The direct costs incurred due to TBI in the USA have been estimated at $13.1 billion per year. An additional $64.7 billion is lost because of missed work and lost productivity. The total medical costs range from $63.4 to $79.1 billion (Salassie 2008, Coronado 2011).
These cost estimates mostly cover direct costs, such as that spent on acute care, hospitalization, acute, and sub-acute rehabilitation. However, these numbers are believed to be an underestimation because they do not cover certain indirect long-term costs such as neurobehavioral management and the impact on families and social order. Worldwide, direct and indirect costs related to TBI borne by the global economy are estimated at approximately $400 billion per year.
Concepts and terms that better define TBI/concussion in the context of the BHET Method
OVER THE YEARS, the pressure to implement well-defined research methodologies combined with our misunderstanding of how the brain works, is injured, and how it recovers has forced us to standardize what many experts believe to be unsound definitions of what a concussion and/or a Traumatic Brain Injury (TBI) is. In fact, we now know that some of our conclusions regarding a brain injury and its impact have been sometimes wrong or misleading. These unsound definitions have caused us to have generations of people with missed cases of concussion and TBI. Imagine playing American Football in the 1960s, 1970s, 1980s, 1990s and even in early 2000. In many cases, you would not be considered to have suffered a concussion or TBI without loss of consciousness (LOC). LOC was a key part of defining a concussion, and this remained the case for many years. While LOC continues to be a factor in the definition, one needn’t have experienced LOC to have suffered concussion or TBI. We now know that most persons who suffer a concussion do not in fact experience LOC. I have seen patients with gunshot wounds to the head with a bullet traversing the frontal lobe of the brain with what we know to be a severe TBI requiring major neurosurgical intervention and yet not have experienced LOC. In a study performed with 343 individuals with concussion, more than 80% did not experience LOC and 95.6% had Glasgow Coma Scale (GCS) scores of 15/15 on presentation to the Emergency Department (ED). A score of 15 represents the best possible score following an injury (Pensford 2019).
A study published by the University of Pittsburgh Medical Center for Sports Medicine determined that only 2 out of 107 athletes with concussion suffered LOC, indicating that approximately 98% of persons with concussion in their program did not suffer LOC. According to Kenzie et al. (2017), LOC during concussion has been evidenced at 14%.
Even today, I hear some of my colleagues in neuroscience say that you must have LOC to be considered as having a concussion or TBI. How sad and uninformed! Several ex-football players who participated in hitting exercises whom I see as patients today tell me that if they did not experience dizziness, spinning sensation, feeling of being in a fog, or daze, they were considered “a softy.” What they did not know at the time is that every time they experienced these symptoms, yet another cerebral concussion was heralded. What we now know is that repeated hits to the head as that witnessed in American Football can lead to long-term consequences, including conditions such as chronic traumatic encephalopathy (also known as (CTE), a form of Dementia commonly seen in athletes with repeated hits to the head (McCrory 2017). Increasingly, data shows that even players with multiple hits to the head who are not considered to have suffered concussion (sub-concussive hits) can suffer long-term consequences such as CTE, a degenerative disorder of the brain caused by TBI and concussion (Moore 2017, McAlister 2017, Gardner 2015, Washington 2016).
Concussion occurs when mechanical forces affect the brain in such a manner that the physiological hierarchical organization and the associated functioning of the brain are disrupted to the extent that the patient experiences signs and symptoms which we now know are characteristics of concussion. These signs and symptoms include the following:
• Physical: fatigue, sleep disturbance, dizziness, spinning sensation, headaches
• Cognitive: mental fog, memory and attentional impairment, word-finding problems, communication problems
• Neurobehavioral: anxiety, depression, panic attacks, low self-esteem, fear, racing thoughts, short fuse, obsessive-compulsive tendencies
At its core, concussion have much to do with an imbalance between energy availability and its utilization throughout the brain or in certain parts of the brain (Giza 2001).
Following concussion/TBI, the delicate hierarchically organized structure of nerve cells or neurons working in an array becomes impaired and disorganized. These structures are responsible for the orderly production of energy to ensure the proper function of the brain. After injury, the brain remains impaired until there is recovery or reorganization of these neurons.
Applying the GCS criteria, approximately 80% of all TBI/concussion cases are classified as mild head injuries (Bazarian 2005, Rutland 2006). Data from various studies have shown that approximately 70–90% of all traumatic brain injuries are considered concussions (Cassidy 2004, Numminen 2011). In most cases, concussion symptoms last for a few days but rarely beyond 10–30 days (McCrory 2013, Broglio 2014).
Patients whose symptoms last for more than 30 days experience more physical, cognitive, and neurobehavioral signs and symptoms (O’Neil 2013, Williams 2015, McCrea 2003, Nelson 2016). When concussion symptoms last longer than 3 months following the initial injury, the condition is labeled as post-concussion syndrome. In this case, there are usually neurophysiological and neuropathological injuries to the brain structures, causing the disorganization and disruption of brain and body cycles, as well as functioning (Silverberg 2011).
Patients with repeated concussions tend to suffer greater long-term effects of concussion and/or TBI.
For the purpose of this book, “concussion” is defined as a milder form of TBI where the patient may or may not experience an alteration in or loss of consciousness for a brief period of time that is generally less than 30 minutes and may have the associated signs and symptoms but no focal neurological deficits. Focal neurological deficits generally involve an impairment in the neurological function of one or more parts of the body after an injury (e.g., weakness on one side of the body). The term “Traumatic Brain Injury” will be reserved for the more severe forms of injury, where there is one or more of the following: significant alteration in or loss of consciousness generally for more than 30 minutes; focal neurological deficits; or abnormal findings on CAT scan or routine MRI related to the injury. Abnormal CAT and MRI scans are rarely seen in concussion, depending upon how concussion is defined in various studies.
Between 5–15% of concussed patients will have trauma-related positive findings on MRI (Ellis 2015, Morgan 2015).
More recent sequences (techniques) in MRI, such as diffusion tensor imaging (DTI), can show abnormal findings in concussion patients that were not previously documented using the CAT scan or the regular MRI sequences (Arfanalkis 2002, Niogi 2008, Wilde 2008).
We now have both anatomic and physiological tools to evaluate one’s brain function after an injury, and while many of these tools are yet in their early stages of development, they tell us quite a bit about how the brain actually works, when an injury occurs, and what happens during recovery. Positron emission tomography (PET) scans and functional MRI (fMRI) are promising, as they look at the metabolism of glucose to reflect the functioning of distinct areas of the brain. The fMRI utilizes cognitive paradigms during imaging to look at the functioning networks and their connections to various areas (nodes) of the brain to determine their relationship while performing certain tasks (Medaglia 2017).
While there are limitations in these methods, they are valuable in the detection of injury and in understanding the patterns of recovery when compared to a normal functioning brain.
Recently, various pronouncements have been made about the identifiable markers of concussion/brain injury, which are found in blood and cerebrospinal fluids and that can be measured in the laboratory