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Shaw Chiropractic Traumatic Brain Injury: How is it documented? There is considerable interest these days on the topic of closed head injury. The seriousness of these injuries can result in long term and profound sequella to the injured victim. Insurance companies seem more willing to settle these cases for higher values than the typical strain and sprain. Attorneys have found that these cases are particularly lucrative if they can be properly documented. Herein lies the problem. How does a treating physician provide adequate documentation of the traumatic brain injured patient? This newsletter will review some of the diagnostic considerations and management approaches which should be considered in the TBI patient. The majority brain injuries would be classified as mild traumatic brain injury (MTBI). What is the definition of a MTBI? The Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine has adopted the following definition: A traumatically induced physiologic disruption of brain function, as manifested by one of the following: 1)Any period of loss of consciousness; 2) Any loss of memory for events immediately before or after the accident.; 3) Any alteration in mental state at the time of accident (e.g., dazed, disoriented); 4) Focal neurologic deficits, which may or may not be transient, but when severity does not exceed the following--loss of consciousness for 30 minutes or less; after 30 minutes, Glasgow Coma Scale (GCS) of 13-15; post traumatic amnesia not greater than 24 hours" You will notice from the definition that loss of consciousness is not essential to have sustained a MTBI. In fact, just like a whiplash injury, it is the acceleration forces which cause the majority of MTBI. The MTBI can be from blunt trauma or acceleration. As we have discussed on numerous occasions, the threshold for soft tissue damage (like brain tissue) is extremely low and can be overcome at G forces sustained in low velocity collisions. The brain matter is composed of many tissues of different densities. Through the shearing forces encountered during brain compression against the internal skull structures these Jello like tissues can undergo disruption of neuronal pathways. These injuries can easily occur when the occupants head is tossed back and forward but the brain is bounced around the interior of the cranium. Usually the brain contusion occurs on the side opposite the direction of head movement due to the fluid based surrounding environment of the brain. This typical injury is termed a coup-contracoup injury. Symptoms often associated with the MTBI patient include irritability, restlessness, lack of ability to concentrate, change in personality, and depression. Patients find themselves intolerable to noises and bothered by children. They often have little control over their emotions and frequently seem angry. They report memory changes as well as memory deficits. They report difficulty with sleeping or have restless sleep associated with bad dreams. Headache is the most common symptom as is usually described as a dull aching, throbbing or pressure sensation. The headaches can occur daily for years or occur only intermittently. They may report speech difficulties due to problems completing the thought process. Tinitus, a ringing in the ear, is also common. Vision changes are also common but not associated with abnormal opthalmologic findings. Diagnostic evaluation of these MTBI can be challenging since they are usually not the result of a organic lesion and therefore somewhat obscure in presentation. The challenge as always is the objectification of the brain damage for 3rd party verification as well as proper management. Attached to this newsletter you will find a list of diagnostic procedures available for brain injuries and their relative value in support of the diagnosis. These include x-rays to rule out fracture, CT, MRI, PET, SPECT, BAER, EEG, and BEAM. After reviewing the procedures you will find that while it may be a challenge these injuries can be objectively documented. A greater challenge will more than likely will be finding a physician who is sensitive to these types of injuries and willing to make the necessary referrals to properly and accurately diagnosis these unfortunate and often overlooked patients. X-Ray: Although essential in the initial evaluation of head trauma to rule out fracture many patients with blunt trauma will require more sophisticated imaging techniques to assess for intracranial bleeding as well as fractures not readily seen on plain film radiographs CAT: Computed Axial Tomography permits the examination of tissue by the same principle as conventional x-ray except that radiation passes successively through tissue from multiple directions. Detectors measure the degree of attenuation of the exiting radiation and computers integrate the information and construct cross sectional images. Use of contrast material enhances the attenuation and provides greater insight into the integrity of the blood brain barrier. CT has the advantage of a short study time and is therefore the preferred method of imaging for rapidly evolving neurologic disorders such as those seem with intracranial bleeding. It is also advantageous in the evaluation of bone and therefore is better suited for the detection of acute cranial fracture. Adverse effect of CT include relatively high doses of ionizing radiation. It is also significantly less sensitive than MRI for brain stem and cerebellum imaging in the posterior fossa as well as the temporal lobes of the middle fossa. The cost of CAT is approximately ½ of MRI imaging for similar areas. MRI Magnetic Resonance Imaging studies place body tissues in strong magnetic fields thereby polarizing the naturally occurring isotopes (atoms). A transient application of a radio frequency pulse perpendicular to the magnetic field reorients the atoms and when the pulse is turned off it attempts to return to the polarized orientation. There is a resulting resonance which is measured by receiver coils and integrated into images which can be constructed from nearly any angle. Recent developments have permitted the assist of the contrast medium gadolinium thereby providing information about the blood-brain barrier like the CAT scan. MRI is advantageous since there is no ionizing radiation and is very sensitive to blood flow. Recent advances in computer techniques using ultrafast and echoplanar acquisition have made MRI and CT equally fast. However, these newer techniques do not provide as much information as the traditional spin echo images. MRI is superior to CT in visualizing the neurologic structures. New techniques including MRA, MR Spectroscopy and Functional MR provide information regarding cerebral metabolites, brain pH, neurotransmitters, cerebral blood flow, oxygenation of hemoglobin. PET Positron Emission Tomography uses a radio ligand with a positron emitting isotope which upon radioactive decay collide with electrons. The collision results in annihilation of both particles and releases energy in the form of twp photons (gamma rays) which can be detected by the scanner. The test can identify cerebral metabolic rates for glucose, and measure cerebral blood flow. The use of PET is limited by it’s high cost and need for a cyclotron nearby. It also has restricted temporal and spatial resolution. SPECT Single Photon Emission Computed Tomography is similar to PET except the radio ligand decay emits only 1 photon. The test is valuable particularly for cerebral blood flow as seen with subarachnoid hemorrhage. SPECT has shortcomings of restricted resolution and quantitation and limited versatility for studying cerebral biochemistry and metabolism. Cost for this procedure are also extremely high. EEG Electroencephalography is a measure of the brains electrical activity. It is performed by applying a series of electrodes to the scalp in specific montages and measuring the electrical activity of the brain. This test has been very helpful for patients with seizure disorders but does not provide much information on patients with closed head trauma or post traumatic headache. BAER Brainstem Auditory Evoked Response testing evaluates the integrity of a portion of the nervous system as it passes through to the brainstem. People with post traumatic brainstem injuries may show abnormalities of conduction through electrical generators which may suggest shearing of nerve fibers and end bulbs in the tracts between the diencephalon and brainstem. BEAM Brain Electrical Activity Mapping (AKA Topographic Brain Mapping, Quantitative EEG, Brain Mapping) combines the technology of a EEG with evoked potential methodology to produce color maps representing the electrical activity of the brain. The test allow for little subjective evaluation. TBI patients may have structural damage which leads to cortical disconnections resulting in an imbalance of brain chemistry and neurotransmission. The BEAM can locate these disconnections with a relatively high degree of certainty. Very mild scarring can be detected and recovery can be monitored. Some controversy exists to the validity of the test. Neuropsychometric Testing: Neuropsychometric testing is the domain of the neuropsychologist. Not all psychologists are trained as neuropsychologists. In fact, there is specific postgraduate training required to be qualified. These specialists run batteries of tests lasting from 2 hours to two days to determine the extent of the brain injury. Their examinations are thorough and provide significant insight into the areas of brain damage and the potential for rehabilitation. Neurologists and physiatrists may treat TBI victims but generally do not perform neuropsychometric testing. Chiropractors, neurologists and physiatrists are generally the specialists requesting these evaluations. These tests and evaluations can objectively document the traumatic brain injury effects of a closed head trauma. Knowing which test to order and when to order them is critical for proper evaluation. Finding a physician who is both familiar with and sensitive to these injuries may present a greater challenge. At SHAW CHIROPRACTIC we work with physicians and testing centers sensitive to the needs of your clients and our patients. Call us for more information. 800-232-6824 |
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