Published in UAB Insight, Summer 2008
Traumatic Brain Injury: Assessment, Impact, and Recovery
ABSTRACT: Traumatic brain injury can result in immediate physiological, cognitive, and behavioral changes leading to an abrupt impairment in decisional capacity. Over time, such decisional capacities may improve.
CME OBJECTIVE: The reader will develop an increased understanding of traumatic brain injury, its impact on decisional capacity and current evaluation methods, and outcomes.
Robert C. Brunner, MD, no conflicts of interest; Daniel C. Marson, JD, PhD, grant and research support NIH; other support Capacity to Consent to Treatment Instrument copyright, Financial Capacity Instrument copyright; Thomas A. Novack, PhD, grant and research support National Institute on Disability and Rehabilitation Research; other support Posit Science
The true burden of traumatic brain injury (TBI) is unknown, but incidence data indicate it is the leading cause of death and long-term disability among Americans younger than 45 years (J Head Trauma Rehabil. 2005;20[3]:229-238). The Centers for Disease Control and Prevention (CDC) report that annually about 1.4 million Americans sustain a TBI, 50,000 of these individuals die, and 80,000 suffer long-term disabilities. More than 5.3 million Americans need long-term or lifelong assistance with activities of daily living because of TBI-related disabilities.
The CDC notes these figures, based solely on hospital admissions, are underestimates. An unknown number of people receive limited or no treatment for their injury. Recent research from Mt. Sinai Medical Center suggests there is a significant rate of "hidden" brain trauma caused by past blows to the head and that these injuries are unrecognized sources of long-term physical, cognitive, and behavioral problems.
Multifocal impairments can affect active participation in self-care and self-awareness, orientation, and medical decision-making. Recovery of capacity in one area may not reflect proficiency in another. TBI also can cause seizures, tremors, and spasticity and increase the risk for Alzheimer disease, Parkinson disease, and other neurological disorders.
As 1 of 14 designated Traumatic Brain Injury Model Systems (TBIMS) programs nationwide, UAB is on the frontline of treatment and rehabilitation of persons with TBI. The National Institute on Disability and Rehabilitation Research selects TBIMS centers for their demonstrated provision of exemplary emergency, acute, and rehabilitative care for TBI. UAB-TBIMS physicians and scientists are conducting novel brain injury research, and ongoing efforts target recovery and rehabilitation of patients with a range of TBI-acquired disabilities.
Injury Assessment
TBI-related impairments require intensive medical care and rehabilitative intervention. Assessment of TBI severity begins in the acute care setting with an evaluation of brain stem and cerebral function. "The Glasgow Coma Scale [GCS] is one tool used to measure TBI severity," says Robert C. Brunner, MD, medical director of the UAB-TIBMS. The GCS assesses patient consciousness levels by evaluating eye opening and verbal and motor responses. GCS results and other measures allow physicians to categorize brain injuries as mild, moderate, or severe.
The severity of injury does not always predict the level of functional impairment. Most patients with mild TBI fully recover cognitive, behavioral, and physical function soon after injury, but about 15% experience chronic problems that interfere with their daily lives (Mt Sinai J Med. 2006;73[7]:999-1005).
The long-term physical and psychological sequelae of TBI can include headaches; sleep disorders; fatigue; anosmia; problems with vision, balance, and hearing; irritability; anxiety; depression; emotional lability; and aggression. Cognitive deficits are more prevalent, and the overall effect of TBI on patients and their families can be devastating, says Professor of Physical Medicine and Rehabilitation and UAB-TBIMS Program Director, Thomas A. Novack, PhD.
Medical Decision Making
Beginning with the onset of injury, TBI patients or their family members must make complex medical decisions about routine medical care, surgical and therapeutic intervention, and potential participation in research.
The nature of these injuries, however, often seriously curtails patients' ability to make critical decisions, says UAB-TBIMS investigator Daniel C. Marson, JD, PhD, director of the Department of Neurology's Division of Neuropsychology and Alzheimer's Disease Research Center. "Abrupt impairment followed by a period of ongoing recovery of medical decision-making capacity [MDC] distinguishes TBI and stroke from disorders such as Alzheimer and Parkinson disease, which are characterized by progressive decline over time," he says.
TBI-related personality changes such as increased impulsivity, lack of insight, and poor judgment are likely to affect patients' MDC (J Neurotrauma. 2005;22 [6]:613-622). Disorientation, confused thinking, and significantly impaired short-term memory also affect decision making.
"Decisional capacity is often impaired or lost at the time of injury, and determining a prognosis for return of MDC can be problematic," Marson says. "When patients cannot participate in meaningful conversations about treatment options, it is unlikely they can provide valid informed consent for medical care. The challenge for clinicians, particularly in patients with moderate and severe TBI, is determining the effect of cognitive deficits on patients' ability to make medical decisions."
The Reclaimed Study
The relationship between TBI impairment, the ability to participate in MDC, and recovery of decisional capacity is unknown, says Marson, who is primary investigator for the Reclaimed Study, an RO1 project funded by the National Institute of Child Health and Human Development and its National Center for Medical Rehabilitation Research.
Initiated in 2007, the 5-year study investigating the natural history of impairment and recovery in individuals with TBI is enrolling 120 participants with varying degrees of TBI and 60 older participants who serve as controls. "Participants are stratified according to severity of their injury. We also are including a fourth stratification called complicated mild TBI," Marson says. Individuals with complicated mild TBI have structural brain changes indicated by computed tomography or magnetic resonance imaging.
To evaluate patients' recovery of MDC, investigators will use the Capacity to Consent to Treatment Instrument (CCTI). Developed by Marson and several UAB colleagues, the CCTI assesses MDC by evaluating four consent abilities: understanding the treatment situation; reasoning about treatment choice; expressing a treatment choice; and appreciating the consequences of treatment choice (Arch Phys Med Rehab. 2005;86:889-895).
The CCTI requires participants to consider two hypothetical medical scenarios, their diagnoses, and the risks and benefits of treatment options at three different times during their recovery. The first evaluation occurs 1 month after TBI. The second and third evaluations take place 6 months and
1 year after injury. "In general, most spontaneous brain injury recovery takes place in the first year," Marson says.
At each patient visit, a study psychiatrist conducts an independent clinical interview to evaluate participants' MDC. The psychiatrist's clinical judgments are compared with the patient's results on the CCTI.
Other study assessments include a battery of cognitive tests that evaluate participants' memory, information processing speed, and conceptual abilities. Investigators also administer a brief version of the Financial Capacity Instrument (FCI). The FCI, also developed by Marson, measures an individual's basic monetary skills: financial conceptual knowledge, cash transactions, checkbook management, bank statement management, and financial judgment (Arch Neurol. 2000;57:877-884).
"Patients," Marson notes, "may have to reacquire skills learned as infants. Those with mild impairments may be disoriented or foggy for a few hours and unable to make decisions for a week. Afterwards the fog may clear, permitting the individual to return to work. With more severe injuries, self-awareness and insight are more impaired. Individuals, unaware of alterations in their cognitive state, may fail to note changes in their normal functional patterns."
Failure to discriminate or monitor one's activities severely impacts a TBI patient's capacity to return to work. "Patients who do not recognize injury-related changes create a problem not only for themselves, but also for family members trying to assist in the recovery process," Marson says.
Marson and colleagues will use data gathered from the Reclaimed Study to generate a longitudinal database that will add to understanding of trajectories of MDC recovery across injury severity. Marson hopes the Reclaimed Study will lead to identification of different patient profiles of MDC that will provide physicians with objective information to evaluate TBI severity, appraise individual assessment responses, and predict the likelihood of reclaimed decision-making capacity.
Keys to Loss and Recovery
The multifocal and widespread neurological injuries caused by TBI lead to diffuse pathological changes that affect a number of neurocognitive functions (J Head Trauma Rehab. 2001;16:343-355).
Initial changes that affect the ability to participate in cognitive tasks are followed by impairment in executive function, self-awareness, goal-setting, and problem-solving. Lack of awareness also is associated with impulsivity, Novack says. "When patients are unable to remember daily life before the injury, they may act on physical needs with no awareness of their injury," he says. "For example, a patient unable to assess the impact of his physical injuries may incorrectly evaluate his ability to stand on a fractured leg, try to stand, and fall."
Recovery of orientation is related to improved functional and cognitive capacity, and measuring this ability provides clinicians with a simple yet valuable indication of patients' recovery, Novack says. "Using the Orientation Log [O-Log], a short 10-item scale, clinicians can serially assess patient orientation to time, place, and situation." The O-Log, developed at UAB as part of Novack's research on TBI, also can be used to monitor declines in orientation and uncover additional medical problems (Rehab Psych. 2005;50[2]:174-176).
Rehabilitation
A neuropsychological evaluation can reveal the nature and severity of cognitive impairment and guide rehabilitation, Novack says. Cognitive rehabilitation typically begins with work on basic orientation skills - the ability to talk, make sense, and participate in meaningful conversations - for increasing periods of time. Therapists target speech and communication skills, memory, problem solving, and mathematical skills. Recovery of higher-level reasoning is stimulated with memory tests and exercises of increasing difficulty, Novack says.
"Tailoring modules to patient needs personalizes the recovery process," Brunner says. "For example, using tax returns to structure therapeutic units for an accountant personalizes cognitive problem solving and simulates workplace skills."
Addressing the long-term physical and emotional symptoms of TBI requires multidisciplinary expertise from physiatrists, neuropsychologists, physical and occupational therapists, social workers, and others. "Education for patients and their families also is important. Rehabilitation often is more effective when patients and family members have a better understanding of the cognitive and physical problems that can arise after TBI," says Brunner, who is medical director of UAB's Spain Rehabilitation Center Traumatic Brain Injury Clinic.
During rehabilitation, patients progress from a need for constant inpatient supervision to a moderate level of independence that allows for monitoring in an outpatient setting. The need for interactive supervision may diminish until the person is completely autonomous and can drive - a crucial marker of independence.
On the Road Again?
Alterations in cognitive and perceptual motor abilities, impulsivity, and judgment can create substantial barriers to safe driving for some TBI survivors (Brain Injury. 2006;20[5]:455-461).
Recovery of sufficient decisional and cognitive capacity for independent driving is a widespread goal for many TBI patients, and screening for driving abilities is of major interest to rehabilitation professionals, Novack says.
"Unfortunately, although more than 60% of individuals with moderate to severe TBI return to driving, only 37% receive a formal driving evaluation," he says. "Recent work suggests patients who return to driving after a severe TBI are at greater risk for motor vehicle accidents than uninjured drivers."
Novack is conducting a 5-year UAB-TBIMS study, funded by National Institute on Disability and Rehabilitation Research, on the effect of visual perceptual training on driving skills of individuals with moderate to severe TBI. The study will employ the Useful Field of View (UFOV) test, developed at UAB by psychologist Karlene K. Ball, PhD, and colleagues at Western Kentucky University.
The UFOV is a screening instrument sensitive to driving safety, and studies have established its reliability and validity with regard to driving ability. Recent research shows training programs can improve UFOV test performance in older adults. Investigators are testing the effectiveness of a self-administered program focusing on visual-perceptual speed for improving UFOV performance in patients with TBI.
Researchers will compare quality of life among patients with severe TBI who are driving with nondrivers. They also will explore the frequency and extent of driving and self-reported safety records of people returning to driving after severe TBI.
"The goal of rehabilitation at our clinic and others that focus on medical evaluation and treatment of TBI is to help each patient become as independent as possible," Brunner says. "The best outcomes are achieved when the patient, their family, and involved health care providers work together to understand and address the functional and emotional changes that affect individuals on so many levels."
FOR MORE INFORMATION:
Dr. Robert Brunner
Dr. Daniel Marson
Dr. Thomas Novack
1.800.UAB.MIST
mist@uabmc.edu