Understanding, addressing traumatic brain injuries leads to better outcomes, experts say
With the vast majority of TBIs being treatable, it behooves employers and insurers to understand the characteristics of these injuries and what they can do to prevent needless suffering and unnecessary costs.
"It isn't like having a burn or something you can see," said Dr. Albert E. Holt, IV, chief medical officer for Paradigm Management Services, a catastrophic specialty networks company. "There are significant neurologic changes occurring inside the head."
Holt is referring to mild or moderate TBIs, which comprise the vast majority of these injuries. Where severe TBIs typically involve readily apparent physical and functional impairments, mild to moderate brain injuries involve a wide range of impairments that may not be obvious for some time.
Nature of TBIs.
TBIs affect approximately 1.7 million people each year at an estimated cost of $60 billion in direct and indirect expenses. In the workplace, they often are the result of falls, being struck by an object and motor vehicle crashes -- which are among the leading causes of workplace injuries, according to the Bureau of Labor Statistics.
"The biggest thing is understanding that TBI typically involves a loss of consciousness," Holt said. "A conk on the head doesn't do it."
But diagnosing a mild-to-moderate TBI is no simple task. "When an injured worker sustains a mild to moderate brain injury, it is quite possible that early testing through CT scan or MRI will be normal," according to a recent Paradigm white paper. "In fact, the results of most early scanning tests for mild TBI are negative."
In such cases, the untrained physician might believe the worker is medically ready to return to work. The problem, according to Paradigm, is that symptoms may not be present or are present but may go unrecognized for weeks, months, or even a year after the incident.
"There are a whole host of things that can happen that can go undiagnosed," Holt explained. "The person is forgetful, or may have simple cognitive problems. Some develop post traumatic stress disorder, but it goes unrecognized as a problem associated with the injury."
Because the symptoms can be subtle and slow to emerge, Holt said many family members, co-workers and employers minimize them. "They'll say, 'oh, he's just a little forgetful.' Or, 'he just can't understand.'"
Without the proper evaluation at the onset of the injury and careful follow up, the complexity of mild TBIs can lead to complications requiring comprehensive intervention and extended periods of disability.
Employers can play a role in helping to detect TBI symptoms in an injured worker. "When [the injured worker] returns to work, they should be monitored closely for changes in behavior in workplace performance -- things that don't show up on an MRI," Holt said. "Being alert for those issues is critical."
Injured workers with TBIs may seem irritable or confused and can be unable to regulate their anger, while others struggle to pay attention and can't appropriately judge or react to social situations they once managed without effort, according to the white paper. These symptoms signal the need to get the injured worker to the appropriate medical provider.
"If someone comes back to the workplace and his performance has changed, or his mood isn't right, or he has sensitivity to light, they ought to be more fully evaluated by a specialist in brain injury," Holt said. "If someone goes to an ER, he'll get an evaluation, but it won't be as complete as going to a specialist in brain injury, a sub specialty of physiatry."
Holt also said many primary care providers are not trained in diagnosing or treating TBIs. He stresses the need to get the worker to the right provider, which would be someone specifically trained in diagnosing and managing traumatic brain injury and its complications.
Once a TBI has been diagnosed, a comprehensive treatment plan can be created to help the person recover to the fullest level of function possible. The type of treatments and therapies that will need to be part of the plan will vary based on the degree of injury and the other neuro-psychiatric manifestations of the TBI.
"If there are cognitive deficits, a structured program will help them to relearn," Holt said. "If there are emotional issues, sometimes both a structured and supervised program, in concert with pharmacological therapies are needed, making sure they are safe and not at risk to themselves."
If medications are called for, Holt says Paradigm's philosophy, as is the recommendation by brain injury specialists, including Paradigm's founder, Dr. Nathan Cope, is to start low and go slow. "Whatever the medications, start at low doses and increase the doses slowly. Sometimes these people are incredibly sensitive to the drugs."
Additional treatments may include relaxation, biofeedback, muscle and nerve blocks, and medication to address headaches. Hormone replacement may be necessary in cases of pituitary gland impairment.
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January 5, 2012
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