Viewpoint: A Primer on Traumatic Brain Injuries

No two patients recovering from a brain injury are alike. The key to the very best possible outcome is to make sure the proper diagnosis is achieved, and treatments are outlined.

First, it is important to know the types of brain injuries seen in workers’ compensation cases, best practices to better understand the injury, the symptoms and how to support appropriate care. We will also review paths to recovery and return to work when possible.

Traumatic brain injury (TBI) as defined by the CDC is caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal brain function. The severity ranges from mild to moderate to severe. It can change the way you think, act, move and feel.

Keep in mind that the brain holds about 70 percent of the one hundred billion nerve cells that we have. They are all connected to each other with long fibers between the cells called axons. The brain is separated into numerous lobes and the stem. Each brain injury may affect a different lobe or area.

In the US, TBI is a major cause of death and disability. Brain injuries are about 30 percent of all injury-related deaths. TBI survivors face effects lasting from days to lifelong. The role of the family is often key to supporting the injured worker and stabilizing the situation.

There are many causes for brain injury. According to the Centers for Disease Control, the leading cause for TBI is falls, across all ages. The number one cause of brain injury-related deaths is motor vehicle accidents. Getting struck by or against a surface, gunshot wounds to the head, assault, and blast injuries are also causes for TBI. Brain injury is not caused by a stroke, although a stroke can occur at the same time.

The types of brain injury include the following:

• Skull fracture – With this injury, the skull cracks, and pieces of it or another object may cut into the brain.
• Intracranial hematoma – With damage to a major blood vessel in the brain or between the brain and the skull, it causes bleeding in the brain.
• Contusion – With enough force, the brain can bruise, and swollen brain tissues mixes with blood released from broken blood vessels.
• Concussion – An impact to the head results in this injury. It is often referred to as a mild TBI, not life-threatening.

When it comes to initial response cornerstones for TBI, there are many options for treatment:

• Urgent Treatment (non-hospital)
• Hospital / Trauma Center
• Centers of Excellence for TBI Acute Rehabilitation
• Home or Post Acute TBI Specialty Programs
• Outpatient or Community Treatment
• Return to Work, which may need vocational support for success

It is essential to obtain as much background information immediately on the site of the injury regarding the nature of the injury. While opinions vary on when to call an emergency responder, a good rule of thumb is to contact emergency responders any time there is a loss of consciousness. Severe injuries should be routed to the nearest trauma center or hospital for transfer to a trauma one facility. The reason it is important to make sure an injured worker is properly evaluated is because issues may or may not be visible or immediately apparent. I have seen a scenario where an injured worker walked away from an accident after his truck rolled over, only to become severely compromised later and have to be airlifted to a hospital due to active bleeding in the brain.

Brain injury outcomes are directly related to the care provided in the pre-hospital situation, so it is important to professionally assess a situation where a brain injury may occur. CT scans are the dominant means of diagnostic scans once an injured worker enters a treatment facility. CT scans are used to diagnose fractures, bleeding, blood clots, contusions and swelling and help neurosurgery determine if immediate craniotomy is needed.

Continuum of care for a brain injury may follow numerous paths. After diagnosis, there may be surgery. Following surgery, there is often acute rehabilitation. Facilities with TBI experience are important when it comes to rehabilitation. There is no set time for brain injury recovery; it varies with every situation. The very best care for the injured worker is what matters most. Rehab can get very complex, and, if there isn’t quality rehab, then the injured worker suffers, and it can get more expensive down the line from a cost management perspective. I often hear from families that they want to have rehab located close to their home. My response is often telling them that you have your whole life to be at home, and only a short while to be in rehab for brain injury. I would rather see injured workers getting the best care possible than being close to home, and sometimes this means even going to another state for rehab.

The role of the nurse case manager in a TBI claim is also essential. An assigned nurse case manager becomes a liaison with all the parties and providers, and this person is facilitating care instead of directing it. As early as possible, even during hospital time, this can occur. With acute rehab, there is a comprehensive, multi-disciplinary team of physicians, nurses, physical, occupational and speech therapists, a neuropsychologist, possibly a recreational therapist and social worker and a community re-entry specialist. And of course, there is the family and the employer.

When it comes to the path of recovery, there are many signs to show progress or lack thereof and to manage the continuum of care. TBI deficits can be categorized into physical deficits (such as headaches, seizures, problems with speech and impaired coordination), cognitive deficits (such as disorientation and short-term memory problems) and behavioral deficits (such as combativeness, lethargy and wandering). Having an injured worker placed in a center of excellence or other facility with a strong rehabilitation program can help address all of these deficits.

Brain injury rehabilitation goals will, of course, vary based on the nature of the injury. No single rehab program will work for all patients. Program elements may include:

• Recovery of Motor Function
• Recovery of Cognitive Function
• Independence of Activities of Daily Living
• Restore Social Functioning
• Improve Quality of Life
• Foster Ability to Participate in the Community
• Return to Work or to School

Having a positive approach can make a difference during recovery. Sometimes, though, families may be in denial about the severity and long-term effects of an injury. Sending people to brain injury support groups early on may not work out since these groups are often led by people who have been living with TBI for some time and have learned to adjust to new ways of living that families of a newly injured worker may have yet to address.

Overall, the effects of a brain injury depend on many factors, from cause to location and severity. Cornerstones of TBI include initial treatment, centers of excellence, the team (which includes the medical team, family, and anyone involved in helping the injured worker), and the plan for recovery. TBI is often one of the most complicated and complex injuries encountered. It requires a continuum of care treatment approach and early assessment can help ensure the injured worker gets the care they need.