the local community. Most have more severe injuries and have lived with their disability longer (10 to 15 years) than the inpatients. The program provides support staff to help with activities of daily living and assists their participation in volunteer work.

Despite the rigorous rehabilitation program, Zitnay laments that "we have reduced mortality, but the morbidity problem still exists. We haven't been able to really break through to make the brain get better."

In the hope of finding the right direction, he is hosting a meeting of experts on brain damage at Memorial Hospital in Johnstown, PA, on October 13-16. "We're going to explore what we need to do next to look at this neuroanatomy," said Zitnay. "How do we get the brain healed?" *

REFERENCES

1. Silver JM, McAllister TW, Yudofsky SC, eds. Textbook of Traumatic Brain Injury. Washington, DC: American Psychiatric Publishing, Inc; 2005:xix.

2. Kraus JF, Chu LD. Epidemiology. In: Silver JM, McAllister TW, Yudofsky SC, eds. Textbook of Traumatic Brain Injury. Washington, DC: American Psychiatric Publishing, Inc; 2005:3-26.

3. American Cancer Society. Cancer Facts and Figures 2005. Atlanta: American Cancer Society; 2005.

4. Tolias C, Sgouros S, Dulebohn SC, et al. Initial evaluation and management of CNS injury. Emedicine. Available at: http://www.emedicine.com/ med/topic3216.htm. Accessed July 18, 2005.

5. Brain Trauma Foundation, Inc. Part 1: Guidelines for the management of severe traumatic brain injury. Brief summary. Available at: http:// www.guideline.gov/summary/summary.aspx?doc_id=3794&nbr=3020&string=Coma. Accessed July 18, 2005.

6. Brain Trauma Foundation, Inc. Part 2: Early indicators of prognosis in severe traumatic brain injury. Brief summary. Available at: http://www. guideline.gov/summary/summary.aspx?doc_ id=3122&nbr=2348&string=Coma. Accessed July 18, 2005.

7. Hartl R, Ghajar J. Neurosurgical interventions. In: Silver JM, McAllister TW, Yudofsky SC, eds. Textbook of Traumatic Brain Injury. Washington, DC: American Psychiatric Publishing, Inc; 2005:51-58.

8. Okie S. Traumatic brain injury in the war zone. N Engl J Med. 2005;352:2043-2047.

9. Besenski N. Traumatic injuries: imaging of head injuries. Eur Radiol. 2002;12:1237-1252.

10. Gennarelli RA, Graham DI. Neuropathology. In: Silver JM, McAllister TW, Yudofsky SC, eds. Textbook of Traumatic Brain Injury. Washington, DC: American Psychiatric Publishing, Inc; 2005:27-50.

11. Ponsford J, Sloan S, Snow P. Traumatic Brain Injury: Rehabilitation for Everyday Adaptive Living. East Sussex, UK: Lawrence Erlbaum Associates Ltd; 1995.

Open for Consultation

The Defense and Veterans Brain Injury Center (DVBIC) is made up of 8 institutions: Walter Reed Army Medical Center in Washington, DC; Wilford Hall USAF Medical Center at Lackland Air Force Base in Texas; the Naval Medical Center in San Diego; Hunter McGuire VA Medical Center in Richmond, VA; James A. Haley VA Hospital in Tampa, FL; the Minneapolis VA Medical Center in Minnesota; the VA Palo Alto Health Care System in California; and Virginia NeuroCare in Charlottesville.

The center serves current and retired military personnel and their dependents and provides evaluation, treatment, and follow-up care for brain injury. The center also assists in managing the long-term effects of the injury and does research on care and treatment.

Active-duty military personnel or their family members or retired military who are being treated for traumatic brain injury (TBI) in private practices are eligible for referral to DVBIC. Furthermore, the DVBIC staff is available for consultation to any physician. Information about the DVBIC is available on its Web site: www.dvbic. org/aboutus.html. The center may be reached by phone at 800-870-9244 or by e-mail at info@dvbic.org.

George Zitnay, PhD, and the staff at Virginia NeuroCare are willing to provide consultative services to any physician anywhere. They may be accessed online at www.vanc.org or by telephone at 434-984-5218.

Constance Miller of Seattle, who suffered a head injury 23 years ago, realized there was a dearth of information on TBI and other neurologic dysfunctions. Her Web site, http://www.headinjury.com, gives a vast array of resources, including lists of rehabilitation hospitals, information on types of brain injuries, a question-and- answer forum for people who want online advice, and information for patients and families about how to deal with brain injury and what to expect. She also runs a telephone hotline (206-621-8558). "Brain injury affects every aspect of [the patient's] life," she explained. Her hotline receives calls from all over the world.

When to Use Diagnostic Scanning

The need for radiographic procedures should be assessed in patients who present at an emergency room or physician's office with a reported head injury or high likelihood of a head injury. Loss of consciousness or amnesia may be an important determining factor for ordering a radiograph. In addition, deep scalp lacerations, persistent headache and/or vomiting, a violent mode of injury, or maxillofacial injuries also warrant radiographic evaluation.¹ Anyone with a moderate or low rating on the Glasgow Coma Scale should be evaluated with CT. The same holds for patients whose radiographic findings show CNS injury.^1,2 Patients with milder injuries may not need scans³; however, some patients are alert and able to speak coherently when they present to the emergency room, only to suffer deterioration later.

Besenski and colleagues³ recommend that a CT scan be obtained immediately after the injury. If the results of the CT scan do not clarify the clinical observations, an MRI scan should be obtained.⁴

A recent report, delivered at the American Institute of Ultrasound in Medicine, found that elevated intracranial pressure, which may result from contusions, lacerations, hematomas, or brain swelling, may be diagnosed in unconscious patients by using ultrasonographic measurement of optic nerve sheath diameter.⁵

REFERENCES

1. Tolias C, Sgouros S, Dulebohn SC, et al. Initial evaluation and management of CNS injury. Emedicine. Available at: http://www.emedicine.com/med/topic3216.htm. Accessed July 18, 2005.

2. Brain Trauma Foundation Inc. Part 2: Early indicators of prognosis in severe traumatic brain injury. Brief summary. Available at: http://www.guideline.gov/summary/summary.aspx?doc_id=3122&nbr=2348&string= Coma. Accessed July 18, 2005.

3. Besenski N, Saini R, Selby JB Jr. CT and MRI detect brain damage after trauma. Diag Imag Eur. 2003; June-July:25-30.

4. Besenski N. Traumatic injuries: imaging of head injuries. Eur Radiol. 2002;12:1237-1252.

5.Tayal VS, Neulander M, Norton H, Blaivas M. Use of emergency department sonographic measurement of optic nerve sheath diameter to detect CT findings of increased ICP in adult head injury patients. Presented at: the 2005 annual meeting of the American Institute of Ultrasound in Medicine; June 19-22, 2005; Orlando, FL.