Walking Wounded: Mild TBIs

By: Dianna L. Anderson BSN, RN, CRRN, CCM, CNLCP and Bob Angell, Ph.D.

Introduction

My friend Pierre, is a former college football player and owns several art galleries in a few western states here in the USA. As a former player, he has many stories about TBIs and how they have affected his friend’s and former colleagues’ cognitive abilities over the years. Before football players start playing for the first time, they go through a series of cognitive tests, so that the team physician has a baseline of normal cognitive abilities. This is important, as most football players receive injuries to the brain during play in the form of concussions or mild TBIs with up to 3.8M concussions yearly in the US. [https://www.healthgrades.com/right-care/brain-and-nerves/tbi-vs-concussion-whats-the-difference, sourced 3 Feb 2022]. Additionally, these injuries result in up to 300,000 hospitalizations and $60 billion in direct hospital costs in the same time frame. [https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC6479246/].

As medical experts, we have been involved with TBIs professionally for many years, even developing material for clinical Grand Rounds (GR). Medical GR are typically found in a teaching hospital, held held weekly or bi-weekly by medical specialty, to review emerging best practice methodologies and treatments to an audience of seasoned clinicians, interested ancillary personnel, training residents, and medical students. We are both on the board of directors of the Brain Injury Research Foundation [https://thebirf.org/who-we-are/] and Ms. Dianna Anderson was a former board member of the Brain Injury Alliance of Utah and has developed and presented formal Medical and Legal Continuing Education (CME/CLE) about TBIs.

Walking Wounded

We recently attended a professional conference with its goal of educating and highlighting Traumatic Brain Injury (TBI) to the legal profession. There were many classes discussing all aspects of this disease. One in particular, was a question-and-answer session with a former NFL football player who had received multiple TBIs and how they have affected his life. Even as a seasoned TBI expert, this was sobering to hear. However, of interest for the legal profession, is that the mild TBI has a very high potential for long-term disability, due to changes in one’s cognition. Multiple TBIs are most common among football players, boxers, recipients of repeated spousal abuse, etc. These individuals are truly the walking wounded.

Classification and Incidence of Traumatic Brain Injury

TBIs occur when normal brain function is interrupted by a direct or indirect insult to the head by a fall, being hit by or against an object, or a motor vehicle accident (MVA). In an MVA, a sudden stop from going 40 mph resulting in an abrupt change of differential speed, can even cause a TBI This is would be an example indirect insult to the brain. The variable forces of loading (impact, acceleration/deceleration), location, and magnitude creates a spectrum of pathophysiological outcomes for the patient. Clinically observed altered brain function after a head injury may include: loss of consciousness, amnesia for events immediately before and after the even, changes in motor control, balance, speech, confusion, disorientation, and/or problems concentrating. The Glasgow Coma Scale (GCS) is the neurological assessment gold standard for classifying TBIs and is beyond the scope of this article. Details are found in the study referenced by this article. There are also emerging ways to determine TBIs through gene expression analysis. [https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC8042258/].

Even mild TBIs will increase an individual’s risk of additional heath issues such as depression, risky behavior such as excessive gambling, abnormal sexual behavior/dysfunction, and/or binge drinking. Additional issues may include neurodegenerative diseases and post-traumatic epilepsy. Due to the variability of cognition post TBI, it is critical to understand all of the long-term aspects of a patient’s dysfunction and diminished quality of life. As part of Applied Medical Litigation Informatics (AMLI), we provide Nurse Life Care Planning services to help guide appropriate settlements for patients with long-term disabilities and also provide testimony as an expert witness in such cases.

In summary, TBIs are extremely nuanced by classification, severity, repeated injury, and long-term patient effects. In our experience and through Pierre’s stories, mild and repeated TBIs appear to be the most prevalent. Regardless of prevalence or severity, all TBIs are significant and present a challenge to all who receive them. For example, as a motorcyclist, I always wear a “brain bucket” (helmet) to protect myself as best I can to mitigate a TBI in case of injury. Also, helmets are useful when skiing, skate boarding, or even riding a bicycle. Remember, even the cool kids are now wearing these. Protect that noggin!!