Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans (2019) / Chapter Skim
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2 Diagnosis and Assessment of Traumatic Brain Injury
2 Diagnosis and Assessment of Traumatic Brain Injury
Pages 23-56
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From page 23... ...
Mechanism of Injury There are various mechanisms that can bring about a traumatic brain injury, which can result in physiologic or structural brain damage. The committee discusses those different mechanisms, which include blunt, non-penetrating TBI injury; penetrating injury; and blast injury.
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. Blast-Induced TBI Blast-induced traumatic brain injury (bTBI)
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Chronic neurologic symptoms following traumatic brain injuries in military personnel are common and can include global disability, neurobehavioral impairment, and psychological comorbidities (Laskowitz and Grant, 2016)
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There are multiple schema that have been developed by several organizations to assist in defining TBI severity (see Table of Case Definitions of Traumatic Brain Injury in Appendix F) which differ slightly from one another according to which criteria are weighed most heavily.
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. The individual's age at the time of initial injury has a significant influence on the risk of accelerated decline (Gardner et al., 2014)
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28 Potential Trajectory Pattern by Post-Injury Phase Factors Influencing Trajectory Severity of injury Glasgow Coma Scale score Mechanism of injury Vulnerability to injury Sex (F more vulnerable than M) Prior TBI Pre-existing CNS conditions Symptom reporting Sex (F report more symptoms than M)
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From page 29... ...
Breaks in the trajectory lines, between phases, indicate a lack of knowledge of how a trajectory in one phase influences the trajectory of the following phase. ADD/ADHD = attention deficit disorder/attention deficit hyperactivity disorder; CNS = central nervous system; F = female; M = male.
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From page 30... ...
. Another recent study found that males, but not females, with TBI performed significantly worse than comparison participants without TBI on a dynamic task of emotional recognition abilities and that the sex difference could not be explained by lesion location, TBI severity, or other neuropsychologic variables (Rigon et al., 2016)
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Their study identified genetic variants primarily involved in two biologic processes: response to injury (cell proliferation, cell death, inflammatory response, and cellular metabolism) and neurocognitive and behavioral reserve (brain development, cognition, and behavior)
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In a study using the same data source, racial/ethnic groups were found to be comparable in terms of injury severity score, TBI severity, and associated injuries. However, after adjusting for confounders including insurance status, non-white patients were 15 percent less likely to be placed in rehabilitation than white patients (Shafi et al., 2007)
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From page 33... ...
However, it is likely that three ongoing, large-scale, multi-center, observational, longitudinal studies that are now in the advanced stages of data collection, curation, and analysis will reveal new information about both the psychosocial and neurobiologic manifestations of mTBI. Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACKTBI)
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From page 34... ...
In particular, the discovery of one or more biomarkers of the chronic effects of TBI could be an important advancement for disability determination if these indicators were sensitive to both current functional effects and vulnerability to future consequences. ESTABLISHING A TBI DIAGNOSIS While the previously described studies may lead to the identification of biomarkers that can confirm the diagnosis of TBI long after injury, at the present time a clinical interview and self-report using a validated screening method is considered the gold standard for determining a comprehensive lifetime history of exposure to TBI.
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. Because many mTBIs are not evaluated at the time of injury, injuries incurred during deployment are typically screened retroactively with the Brief Traumatic Brain Injury Screen (BTBIS)
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The evaluator scores the section as "abnormal," "normal," or "deferred." The Brief Traumatic Brain Injury Screen The BTBIS is a one-page paper-and-pencil questionnaire designed by the DVBIC to screen for TBI in service members (DVBIC, 2007; Schwab et al., 2007)
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None of the above 3. Are you currently experiencing any of the following problems that you think might be related to a possible head injury or concussion?
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. They all include similar criteria concerning which factors to consider; they vary primarily on the criteria for diagnosis of mTBI, whereas moderate to severe TBI is consistently defined as a loss of consciousness of greater than 30 minutes, posttraumatic amnesia lasting longer than 1 day, and a score on the Glasgow Coma Scale of less than 13, with or without abnormal imaging.
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DSM-5 identifies age, a prior history of brain damage, and a history of substance abuse as factors that might impede recovery following any type of TBI. DSM-5 lists the common symptoms that further support the diagnosis of major or mild neurocognitive disorder due to traumatic brain injury.
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More severe sequelae are factors beyond the initial injury presentation. For example, likely due to psychologic factors.
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Advanced Imaging Techniques Diagnosing brain injury for all levels of TBI severity is a particularly active area of research. Advanced MRI imaging techniques such as diffuse tensor imaging (DTI)
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Limitations of Current Approaches in the Clinical Diagnosis of Mild Traumatic Brain Injury The current methods of mTBI diagnosis rely on a report of certain symptoms at the time of injury from the person who was injured or from a witness. The immediate symptoms that indicate mTBI are a brief loss of consciousness or a period of amnesia or confusion, or both.
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. Health Care Professionals Trained to Diagnose Traumatic Brain Injury Given the complexities in diagnosing TBI, especially mTBI, and the time that might have elapsed since the original injury, a diagnostician needs to be trained on and familiar with the standard diagnostic tools (discussed earlier in the chapter)
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The committee recommends that the Department of Veterans Affairs allow health care professionals who have specific traumatic brain injury (TBI) training and experience, in addition to the current required specialists, to make a TBI diagnosis.
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(2017) reported that behavioral health diagnoses were twice as common in those with a history of a TBI diagnosis, regardless of severity, as those without.
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Screening instruments vary in the extent to which their psychometrics have been established, with single-item screens tending to be the least reliable and least likely to capture all TBIs. Because many mTBIs are not evaluated at the time of injury, injuries incurred during deployment are typically screened retrospectively with the Brief Traumatic Brain Injury Screen (DVBIC, 2007; Schwab et al., 2007)
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The committee believes that it is the training and experience and not necessarily the specialty that renders a health care professional capable of an accurate diagnosis. The committee recommends that the Department of Veterans Affairs allow health care professionals who have specific traumatic brain injury (TBI)
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2010. Sex differences in outcome after mild traumatic brain injury.
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2017. Inflammation relates to chronic behavioral and neurological symptoms in military personnel with traumatic brain injuries.
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2017. Understanding treatment of mild traumatic brain injury in the military health system.
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DIAGNOSIS AND ASSESSMENT OF TRAUMATIC BRAIN INJURY 51 Continuum Journal of Neuropathology & Experimental Neurology Greenfield s Neuropathology Archives of Physical Medicine and Rehabilitation Archives of Orthopaedic and Trauma Surgery Archives of Surgery Brain Injury JAMA New England Journal of Medicine JAMA Exploring the biological contributions to human health: Does sex matter? British Journal of Sports Medicine Annals of Emergency Medicine Advances in Neurobiology Scientific World Journal Brain Injury Journal of Neurotrauma Journal of Neurotrauma Translational research in traumatic brain injury
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2016. Role of pre-morbid factors and exposure to blast mild traumatic brain injury on post-traumatic stress in United States military personnel.
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2017. Systematic review of genetic risk factors for sustaining a mild traumatic brain injury.
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2017. Structural imaging of mild traumatic brain injury may not be enough: Overview of functional and metabolic imaging of mild traumatic brain injury.
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2014. White matter integrity and cognition in mild traumatic brain injury following motor vehicle accident.
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56 TRAUMATIC BRAIN INJURY IN VETERANS Journal of Neurotrauma Archives of General Psychiatry Journal of Neurotrauma,
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