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TBI Treatment: No Simple Answers

As published in Louisiana Advocates (December 2015 Vol. XXX. No. 12.), a publication of Louisiana Association for Justice. All rights reserved.

Even with all of the media coverage of military and sports brain injuries, traumatic brain injury (TBI) incidents appear to still be on the rise. An estimated 1.7 million people sustain a TBI annually, with about 75 percent of those injuries being concussions or other forms of mild traumatic brain injury (MTBI).1 In one year alone, TBIs accounted for approximately 2.2 million emergency room visits, 280,000 hospitalizations, and 50,000 deaths.2

While prevention is the key public health goal for reducing TBIs, their associated medical costs, and the loss of quality of life, it is also important for public health, clinical practice, and research personnel to design and evaluate rehabilitation strategies to reduce the negative, potentially long-term health effects of TBI.3

Likewise, attorneys who represent clients with TBI injuries must not only assist those clients in acquiring funding to cover treatment, but also they must keep up to date on potential treatments that may be beneficial to particular clients. Most attorneys are not doctors; therefore, an overview of the various treatments available is helpful.

TBI cases may easily take a year or more to resolve, and during that time a client will benefit from personalized, integrated, patient-centered care designed to produce the best health outcome during the litigation process and beyond.

Common diagnostic and treatment methods

Methods for diagnosing TBI have changed little in the past few years. These include:

• the Glasgow Coma Scale4 (used in emergency situations to determine consciousness level);

• magnetic resonance imaging (MRI)5 and computerized tomography (CT)6 scans (used to check for signs of internal bleeding or otherabnormalities);

• perfusion single-photon emission computed tomography (SPECT)7 that use radioactive tracers to document cerebral regional blood flow;

• DTI scans8 (more sophisticated, detailed image

portraying white matter abnormalities); and

• neuropsychological assessments9 (for treatment and rehabilitation when a TBI affects behavior, emotions, or cognitive ability).

Traditional inpatient programs for more severe brain injuries remain the treatment of choice, and there are several inpatient facilities in Louisiana.10 More common treatments for MTBI include pain management; neurological treatment; and multiple therapies, including cognitive, speech, physical, occupational, and vocational.11

However, since no two TBIs are the same, there cannot be one universal treatment plan. TBI symptoms include post-traumatic stress disorder, ongoing pain, depression and anxiety, memory problems, difficulty sleeping, headaches, mood disorders, possible medication side effects, and difficulty adjusting to family and/or work life after injury,12 among other things.

Because of the range of symptoms and individual preferences, some or all of the integrative or alternative treatments may not be good options for some clients. Nevertheless, it can only help to be aware of the different kinds of treatments and their benefits.

Consider other treatment options

Integrative medicine incorporates evidence-based complementary and alternative treatments into traditional medical treatment.13 Integrative medicine practitioners are partners with the individual patient and develop a comprehensive plan addressing the physical, psychological, environmental, familial, and spiritual issues of that patient. It seeks to treat the whole person, not just individual symptoms.14

Integrative medicine is not the same as alternative medicine, as the integrative approach combines conventional medical treatment with other treatment options that have demonstrated scientific reliability.15 Given that each TBI is unique, it seems worthwhile to investigate integrative medicine to increase a client’s chance of a full recovery.

Chiropractic care16 may help where there is also an injury to the neck. The spinal cord is thickest in the upper cervical (neck) region where it completely fills the spinal canal. The spinal cord is insensitive to pain and is often overlooked. If injured, it may become swollen, creating symptoms indistinguishable from mild brain injury.17

Compression of the spinal cord can result in disturbance of the function of the body below the area of subluxation. Symptoms often affecting the head above the subluxation may be due to compression of the nerves and blood vessels that supply the head, especially the vertebral arteries.18 Chiropractic care should be considered as one potential part of a comprehensive treatment plan.

A headache specialist may be consulted for diagnosis and treatment of painful disorders of the head, face, and neck.19 Generally, a headache specialist is a neurologist with additional certification in headache medicine and not simply a medical doctor who treats headaches or a pain management clinic.20

Currently five physicians in Louisiana are board certified in headache medicine.

With hyperbaric oxygen therapy (HBOT), a patient inhales 100 percent oxygen in a total body chamber that has increased atmospheric pressure. The oxygen dissolves into the body’s fluids and bone. This increased oxygen helps white blood cells kill bacteria, reduces swelling, and allows new blood vessels to grow more rapidly into the affected areas. It is a simple, non-invasive, and painless treatment.21 HBOT is used to treat many diseases as well as the after-effects of strokes.

A recent analysis of multiple studies found that HBOT reduced mortality, but it did not appear to improve long-term outcomes for patients.22 However, those studies dealt with serious TBI cases. More recent studies of MTBI cases where HBOT was used demonstrated improvement, although more research needs to be done.23

Some insurance companies may not cover HBOT for treatment of MTBI as it is still, for now, considered non-traditional treatment for TBI.

Near-infrared light therapy (NIR) for MTBI has been shown to stimulate healing of damaged brain tissue.24 Specific effects include increased cerebral blood flow, angiogenesis (generating new blood vessels), and neural cell growth.25 NIR may stimulate vasodilation, immune response, and neurotransmission.

Although more research is necessary, animal and human studies demonstrate that NIR may help reverse brain damage, especially in conjunction with cognitive therapy and exercise. It also has been shown to be beneficial in treating PTSD, often another symptom of TBI.26

Acupuncture, developed in China, is the practice of inserting fine needles into the patient’s skin at specific points with the intent to cure disease or relieve pain.27 The needles are so thin that the patient experiences very little discomfort.28 Generally, a treatment series will involve one or two treatments per week for approximately eight weeks.29

Although no two patients respond exactly the same to this treatment, it has very few risks.30 Acupuncture is worth investigating as a possible pain treatment that does not use drugs that may cause drowsiness or be potentially addictive and end up causing more harm than good.

Ayurvedic medicine is an alternative medicine that integrates the body, mind, and spirit. Its holistic approach focuses on diet, herbal remedies, exercise, meditation, breathing, yoga, and physical therapy. It is an ancient, traditional system of medicine developed in India.31 However, since there is no regulation of the herbs used in Ayurvedic medicine and its practitioners are not licensed in the United States, it is good to consult a primary care doctor about adding this alternative treatment to traditional treatment, in particular because some herbal remedies may conflict with prescribed medications.32

There is some evidence that meditation may help patients with TBI, especially when combined with other practices.33 Individuals with MTBI have improved their quality of life, memory, and attention, while reducing depression, after only ten to twelve weeks of meditation.34 The various practices include, along with meditation, breathing exercises, guided visualization, and reframing the TBI through acceptance.35

There is also clinical evidence that yoga can be helpful when treating anxiety and sleep disorders, depression, and some of the other common symptoms accompanying a brain injury.36

These are only a few of the constantly changing treatment protocols for TBI. And while this continual evolution may make assisting TBI clients more time consuming for attorneys, it is good news for clients. As more light shines on this invisible injury, additional and better treatment options can only improve the chances for a more complete recovery from TBI, which is what attorneys ultimately seek for their brain-injured clients.

Endnotes

1. http://www.cdc.gov/traumaticbraininjury/pdf/BlueBook_factsheet-a.pdf.

2. http://www.cdc.gov/traumaticbraininjury/pdf/TBI_Report_to_Congress_Epi_and_Rehab_Snapshot-a.pdf, pg. 2.

3. Id.

4. http://www.brainline.org/content/2010/10/what-is-the-glasgow-coma-scale.html.

5. http://www.emedicinehealth.com/magnetic_resonance_imaging_mri/article_em.htm.

6. http://www.emedicinehealth.com/ct_scan/article_em.htm.

7. Weston, Jon. “Near Infrared Light Therapy Treatment of mild Traumatic Brain Injury,” BioCare Systems, Inc., http://www.biocaresystems.com.

8. http://www.ninds.nih.gov/news_and_events/news_articles/DTI_as_mTBI_biomarker.htm.

9. http://www.brainline.org/content/2011/10/a-guide-to-neuropsychological-testing.html.

10. https://treatment.psychologytoday.com/rms/prof_results.php?state=LA&spec=206.

11.http://www.brainline.org/landing_pages/categories/rehabilitation.html.

12. http://dvbic.dcoe.mil/training/webinars/2013/role-integrative-medicine-treatment-tbi.

13. https://aihm.org/about/.

14. MacDonald, Margaret, M.D, B.C.N. and Drake, David F., M.D. “The Role of Integrative Medicine in the Treatment of TBI,” December 18, 2013, p. 19.

15. https://www.dukeintegrativemedicine.org/about/what-is-integrative-medicine/.

16. http://www.acatoday.org/.

17. http://www.yourspine.com/Chiropractor/Pain+Issues/Head+Injury.aspx.

18. Id.

19. http://www.michiganheadache.com/specialist.asp.

20. http://www.ucns.org/go/subspecialty/headache.

21. http://www.hbot.com/about-hbot.

22. “Near Infrared Light Therapy Treatment of Mild Traumatic Brain Injury,” supra.

23. Id.

24. Id.

25. Id.

26. Id.

27. http://www.medicalacupuncture.org/.

28. http://www.mayoclinic.org/tests-procedures/acupuncture.

29. Id.

30. Id.

31. http://www.ayurvedanama.org/.

32. Id.

33. http://hprc-online.org/mind-tactics/hprc-articles/can-meditation-help-tbi.

34. Id.

35 Id.

36. http://journal.frontiersin.org/article/10.3389/fpsyt.2012.00117/full.

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