Note that “traumatic brain injury” or “TBI” and “brain injury” are often used interchangeably to describe all forms of injury, including severe traumatic brain injury and concussion. “Concussion” and “cerebral concussion” are also used interchangeably.
Words and Concepts that Truly Define the Hierarchical Brain
Defining certain concepts and categorically organizing such concepts in a meaningful way to effectuate diagnosis and treatment and predict outcomes is what BHET is all about. While there are various approaches to evaluate and treat TBI/concussion, the BHET method espouses that there can indeed be a right and wrong way to evaluate and treat persons who carry the diagnosis of TBI or concussion.
Structural Anatomy: Relates to the physical structures of the nervous system that are both microscopic (also referred to as histological anatomy) and macroscopic that can be seen with the naked eye (also referred to as gross anatomy).
Physiology: Deals with the biology of how all living organisms work in relation to physical and chemical processes.
Cognitive or Neurocognitive or Neuropsychological Functioning: Deals with the cognitive function of humans that allows us to behave in certain ways that express who we are, what we believe, what is important to us, and how we relate to each other. It involves how we communicate, understand, express emotions, learn, memorize, perceive, process information, and relate to others and the world around us.
Neurobehavioral Functioning: Relates to how we react to who we are, what we perceive others to be, and how we respond to a situation. For example, anger, depression, anxiety, paranoia, and obsessive-compulsive tendencies are more neurobehavioral and can occur as a result of physical and neurocognitive factors, the environment, injury, or genetic defects that impact our physiological, functional, and our structural order.
Psychosocial: Looks at how the psychological factors and the social environment impact the physical health and mental wellness of an individual and their ability to function in society.
The hierarchical approach takes into consideration the following concepts:
1. Understanding the normal working of the brain and the working of the brain following injury – Having knowledge of the normally working brain enables a comparative understanding of the levels of disorganization that occur following injury and the subsequent reorganization that occurs during the recovery process. Anatomical, structural, and physiological disorganization produces a certain symptoms complex. Patients are not only treated according to the level of signs (what the professional finds) and symptoms (what the patient experiences) but also based on an understanding of the anatomical, structural, and physiological disorganization that disrupts the hierarchical order of functioning. This disruption can produce a complex set of symptoms reported by the patient and signs noted by families, caregivers, and through a meticulous evaluation performed by qualified clinicians. In doing so, BHET focuses on determining the level and severity of injury at every stage of the recovery process in terms of the hierarchical organization. BHET utilizes realistic evaluation methods to properly classify those conditions.
2. Treatment Concepts – The simple principles of what to treat first, where to start, how one sign or symptom relates to another, what athe triggers of a sign or symptom are, how to proceed with and when to end a treatment modality, are all critical issues in TBI/concussion. It is essential to establish the order and sequence of administering a treatment modality after the condition has been properly staged and classified. Once the level of disruption is established, there is generally an attempt to match the available treatment modalities to the patient based upon the level established. While the levels cannot always be neatly defined, any effort to classify the disorder into a hierarchy will go a long way towards treatment planning. BHET also provides sensible, logical, and whenever possible consensual and evidence-based tangible treatment modalities that generally produce positive results. This facilitates an approach that determines what should be evaluated and treated in the appropriate sequence and manner for effective recovery. This model utilized to treat TBI has the level of hierarchical organization and reorganization following TBI/concussion as its focus. Addressing those issues utilizing the BEHT method has made the concepts meaningful. Clinicians must resist the urge to start treatment when they have no idea what they are treating but feel the urge to do something because of the suffering reported by patients and their families. Such issues of treatment will be addressed in the second volume of this book series.
BHET provides a framework that can be utilized for making critical decisions about staging, prognostication, and treatment. This book was designed to bridge a significant chasm that exists among the various healthcare professionals and between health professions and the lay public. By taking this very complex area of neuroscience that utilizes case histories and models, BHET makes it easy to understand this complex condition.
A major point of failure with clinicians treating TBI is their limited understanding of the hierarchical organization of the brain before and after injury and the subsequent recovery path that the brain follows during recovery. I have personally seen patients be harmed because of this misunderstanding. In fact, certain treatment modalities are often administered at the wrong time or stage of recovery because of a misunderstanding of the brain’s hierarchal organization and the process by which such disorganization is restored following injury. BHET was developed based on my experience as a neuroscientist working in the field of brain injury with a team of colleagues who I have come to respect and admire. In developing this method, I have been able to utilize my experience in leadership and business, the practice of neuroscience, knowledge of the human condition, and my understanding of how the nervous system works, in order to conceptualize and implement BHET.
Features of Cerebral Concussion and TBI
Key Elements that Define Concussion
ONE OF THE best definitions provided for concussion is based on a consensus statement provided at the 4th International Conference on Concussion in Sports held in November 2012 in Zurich. This very progressive definition evolved from the changing evidence that we now have on concussion. The definition is as follows: “Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic, and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:
1. Concussion may be caused by a direct blow to the head, face, neck, or elsewhere on the body with an ‘impulsive’ force transmitted to the head.
2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.
3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury, and as such, no abnormality is seen on standard structural neuroimaging studies.
4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged” (McCrory 2013).
BHET defined: Concussion occurs when mechanical forces affect the brain in such a manner that it disrupts the structural and physiological hierarchical organization and the associated functioning of the brain to the point that the patient experiences signs