The Bio-psycho-social Aspects of Traumatic Brain Injury

By Daniel Aryeh, Jamaica Hospital

It is incredible when one thinks about how, in a split second, the life of a previously healthy individual could be tragically and permanently altered. That person may not even realize anything has happened to them, while the family may then go through a mourning process of burying the person they previously knew and try to develop a relationship with a new and perhaps less likable stranger. Head injuries can have a devastating impact on the injured individual, the family and the community.

The brain controls the actions of our bodies and allows us to think, learn, feel and remember. It is protected by our hair, skin, skull, dura, and cerebro-spinal fluid, while our circulatory system ensures the right amount of blood flow to the brain for oxygen and nutrition. Even though the brain is very protected, it may be injured, and each injury is different from the next.

Some types of brain injury include skull fractures, contusions or concussions, coup-contra coup, hematomas, hemorrhages, diffuse axonal injury, hydrocephalus, and anoxia. Damage to the brain may occur immediately upon injury or may develop over time due to bleeding or swelling. When, this occurs, it may increase the skull's intracranial pressure, and since the skull is not flexible, it may cause an increase in the pressure on the brain tissue. As a result, the contents of the skull may shift, thereby causing a more generalized response or damage, rather than having a more focal or localized effect.

Problems or disorders that survivors of head injuries may experience are one or all of the following: physical problems, movement disorders, sensory impairment, communication disabilities, eating control problems, seizure disorders, paralysis, cognitive problems, behavioral problems, and coma. Cognitive disabilities that may exist include memory defects, concentration deficits, learning disabilities and the inability to make judgments, think quickly or plan ahead. Emotional or behavioral impairments include mood swings, depression, anxiety, aggression, sexual dysfunction or inappropriateness, agitation, self-centeredness, childishness, lack of ambition, and changes in one's usual personality. Overall, brain injuries may lead to a decline in the individuals functional status, as well as, a loss in productivity of the person who had the injury and by the persons family members who are caring, for them. Thus, the overall costs and overall loses for such an injury are immeasurable and could never be completely accurate for statistical purposes.

In order to provide some insight on the monetary costs of brain injuries, Max, MacKensie and Rice, in 1991, undertook a large-scale analysis of data collected in the United States through 1985. They found that the average lifetime cost per person for a head injury across all levels of severity was approximately $85,000. Very severe cases of traumatic brain injuries, however, increased the overall lifetime cost by a factor of four, to a combined total of $300,000 per person. Loss of productivity over a lifetime showed even more of a dramatically higher overall cost for such people.

Miller (1995) used worker's compensation data from the late 1980's to evaluate injury costs across a wide variety of injuries. Comprehensive medical costs amounted to more than $300,000 per person. When including quality of life in cost calculations, Miller (1994) found that the most seriously injured persons have projected expenses of up to $2.4 million, which is eighteen times higher than in mild brain injury cases.

Recent insurance data by the American Re-Insurance Company (1993) indicates that costs can vary across different degrees of traumatic brain injury severity. For example, extrapolated over the individual's expected life span, severely injured people were found to require almost forty times as much financial support than those who had only mild injuries ($3,157,150 vs. $85,150). Those individuals with moderate injuries were found to require about eleven times as much financial support ($941,280 vs. $85,150). It is believed that the cost of traumatic brain injuries in the United States is estimated to be at about $48.3 billion annually. Hospitalization accounts for $31.7 billion and fatal brain injuries cost the nation $16.6 billion each year (Lewin, 1992).

It is estimated that about 1.9 million Americans suffer from some kind of head injury each year, 373,000 of which result in hospitalization (Conforti, A., 1999). After one brain injury, the risk for a second injury is nearly three times greater. After the second injury, the risk for a third injury is about eight times greater (Annegers, Garbow, and Kurtland et al., 1980). According to The National Center for Health Statistics (1996), more than 50,000 people die each year as a result of traumatic brain injuries. Males sustain nearly two times as many head injuries as females (The National-Brain Injury Association, 1999). It is believed that traumatic brain injury is the number one killer and disabler of persons under the age of forty, the majority whom are young adults (The Saskatchewan Brain Injury Association, 1999). Thus, many survivors will have normal life expectancies but will require specialized care. One should also make note to the fact that more brain inured individuals are surviving their initial injuries now more than in earlier years because of the steady advance in technology and neuro-surgical intensive care. According to the National Pediatric Trauma registry, about one-third of all pediatric injury cases in the United States are related to brain injury. 30,000 of which result in permanent disabilities annually (The National Brain Injury Association, 1999).

Although a few studies report that there is a higher incidence of brain injury in nonwhites than whites, such information has not yet been proven accurate. This is because hospital data varies widely in noting ethnicity or race in medical records. Socioeconomic status, on the other hand, is a good risk marker, with several studies showing that the estimated average annual number of injuries was higher in families with the lowest income levels (Kraus, MacArthur 1999 p.9). It is believed that 50% of all head injuries are due to motor vehicle accidents, 21 % are due to falls, 12% are due to firearms, 10% are due to sports and recreation, and 7% are due to other causes, such as cancer, hemorrhages and encephalitis (Conforti, A., 1999).

The statistics above show that the incidence of traumatic brain injury is high in the United States, however, it is impossible to know exactly how high this rate is. One reason for this is primarily because many head injuries are not included in official statistics which could be due to the fact that definitions of Traumatic Brain Injury vary amongst research groups and agencies that track traumatic brain injury incidences. For example, many people with mild injuries do not gain access to the health care system because many such injuries are labeled incorrectly or are ignored. Further, many of these individuals who may have all of the symptoms of having traumatic brain injury do not know the cause of their symptoms.

The most effective type of treatment for any form of injury or medical problem is prevention. In order to help decrease the annual incidence of traumatic brain injuries in the United States and lessen the severity of those that do occur, numerous preventive measures exist. For example, health education, which includes the education of people regarding the harmful effects of alcohol and substance abuse or wearing the appropriate head gear when playing sports, crime victims and domestic violence organizations, defensive driving classes and the legislation requiring the use of air bags, seat belts and car seats, suicide hot lines and organizations, and psycho-social counseling. Also, last summer, Congress passed The Traumatic Brain Injury Act, which gave official recognition to traumatic brain injuries and authorized $24.5 million over the next three years in research, medical consensus building, and state grants (www.neuroskills.com, Feb. 1999).

Unfortunately, unless we are willing to remove all risks from daily life, head injuries will continue to occur and as stated previously, given the extremely sophisticated medical technology that we now possess more individuals are now able to survive catastrophic head injuries and remain in the community for near normal life spans. In order to provide for the variances in the levels of specialized care required by each individual and their families, numerous organizations, services, publications, and centers exist.

Ideally, rehabilitation should begin in the intensive care unit, where activities initiated can reduce complications and sometimes, the length of hospitalization. At this level, doctors try to medically stabilize the patient, while nurses and therapists help orient the patient, prevent pressure sores and contractures, promote bowel and bladder hygiene, and begin with exercises and functional activity training, if feasible. Once medically stable, the individual can then be transferred to an acute rehabilitation facility, where he/she will spend several hours a day in a structured rehabilitation program, while receiving the continued medical attention the he/she still needs. Patients at this level may range from comatose to being physically functional with some physical and cognitive deficits. After the rehabilitation stage, the patient may advance either to a sub-acute rehabilitation facility, an independent living facility, or go home to live by themselves or with a friend or family member.

In the acute rehabilitation setting, such as The Jamaica Hospital Brady Institute for Traumatic Brain Injury and Coma Recovery, therapeutic treatment may include:
I ) Sensory-motor stimulation - to increase the level of arousal of a comatose patient by introducing various stimuli to them.
2) Therapeutic positioning - to prevent pressure sores and contractures from developing or getting worse.
3) Splinting - to promote prolonged stretching to joints that may have already developed contractures.
4) Pain modalities - such as electrical stimulation, ultrasound, massage, hot/cold packs, and whirlpool treatments.
5) General strengthening and conditioning exercises.
6) Bed mobility and transfer training.
7) Balance and coordination training.
8) Ambulation, gait, and stair negotiation training with or without an appropriate assistive device.
9) Speech and swallow training.
10) Community re-entry training - to help re-introduce society to the patient and vice-versa.
11) training, in activities of daily living, such as dressing, homemaking, and hygiene, with or without appropriate assistive devices.
12) Experienced psychologists, cognitive therapists, and vocational therapists - work with the patients to educate and orient them, improve their reading and writing skills, and help restore and ensure their mental and psychological well-being.
13) Therapeutic recreation - to help patients enjoy leisure activities, explore their emotional needs, and learn to interact with others.

At Jamaica Hospital's Traumatic Brain Injury unit, plans of care are individualized and based on each patients needs. In order to achieve maximal results from the different therapies that are offered, treatments sessions are independent, as well as, interdisciplinary. This means that each department involved in the patient's care, not only establishes their own goals, but implements goals that are discussed and carefully set by all of the disciples together. Communication amongst the staff is highly recommended, and inter-disciplinary meetings occur every two weeks so that each discipline can convey their information about the patient to the other team members and record pertinent information provided by them. Family members are, also, usually encouraged to participate in the patient's therapeutic care, since the patient may respond better to a face that they recognize than to someone who is a stranger to them. They can relay to the staff what the patient was like previously, what their likes and dislikes were, and any other pertinent information that may help the staff enhance, and hasten the recovery of the individual. It also helps the family members overcome their feelings of fear, panic, and despair.

In the sub-acute rehabilitation setting, which is often in a skilled nursing facility or nursing home, facilities may vary in their policy for admission. This could be based on age, level of severity of disability, and the type of insurance accepted. Some provide short term rehabilitation, while others provide long-term care. Most importantly, those involved in the patients' care should consider how he/she will get along there. For example. are there others with whom he/she can identify? Are the services provided right for the patient? Does the staff seem to understand traumatic brain injuries? Therefore, reading about the facility, talking to other patients, and their family members at the facility, as well as, visiting the facility, itself, is highly recommended before making any final decisions. The Joint Commission of Accreditation of Health Care Organizations can tell you if the facility has any complaints against it, as well as, provide you with information regarding the type, capacity, certification, services, and violations for any facility.

Independent living facilities usually have several different levels ranging from people requiring more assistance to those who are living independently and simply need monitoring. Services may include shopping for the patient, house cleaning, cooking and recreational programs. They may receive medical care based on the individual's health needs, as well as, therapeutic and transportation services. Such facilities are usually very expensive and either, partially or not covered by insurance companies, depending on the patient's severity of disability and the patient's insurance carrier policy.

Patients who end up going home may require continued services at home or on an outpatient basis. Home-care may include a visiting nurse, home health aid or personal assistant, physical therapy, occupational therapy, and speech therapy. Outpatient care is provided at a facility to where the patient is brought between one to three times a week to receive cognitive, speech, vocational, occupational, and/or physical therapy. One may also receive continued psychological or psychiatric services if medically necessary.

Schools, cultural centers, and community organizations may also provide classes for people with brain injuries, called ESL, or English as a Second Language. Such classes are important to avoid the double handicap of having a brain injury and not being able to speak the language of their predominant culture. Some patients may have never learned English, while others, who are bilingual, may have returned to their mother language and forgotten there English skills. It is best to find an ESL class that specializes in working with people from that culture in order for the classes to be most effective and beneficial for the individual.

Overall, the goal of rehabilitation is to try to maximize the mental and functional status of the individual as quickly as possible. It also exists to help meet the needs of those family members that are involved in the care of that person. Social workers, psychologists and support groups can help provide people with an education about traumatic brain injury, -teach them how to cope with it, and provide emotional support on a one-on-one or group basis. They can also help the individual and family members deal with death and bereavement, if necessary.

At all levels, finances always remain a very difficult area for those with traumatic brain injuries. Sometimes, the individual and their family are already in some type of financial crisis when the injury strikes. Other times, it is the injury itself that puts the family in financial dilemmas, either by the loss of income or the burdens of medical bills. Whatever the situation, financial aid and assistance will usually be needed.

Social services and many agencies exist in order to help people with credit counseling and money management, provide benefits counseling such as helping one apply for SSI, SSDI, appeal adverse determinations, or help with getting Medicare and/or Medicaid. They can also assist in establishing the appropriate continued care for the patient, as well as, ordering equipment needed. Legal advocacy agents can also help people in cases such as no fault or worker's compensation, with estate planning, trusts, and wills.

In conclusion, traumatic brain injuries can range from mild to severe. Its effects are not only physically, psychologically, and socially challenging for the individual suffering from the injury, but for the family members caring for them, as well. Numerous preventive measures have been introduced to our society to decrease the incidence and lessen the severity of such injuries. However, many organizations exist, and are still very much needed today in order to assist individuals and their family members cope with the effects of brain injuries. Unless, we remove all risk factors from our daily lives, brain injuries will continue to occur with increasing rates of survival, secondary to the continuing advances in medical technology every day. Your life is in your own hands - take good care of yourself!

References

American Re- Insurance Company (1993). Guidelines for reserving traumatic brain injury. Princeton, NJ: American Re- insurance Co..

Annegers, J.F., Garbow, J.D., Kurtland, L.T. et al (1980). The Incidence, Causes, and Secular Trends of Head Trauma in Olstead County. Minnesota 1935 - 1974. In biausa.org, The Costs and Causes of Traumatic Brain Injury [on-line]. Available: http://www.biausa.org/costsand.htm. (November 10, 1999).

Conforti, A. (1999). The brady institute for TBI and coma recovery [on-line]. Available: http://www.jamaicahospital.org/brady1.htm. (November 6,1999).

Kraus, J.F., MacArthur, D.L. (1999). Incidence and prevalence of, and costs associated with, traumatic brain injury. In E.R., Griffith, J.S., Kreutzner, B., Pentland, & M., Rosenthal (ed.), Rehabilitation of the adult and child with traumatic brain injury. (pp. 9-16): F.A. Davis.

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Miller, T.R., et al (1995). Databook on nonfatal injury: incidence, costs and consequences. Washington DO Urban Institute.

Mitiguy, J.S., Thompson, G., and Wasco, J. (1990). Understanding brain injury: acute hospitalization. Massachusetts: New medico Head Injury Systems.

The National Brain Injury Association (1999). The costs and causes of traumatic brain injury [on-line]. Available: http://www.biausa.org/costsand.htm. (November 10, 1999).

The National Brain Injury Association (1999). Prevention [on-line]. Available: http://www.biausa.org/peventi.htm. (November 10, 1999).

The Saskatchewan Brain Injury Association (1999). Reference (stats, and facts). [online] Available: http://www.sfn.saskatoon.sk.co/health/shia/refer.html. (November 6, 1999).

Unpublished data from Multiple Cause of Death Public Use Data from the National Center for Health Statistics, 1996. In biausa.org, The- Costs and Causes of Traumatic Brain Injury [on-line]. Available: http://www.biausa.org/costsand.htm. (November 10, 1999).