Traumatic Brain Injury Rehabilitation Medicine 9781780844602, 9781780844619

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Traumatic Brain Injury Rehabilitation Medicine Editors David X Cifu Virginia Commonwealth University, USA Blessen C Eapen University of Texas Health Science Center at San Antonio, USA

Published by Future Medicine Ltd Future Medicine Ltd, Unitec House, 2 Albert Place, London N3 1QB, UK www.futuremedicine.com ISSN: 2047-332X ISBN: 978-1-78084-461-9 (print) ISBN: 978-1-78084-460-2 (epub) ISBN: 978-1-78084-459-6 (pdf) © 2015 Future Medicine Ltd All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without prior written permission of the copyright holder. British Library Cataloguing-in-Publication Data. A catalogue record for this book is available from the British Library. Although the author and publisher have made every effort to ensure accuracy of published drug doses and other medical information, they take no responsibility for errors, omissions, or for any outcomes related to the book contents and take no responsibility for the use of any products described within the book. No claims or endorsements are made for any marketed drug or putative therapeutic agent under clinical investigation. Any product mentioned in the book should be used in accordance with the prescribing information prepared by the manufacturers, and ultimate responsibility rests with the prescribing physician. Senior Manager: Production: Kathryn Berry Managing Production Editor: Aashni Shah Production Editors: Dharmesh Patel, Pamela Cooper & Hollie Franklin Graphics & Design: Clare Dolan & Tulsi Voralia Commissioning Editor: Duc Hong Le

Contents Traumatic brain injury rehabilitation medicine David X Cifu & Blessen C Eapen Epidemiology of traumatic brain injury Jud C Janak, Mary Jo Pugh & Jean A Langlois Orman Traumatic brain injury diagnosis classification and evaluation Yevgeny Zadov & Nikole Zadov Nonoperative management of acute traumatic brain injury Ajit B Pai Complications of traumatic brain injury John Dennis Alfonso, Blessen C Eapen & David X Cifu Sensory and system deficits following brain injury Neera Kapoor, John-Ross Rizzo, Derrick Allred & Carlos A Jaramillo Neuropharmacology in the medical management of acute traumatic brain injury Emerald Lin, Neil N Jasey, Christine Greiss & Peter Yonclas Traumatic brain injury rehabilitation Michael Yochelson & Amy Murphy

3 7 37 47 61 77 101 119

Contents Continued Imaging evaluation of traumatic brain injury David F Tate, Matthew W Reid & Gerald E York Prognosis in traumatic brain injury Heidi N Fusco & Jaime M Levine Sports concussions Daniel L Santa Maria & Joshua Goodwin Pediatric traumatic brain injury Udayan Kulkarni & Charles Dillard Disorders of consciousness Brian D Greenwald & Min Jeong Park Return to school and return to work after traumatic brain injury Paul Wehman, Pamela Targett, Charles Dillard & Priya Chandan Serum ‘central nervous system specific’ protein biomarkers of traumatic brain injury Teresa M Evans & William E Haskins

145 165 177 191 205 221 247

Contents Continued Emerging therapies in traumatic brain injury Diana S Busingye, Renée J Turner & Robert Vink Complementary and alternative medicine in traumatic brain injury Elizabeth Jayne Halmai & Rebecca N Tapia

261 273

About the Editors David X Cifu David Cifu, MD, is Chairman and the Herman J Flax, MD, Professor of the Department of PM&R at the VCU School of Medicine in Richmond, Virginia, Senior TBI Specialist for the US Department of Veterans Affairs, and Past President of the AAPMR. He has been funded on 38 research grants for over $128 million, including PI of the VA/DoD $62.2 million Chronic Effects of Neurotrauma Consortium (CENC). He has delivered more than 500 scholarly lectures, published more than 200 scientific articles and 65 abstracts, and co-authored 30 book chapters.

Blessen C Eapen Blessen C Eapen is currently the Section Chief for Polytrauma Transitional Rehabilitation Center and Adjunct Assistant Professor in the Department of Rehabilitation Medicine at the University of Texas Health Science Center in San Antonio. He is board certified in Physical Medicine and Rehabilitation and Brain Injury Medicine and serves as the program director for the Traumatic Brain Inury/Polytrauma Clinical Fellowship program. He is also the Director of the San Antonio Polytrauma Rehabilitation Center Emerging Consciousness Program and Co-Director for the San Antonio Polytrauma TBI Model System. His current research includes nonpharmacologic management of post-traumatic headaches and the chronic effects of neurotrauma.

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Foreword Traumatic brain injury rehabilitation medicine

David X Cifu & Blessen C Eapen Traumatic brain injury (TBI) is a major cause of death and disability worldwide and a serious public health problem [1]. Increasingly, awareness of the short and long-term impacts of TBI has made headlines and has driven the need to enhance knowledge on management strategies. More than 3.5 million individuals sustain TBIs in the USA annually, with a global incidence of 26– 798 per 100,000 [2]. The actual incidence is likely far higher, but it is difficult to ascertain given the differences in definitions, consistent utilization of formal healthcare systems after injury, standardized reporting and outcome measures. TBI results from an impulsive force transmitted to the brain that produces a diminished or altered level of consciousness associated with loss of memory and which can lead to acute and chronic physical, cognitive and behavioral impairments [3,4]. Severity of injury from TBI spans a spectrum from mild, such as seen with a sports or blast concussion, to severe, such as seen with disorders of consciousness (coma). Making the diagnosis and assessing severity of TBI remains a clinical decision, although increasingly innovative imaging, biomarker and electrophysiologic technologies may offer opportunities to support these assessments. Survivors of TBI may be left with significant neurological deficits and develop permanent life-long disabilities with resulting socio-economic burden [5,6]. Although, current research supports little can be done to reverse the initial damage to the brain, advances in acute rehabilitation, medical and surgical care have enhanced survival and outcome and improved the management of short- and long-term symptoms.

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Cifu & Eapen In this book, we review the epidemiology, diagnostic approaches, clinical care, multiple organ system complications, sensory deficits, prognostic factors and the rehabilitation management of brain injury. Additionally, we discuss the use of advanced neuroimaging techniques and biomarkers to improve diagnosis, prognostication and to guide care recommendations. This book also provides updates on interventions to enhance return to full activities, school and work after TBI. Finally, we summarize emerging novel therapeutics, neuropharmcological therapy and the integration of complementary and alternative medicine into established brain injury treatment programs. Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.

References 1. CDC. Traumatic Brain Injury – Injury Center (2014). http://www.cdc.gov/ traumaticbraininjury/ 2. Hyder AA, Wunderlich CA, Puvanachandra P, Gururaj G, Kobusingye OC. The impact of traumatic brain injuries: a global perspective. Neurorehabilitation 22, 341–353 (2007).

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3. Menon DK, Schwab K, Wright DW, Maas AI. Position statement: definition of traumatic brain injury. Arch. Phys. Med. Rehabil. 91, 1637–1640 (2010). 4. Hart T, Sherer M, Whyte J, Polansky M, Novack TA. Awareness of behavioral, cognitive, and physical deficits in acute traumatic brain injury. Arch. Phys. Med. Rehabil. 85, 1450–1456 (2004).

5. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J. Head Trauma Rehabil. 21, 375–378 (2006). 6. McGarry LJ, Thompson D, Millham FH et al. Outcomes and costs of acute treatment of traumatic brain injury. J. Trauma Acute Care Surg. 53, 1152–1159 (2002).

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About the Authors Jud C Janak Jud C Janak obtained his master’s (2011) and doctoral degrees (2014) in Epidemiology from the University of Texas Health Science Center School of Public Health. From 2012–2014, he was a National Institute of Occupational Safety and Health (NIOSH) Trainee focusing on injury research among the US military population. He is currently a Oak Ridge Institute for Science and Education Postdoctoral Fellow at the United States Army Institute of Surgical Research. His research currently focuses on combat casualty care such as combat-related burns and genitourinary injuries.

Mary Jo Pugh Mary Jo Pugh is a VA research scientist and an Associate Professor in the Department of Epidemiology and Biostatistics at the University of Texas Health Science Center, San Antonio. Her early work focused on the epidemiology of epilepsy in the VA healthcare system with a focus on older patients. As a veteran who experienced two moderate traumatic brain injuries (TBIs) during her Air Force service, she became interested in examining the chronic effects of neurotrauma in the veterans from the Afghanistan and Iraq wars. She has over 75 peer-reviewed publications including papers examining the association between TBI severity and epilepsy.

Jean A Langlois Orman Jean A Langlois Orman obtained her master’s (1987) and doctoral degrees (1991) in public health from the Johns Hopkins University School of Public Health, Baltimore (MD, USA). She has worked as an epidemiologist at the National Institutes of Health, Bethesda (MD, USA), Centers for Disease Control and Prevention, Atlanta (GA, USA), and as a scientific program manager for traumatic brain injury and stroke research at the Department of Veterans Affairs, Washington, DC (USA). She is currently the Chief of Statistics and Epidemiology at the US Army Institute of Surgical Research, Fort Sam Houston, San Antonio (TX USA). She has received awards from the North American Brain Injury Society and the Brain Injury Association of Ohio (USA) for her research on TBI. She has published two book chapters on TBI and has more than 60 peer-reviewed publications.

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Chapter

1 Epidemiology of traumatic brain injury

Introduction What is traumatic brain injury? How is TBI severity described? How often do TBIs occur each year around the world? What is the incidence of TBI-related mortality? Who has the highest incidence of TBI by age, sex & level of medical care? What is the distribution of TBI by severity? What are the external causes of TBI? Lifetime prevalence Outcomes Current issues in traumatic brain injury epidemiology: concussions/mTBIs in athletes & military service members Summary & conclusion

8 8 9 10 10

19 20 20 22 23

Jud C Janak, Mary Jo Pugh & Jean A Langlois Orman This chapter provides an overview of the global burden of traumatic brain injury (TBI). Information about the incidence, demographics, prevalence of a history of TBI and other long-term outcomes is presented for the USA and selected other countries. This chapter concludes by highlighting the epidemiology of repetitive brain trauma from mild traumatic brain injuries (mTBIs) or concussions in both sports and the military because of the current concern that they might lead to neurodegenerative conditions such as chronic traumatic encephalopathy (CTE).

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Janak, Pugh & Orman Introduction The first known epidemiologic evidence concerning head injuries is described in 14 case histories from the Edwin Smith Papyrus, the oldest known medical document [1]. More than 3500 years later TBI remains a significant public health concern around the world. More severe TBI is related to an increased risk of death post-trauma and decreased life expectancy [2]. TBI can also lead to the onset or worsening of psychiatric conditions (e.g., depression, psychotic disorders, substance abuse, suicide) and neurodegenerative diseases (e.g., Alzheimer’s, CTE, Parkinson’s). As a result, TBI is now considered not only an injury event but also a ‘disease process.’ Although the effects of more severe TBI have long been recognized, during the past two decades research on both the sports field and the battlefield has increased awareness about the potential serious consequences [3-5] of socalled ‘mild’ traumatic brain injuries or concussions among civilians, military personnel and veterans. This heightened awareness has sparked interest in better understanding the international burden of TBI. In this chapter, studies from the USA are highlighted because data are more available compared with many other countries. Where possible, data from other countries are also presented and compared with US data. A note about terminology: the terms concussion and mTBI are often used interchangeably. However, ‘concussion’ is preferred because it refers to a specific injury event that may or may not be associated with persisting symptoms. Because both terms are used in the literature cited here, the term ‘concussion/mTBI’ is used in the remainder of this chapter.

What is traumatic brain injury? TBI is an alteration in brain function, or other evidence of brain pathology, caused by an external force [6]. A more detailed definition that describes the complexity of TBI is as follows: TBI is a traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs immediately following the event [7]: 





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Any period of loss of or a decreased level of consciousness (LOC). Any loss of memory for events immediately before or after the injury (post-traumatic amnesia [PTA]). Any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.) (Alteration of consciousness/mental state [AOC]).

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Epidemiology of traumatic brain injury Table 1.1 Severity of brain injury stratification. Criteria

Mild/concussion

Moderate

Severe

Structural imaging

Normal†

Normal or abnormal

Normal or abnormal

Loss of consciousness (LOC)

0–30 min

>30 min and 24 h

Alteration of consciousness/mental state (AOC)

A moment up to 24 h

>24 h. Severity based on other criteria

Post-traumatic amnesia (PTA)

≤1 day

>1 and 7 days

Glasgow Coma Scale (best available score in first 24 h)‡

13–15

9–12

3–8

† Note

that minor abnormalities possibly not related to the brain injury may be present on structural imaging in the absence of LOC, AOC, PTA. ‡ Some studies report the best available Glasgow Coma Scale score within the first 6 h or some other time period. Adapted from [7].





Neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/plegia, sensory loss, aphasia, etc.) that may or may not be transient. Intracranial lesion.

These criteria define occurrence of a TBI ‘event.’ Those with a history of such an event who experience any of the above signs and symptoms immediately or shortly afterwards can be said to have sustained a TBI even if they recover from the initial symptoms. Of note, TBI definitions, including for concussion/mTBI, vary considerably across studies, making it difficult to compare findings [8,9].

How is TBI severity described? TBI severity is typically categorized based on the length of time the person experiences LOC, PTA, and/or AOC and is best assessed at the time of initial injury. According to the International Work Group on Demographics and Clinical Assessment of TBI [8], assessment of these neurological changes is necessary in order to differentiate concussions/mTBIs from more severe brain injuries. The criteria for categorizing TBI severity are summarized in Table 1.1. At the least severe end of the spectrum is concussion/mTBI in which AOC and PTA may be very brief, in some cases lasting only a few seconds or minutes. A concussion/mTBI can occur with an alteration of consciousness alone and no loss of consciousness.

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Janak, Pugh & Orman The Glasgow Coma Scale score (GCS), a measure of the injured individual’s responsiveness, is also commonly used to assess initial TBI severity [10]. GCS scores range from 8 to 15, with the highest scores indicating the least severe injuries. Persons with a concussion/mTBI typically have an initial GCS score ranging from 13 to 15. A score of 15 indicates that this scale identified no deficits; however, symptoms not assessed by the scale may still be present.

How often do TBIs occur each year around the world? TBI ‘incidence’ refers to the number of new cases of TBI during a given time. TBI incidence rates are typically reported as the number of new cases of TBI in one year per 100,000 population. Based on available published data, the global incidence rates of TBI vary dramatically from approximately 26 per 100,000 in Israel to 798 per 100,000 in the USA (Figure 1.1). Differences in rates among similar countries within the same region are also substantial; for example, the reported rate for Australia is 107 TBIs per 100,000 while for nearby New Zealand it is 790 per 100,000. One reason for such differences in reported TBI incidence is that some countries use data only from one or two medical care settings and not for the full range of TBI severity. For example, the relatively low TBI incidence rate for Australia [11] was based on data for more severe TBIs from hospital records only, while the New Zealand rates included data from death certificates and hospitals as well as from outpatient clinics and general practitioners, where more of the less severe TBIs are treated [12]. The majority of incidence rates reported on the map are estimated from hospitals and/or emergency department records only and thus are underestimates of the true incidence (Table 1.2). The second reason for differences in the reported incidence is that estimates may not be derived from a nationally representative sample, but rather, limited to a specific region of a country that may have a higher or lower incidence than the country as a whole. For example, one report of TBI in China is for urban areas only where the incidence may be higher or lower than in some other parts of the country [13]. In addition, the data for some countries may be from as long ago as 25 years [13] and thus may not reflect current rates. Finally, some reported incidence rates are age-standardized and not directly comparable to nonstandardized incidence rates or incidence rates that use different standards. Despite these limitations, this map presents the most recent reported TBI incidence rates in the current literature. International experts advocate the use of a common methodology that should be applied globally [14-16].

What is the incidence of TBI-related mortality? In the USA, the annual average death rate associated with TBI from 1997– 2007 was 18.4 per 100,000 [45]. The death rate was three times higher for

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United States 798

Argentina 322

Brazil 360 Spain 48

Portugal 137

United Kingdom 453

South Africa 317

France 282 Italy 213

Iran 57

Australia 107

Israel Pakistan 26 50

Greece 31

Qatar 42

Incidence rate per 100,000 26–50 51–101 Norway Denmark 102–213 Sweden 84 Finland 157 214–322 259 101 323–798 Canada European Union Germany 144 457 235

Figure 1.1 Incidence rate of traumatic brain injury by country.

Fiji 43

South Korea 236

China 56

New Zealand 790

Taiwan 242

India 150

Epidemiology of traumatic brain injury

11

12

Retrospective and prospective surveillance system from city of Hamilton and Waikato District

Inpatient Hospital Data from the German Federal Statistical Office

Emergency Department visits at Royal Devon and Exeter Hospital

New Zealand (March 1, 2010–Feb 28, 2011)

Germany (2011)

UK (April 1997–March 2003)

[20]

[19]

457‡

453

[18]

[17]

Ref.

790

798‡

Incidence† rate

¶ Incidence rate

obtained from English abstract of non-English manuscript which may have resulted in the inability to complete table fully. calculated for patients aged 15 years and older. †† Reported incidence rate was hand calculated from two distinct regions of Taiwan. ‡‡ South Korean incidence rates estimated from a formula (Head Injuries = Traffic Accidents/0.625). §§ Hand calculated total number of TBI cases for the year 2000 using the reported incidence rate for the year 2000 and the reported stable population of 4,480,000, the total number of reported TBI cases from 1996–2000 was 55,368. ## The number of TBI cases for 1991–1993 were not reported, the total number of TBI cases reported from 1979–1993 was 166,443. ††† Hand calculated incidence rate combining reported results stratified by sex. ‡‡‡ Hand calculated incidence rate using the reported number of cases and the estimated population of Greece (11,237,094) in 2008 from the World Bank. TBI: Traumatic brain injury.

§ Not Available. # Incidence rate

362,844

1369

2,430,712

Number of TBI cases

National Health Service Centre 11,700 for Clinical Coding and Classification based on ICD-10-CM

ICD-10-CM

BIONIC criteria for population-based studies of TBI incidence and outcomes based on WHO Injury Surveillance Guidelines

ICD-9-CM

TBI criteria

per 100,000, incidence rates not reported as integers were rounded up. are age standardized.

‡ Reported incidence rates

Emergency Department Visits, Hospitalizations and Deaths

USA (2009)

† Incidence Rates

TBI case ascertainment

Country and date(s)

Table 1.2 Incidence Rate Table for Figure 1.1.

Janak, Pugh & Orman

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Trauma hospitals in Johannesburg

Hospital admissions and death Head trauma defined as certificates in Aquitaine, contusions, lacerations, skull France fractures, or brain injuries and/or LOC after a relevant injury

South Africa (1986)

France (December 1985–December 1986)

Modification of the Head and Spinal Cord Injury Survey (ICD-9-CM) 8940

599

[23]

317‡ ,¶

[24]

[22]

322# ,¶

282

[21]

Ref.

360#

Incidence† rate

‡ Reported

per 100,000, incidence rates not reported as integers were rounded up. incidence rates are age standardized. § Not Available. # Incidence rate obtained from English abstract of non-English manuscript which may have resulted in the inability to complete table fully. ¶ Incidence rate calculated for patients aged 15 years and older. †† Reported incidence rate was hand calculated from two distinct regions of Taiwan. ‡‡ South Korean incidence rates estimated from a formula (Head Injuries = Traffic Accidents/0.625). §§ Hand calculated total number of TBI cases for the year 2000 using the reported incidence rate for the year 2000 and the reported stable population of 4,480,000, the total number of reported TBI cases from 1996–2000 was 55,368. ## The number of TBI cases for 1991–1993 were not reported, the total number of TBI cases reported from 1979–1993 was 166,443. ††† Hand calculated incidence rate combining reported results stratified by sex. ‡‡‡ Hand calculated incidence rate using the reported number of cases and the estimated population of Greece (11,237,094) in 2008 from the World Bank. TBI: Traumatic brain injury.

† Incidence Rates

Emergency department patients

Argentina (1 October 2000–30 September 2001)

2151

Number of TBI cases

Guidelines from The Study 1540 Group on Head Injury of the Italian Society for Neurosurgey

Hospital stay in S˜ao Paulo for a NA§ minimum of 1 day

TBI criteria

Brazil (July 1986–June 1987)

Table 1.2 Incidence Rate Table for Figure 1.1 (cont.). Country and date(s) TBI case ascertainment

Epidemiology of traumatic brain injury

13

14

Medline review on TBI related articles from 1980–2003

European Union (1980–2003)

NA

[27]

236‡‡

[28]

[26]

242††

235

[25]

Ref.

259

Incidence† rate

¶ Incidence rate

obtained from English abstract of non-English manuscript which may have resulted in the inability to complete table fully. calculated for patients aged 15 years and older. †† Reported incidence rate was hand calculated from two distinct regions of Taiwan. ‡‡ South Korean incidence rates estimated from a formula (Head Injuries = Traffic Accidents/0.625). §§ Hand calculated total number of TBI cases for the year 2000 using the reported incidence rate for the year 2000 and the reported stable population of 4,480,000, the total number of reported TBI cases from 1996–2000 was 55,368. ## The number of TBI cases for 1991–1993 were not reported, the total number of TBI cases reported from 1979–1993 was 166,443. ††† Hand calculated incidence rate combining reported results stratified by sex. ‡‡‡ Hand calculated incidence rate using the reported number of cases and the estimated population of Greece (11,237,094) in 2008 from the World Bank. TBI: Traumatic brain injury.

§ Not Available. # Incidence rate

Restricted to studies of European populations, without restrictions on age, gender or severity of TBI

per 100,000, incidence rates not reported as integers were rounded up. are age standardized.

‡ Reported incidence rates

† Incidence Rates

Traffic Accident Statistics collected by the National Police Agency in 1998

South Korea (1998)

7228

22,000 annually

Number of TBI cases

Head injury reported as region 109,462 of body injured in traffic accident

Hospitals records in Taipei City ICD-9-CM and Hualien County

Taiwan (2001)

ICD-9-CM ICD-10-CM

Hospital Discharge Register at the National Board for Health and Welfare

TBI criteria

Sweden (1987–2000)

Table 1.2 Incidence Rate Table for Figure 1.1 (cont.). Country and date(s) TBI case ascertainment

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Danish National Hospital Register

Neurotrauma hospital registry ICD-10-CM at National Institute of Mental Health and Neurosciences in Bangalore

National Ambulatory Care Reporting System and the Discharge Abstract Database for hospitals and emergency department visits in Ontario

Denmark (1991–1993)

India (March 2000–March 2001)

Canada (2006–2007) ICD-10-CM

18,033

[31]

[32]

150

144‡ ,†††

[30]

157‡

NA## 7164

[29]

213

9516§§

Ref.

Incidence† rate

Number of TBI cases

‡ Reported

per 100,000, incidence rates not reported as integers were rounded up. incidence rates are age standardized. § Not Available. # Incidence rate obtained from English abstract of non-English manuscript which may have resulted in the inability to complete table fully. ¶ Incidence rate calculated for patients aged 15 years and older. †† Reported incidence rate was hand calculated from two distinct regions of Taiwan. ‡‡ South Korean incidence rates estimated from a formula (Head Injuries = Traffic Accidents/0.625). §§ Hand calculated total number of TBI cases for the year 2000 using the reported incidence rate for the year 2000 and the reported stable population of 4,480,000, the total number of reported TBI cases from 1996–2000 was 55,368. ## The number of TBI cases for 1991–1993 were not reported, the total number of TBI cases reported from 1979–1993 was 166,443. ††† Hand calculated incidence rate combining reported results stratified by sex. ‡‡‡ Hand calculated incidence rate using the reported number of cases and the estimated population of Greece (11,237,094) in 2008 from the World Bank. TBI: Traumatic brain injury.

† Incidence Rates

ICD-9-CM

Hospital records from Veneto Region

Italy (2000) ICD-8-CM

TBI criteria

Table 1.2 Incidence Rate Table for Figure 1.1 (cont.). Country and date(s) TBI case ascertainment

Epidemiology of traumatic brain injury

15

16

National Hospital Morbidity Database

National Hospital Discharge Registry

Ulleval University Hospital Records

Australia (2004–2005)

Finland (1991–2005)

Norway (15 May 2005–14 May 2006)

445

77,959

21,778

NA

Number of TBI cases

84

[36]

[35]

[34]

107‡ 101

[33]

Ref.

137#

Incidence† rate

obtained from English abstract of non-English manuscript which may have resulted in the inability to complete table fully. calculated for patients aged 15 years and older. †† Reported incidence rate was hand calculated from two distinct regions of Taiwan. ‡‡ South Korean incidence rates estimated from a formula (Head Injuries = Traffic Accidents/0.625). §§ Hand calculated total number of TBI cases for the year 2000 using the reported incidence rate for the year 2000 and the reported stable population of 4,480,000, the total number of reported TBI cases from 1996–2000 was 55,368. ## The number of TBI cases for 1991–1993 were not reported, the total number of TBI cases reported from 1979–1993 was 166,443. ††† Hand calculated incidence rate combining reported results stratified by sex. ‡‡‡ Hand calculated incidence rate using the reported number of cases and the estimated population of Greece (11,237,094) in 2008 from the World Bank. TBI: Traumatic brain injury.

¶ Incidence rate

§ Not Available. # Incidence rate

ICD-10-CM

ICD-9-CM ICD-10-CM

per 100,000, incidence rates not reported as integers were rounded up. are age standardized.

‡ Reported incidence rates

† Incidence Rates

NA

Hospital admissions and total mortality

Portugal (1997) ICD-10-CM

TBI criteria

Table 1.2 Incidence Rate Table for Figure 1.1 (cont.). Country and date(s) TBI case ascertainment

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Administered survey to respondents selected by random sample from six cities in the People’s Republic of China

Various neurosurgical centers in Pakistan

National Hospital Discharge Register

China (1983)

Pakistan 1 July 1995– 30 June 1999)

Spain (2000–2009)

21

Number of TBI cases

ICD-9-CM

206,503

Referral from family physicians 260,000 and hospitals

Self-report confirmed with 35 uniform diagnostic criteria performed by neurologists and neurosurgeons

Self-report

TBI criteria

[39] [40]

48‡

[38]

56‡

50

[37]

Ref.

57

Incidence† rate

‡ Reported

per 100,000, incidence rates not reported as integers were rounded up. incidence rates are age standardized. § Not Available. # Incidence rate obtained from English abstract of non-English manuscript which may have resulted in the inability to complete table fully. ¶ Incidence rate calculated for patients aged 15 years and older. †† Reported incidence rate was hand calculated from two distinct regions of Taiwan. ‡‡ South Korean incidence rates estimated from a formula (Head Injuries = Traffic Accidents/0.625). §§ Hand calculated total number of TBI cases for the year 2000 using the reported incidence rate for the year 2000 and the reported stable population of 4,480,000, the total number of reported TBI cases from 1996–2000 was 55,368. ## The number of TBI cases for 1991–1993 were not reported, the total number of TBI cases reported from 1979–1993 was 166,443. ††† Hand calculated incidence rate combining reported results stratified by sex. ‡‡‡ Hand calculated incidence rate using the reported number of cases and the estimated population of Greece (11,237,094) in 2008 from the World Bank. TBI: Traumatic brain injury.

† Incidence Rates

Administered survey to respondents from households selected by a cluster random sampling strategy

Iran (23 September 2007–22 September 2008)

Table 1.2 Incidence Rate Table for Figure 1.1 (cont.). Country and date(s) TBI case ascertainment

Epidemiology of traumatic brain injury

17

18

Regional hospital

Israel

1370

[42]

[43]

[44]

31‡‡‡

26#

[41]

Ref.

42

43

Incidence† rate

¶ Incidence rate

obtained from English abstract of non-English manuscript which may have resulted in the inability to complete table fully. calculated for patients aged 15 years and older. †† Reported incidence rate was hand calculated from two distinct regions of Taiwan. ‡‡ South Korean incidence rates estimated from a formula (Head Injuries = Traffic Accidents/0.625). §§ Hand calculated total number of TBI cases for the year 2000 using the reported incidence rate for the year 2000 and the reported stable population of 4,480,000, the total number of reported TBI cases from 1996–2000 was 55,368. ## The number of TBI cases for 1991–1993 were not reported, the total number of TBI cases reported from 1979–1993 was 166,443. ††† Hand calculated incidence rate combining reported results stratified by sex. ‡‡‡ Hand calculated incidence rate using the reported number of cases and the estimated population of Greece (11,237,094) in 2008 from the World Bank. TBI: Traumatic brain injury.

§ Not Available. # Incidence rate

NA

Trauma patients with at least 3383 one requiring admission to the hospital and transfer to a higher level unit or trauma resulted in death

per 100,000, incidence rates not reported as integers were rounded up. are age standardized.

‡ Reported incidence rates

† Incidence Rates

Hospitals in Greece receiving trauma patients

Greece (12 months)

1919

Emergency Medical Services Registry of Hamad Medical Corporation

Qatar (2007) ICD-9-CM

Medical notes describing head 276 injury

Fiji Injury Surveillance in Hospital System

Fiji (1 October 2005–30 September 2006)

Number of TBI cases

TBI criteria

Table 1.2 Incidence Rate Table for Figure 1.1 (cont.). Country and date(s) TBI case ascertainment

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Epidemiology of traumatic brain injury Figure 1.2 Estimated average incidence rates of traumatic brain injury-related emergency department visits, hospitalizations and deaths, by age group, USA, 2002–2006. 1400 Emergency department visits Hospitilizations

1200

Deaths

Per 100,000

1000 800 600 400 200 0 5–9 0–4

15–19 10–14

25–34 20–24

45–54 35–44

65–74 55–64

≥75

Age group

Reprinted from Centers for Disease Control and Prevention [49].

males than females (28.8 vs 9.1 per 100,000) and highest for those 20–24, 75–84 and 85 years and older (25.4, 48.7 and 95.1 per 100,000, respectively). The three leading causes of TBI related deaths were firearms (34.8%), motor vehicles (31.4%) and falls (16.7%). Select mortality rates in other countries ranged from a low of 15 per 100,000 among European countries [46] to 20 per 100,000 in Bangalore, India [47]. Similar to the USA, the average mortality rate among hospitalized patients diagnosed with a TBI from 1991–2005 was 18.3 per 100,000 in Finland [48].

Who has the highest incidence of TBI by age, sex & level of medical care? Differences in TBI incidence rates by medical care setting are also important in understanding the demographic groups at highest risk. Using the USA as an example, very young children aged 0 to 4 years had the highest rate of TBI-related emergency department visits (1256 per 100,000 population), followed by older adolescents aged 15 to 19 years (757 per 100,000) [49]. However, the highest rates of TBI-related hospitalization and death occurred among adults aged 75 years and older (339 per 100,000 and 57 per 100,000, respectively) (Figure 1.2). The age groups 0–4 years, 15– 19 years and ≥65 years were at greatest risk of TBI based on data from all

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Janak, Pugh & Orman three sources (emergency department visits, hospitalizations and deaths). In every age group, TBI rates were higher for males than for females. Countries with available data represented in Figure 1.1 report similar trends by age categories and sex despite differences in the estimated incidence rates. For example, in Finland, the age groups at the highest risk for TBI were 0–9 years, 10–19 years and ≥50 years with males experiencing a higher incidence compared with females across all age categories [48].

What is the distribution of TBI by severity? In the USA, greater than 85% of medically treated TBIs are considered ‘mild’ [50]. However, the true proportion is believed to be higher because many concussions/mTBIs are underreported and untreated [51-53]. Among hospitalized cases in the USA, which comprise the smallest proportion of total TBIs, approximately 20% are in the severe range [54]. Although severe TBIs represent a relatively small proportion of all TBIs, the impact on the injured individual’s health, their family and society is much greater than for less severe injuries. There is less evidence about the distribution of TBI severity in other countries. However, a large prospective study from hospital emergency departments in two regions of Germany reported that approximately 91% of TBIs were classified as mild, 4% as moderate and 5% as severe [55]. By comparison, approximately 95% of TBIs were classified as mild and 5% were classified as moderate to severe in New Zealand [12].

What are the external causes of TBI? External cause refers to the nature of how an injury occurred (e.g., motor vehicle crash or assault) [56]. The intent underlying the injury (intentional vs unintentional), mechanism of injury (e.g., gunshot wound) and the object involved (e.g., baseball bat), where appropriate, are important dimensions to report in order to fully capture the external cause of an injury. Around the world, motor vehicle crashes are the primary external cause of TBI among young and middle aged adults while falls are the primary cause among young children and older adults [57]. More specific data are presented below. Motor vehicle crashes (MVC)

Motor vehicle traffic injuries were the second leading cause of TBI (17.3%) in the USA after falls (35.2%) when emergency department visits, hospitalizations and deaths were combined [49]. However, after considering individual medical care settings, MVC’s were the leading cause of TBI hospitalizations and deaths. The motor vehicle traffic-related TBI rate was highest among adolescents and young adults (15–24 years).

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Epidemiology of traumatic brain injury Road traffic crashes are the leading cause of TBI worldwide and are projected to be the 4th leading cause of disability-adjusted life years and 8th leading cause of death by 2030 [57,58]. Furthermore, the burden of TBIs from road traffic crashes is projected to be disproportionately greater in middle and low-income countries. For example, a prospective neurotrauma registry in Bangalore, India reported that road traffic injuries accounted for 59% of TBIs with 43% of these injuries occurring among 21–35 year olds [47]. Interestingly, motor vehicle occupants are not the subgroup that most often sustain traffic-related TBIs. Rather, motorcyclists (33%), pedestrians (31%) and cyclists (21.9%) accounted for the largest percentages of traffic-related TBIs while motor vehicle occupants comprised only 14% according to a prospective study in 2004 of 77 hospitals in Eastern China [59]. These results highlight the growing concern of TBIs from MVCs in the developing world as a consequence of accelerating urbanization and industrialization among countries with rapidly growing populations. Falls

In the USA, falls were the leading cause of TBI (35.2%) when emergency department visits, hospitalizations and deaths were combined [49]. They were also the leading cause of TBI-related hospitalizations and emergency department visits among young children (0–4 years) and older adults (≥75 years). Falls are a growing global concern as an external cause of both morbidity and mortality. For example, falls increased from the 30th leading cause of death in 1990 to the 22nd leading cause of death in 2010 [60]. Further, the number of global deaths associated with falls is projected to increase from 2002 to 2030 [58]. Finally, falls were the 19th leading cause of disability-adjusted life years in 2010 and in the top 10 for three different geographic regions (Western Europe, Central Europe and Australia) [61]. TBI-related falls across different countries reveal other important trends. Falls are a frequent cause of TBI in India and accounted for approximately 50% of fall-related TBI internationally [57]. An aging global population will likely increase the importance of falls as an external cause of TBI. For example, the age adjusted incidence due to falls in older adults (≥65 years) from the Netherlands National Hospital Discharge registry increased from 53.1 per 100,000 in 1986 to 119.1 per 100,000 in 2008 [62], and the incidence rate increased by 11.6% annually from 2001 to 2008. Violence from assaults

Assaults accounted for 10% of TBIs in the USA when emergency department visits, hospitalizations and deaths were combined [49], and were the second leading external cause of TBI from emergency department visits among

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Janak, Pugh & Orman 20–24 year olds (160.8 per 100,000). Firearms were the leading cause of TBI-related death among adults (20–74 years) from 1989–1998 [63]. The estimated global incidence of violence related TBI’s resulting in short-term disability was 43 per 100,000 [57]. Relatively high rates of these violence-related-TBIs were reported for Sub-Saharan Africa (144 per 100,000), Latin America and Caribbean (66.5 per 100,000), and Former Soviet Economies of Europe (54.7 per 100,000). Young and middle-aged adult males are at increased risk for assault-related TBIs internationally. Assaults accounted for approximately 17% of TBIs in New Zealand with an incidence rate of 132 per 100,000 [12]. Males (433 per 100,000) and females (145 per 100,000) aged 15–34 had the highest incidence rate of assault related TBI across all age categories, with the incidence rate for males nearly 3 times greater than that for females. Asian countries report similar trends by age and gender; however, the impact due to firearms is substantially less than in the USA. For example, assault was the third leading cause of TBI (10%) in Bangalore, India [47] and most common for men between the ages of 21–40 years old, but a blunt instrument rather than a firearm overwhelmingly caused assault-related TBI. Similarly, a retrospective analysis of 11 hospitals in China reported that approximately 10% of all head traumas had a violent external cause with blunt objects (55.9%) being the most common instrument used and firearms (0.44%) being the least common [64].

Lifetime prevalence Lifetime prevalence of a history of TBI refers to the number or percent of individuals who have ‘ever’ experienced at least one TBI regardless of whether they have persisting symptoms or related disability. This information is important to ascertain because specific characteristics of a lifetime history of TBI, including history of a TBI sustained early in childhood, were predictive of cognitive performance, cognitive complaints and severity of alcohol and drug abuse in adulthood [65]. In addition, knowledge of a person’s lifetime history of TBI may be essential in designing effective treatments for TBI comorbidities such as substance abuse and mental illness [66]. The number of published studies reporting a true lifetime prevalence of TBI is limited. One reason for the lack of published studies is that a cohort of persons must be followed longitudinally from birth throughout their lifetime to identify TBIs as they occur and thus ensure the most complete ascertainment possible in order for the findings to be accurate. Despite obvious challenges, some studies have used a detailed questionnaire to assess the history of TBI based on recall of past TBI events [67,68].

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Epidemiology of traumatic brain injury Among the few published birth cohort studies, one in Finland reported the prevalence of a history of confirmed TBI ascertained from hospital admissions and outpatient clinics was 2.9% among males and 1.9% among females up to the age of 15 years [69]. Another birth cohort study in New Zealand reported approximately 38% of males and 24% of females experienced at least one TBI up to the age of 25 years based on TBI diagnoses determined by the child’s history of medical attendances to a general practitioner, specialist and hospital admission [70].

Outcomes TBI may initiate or accelerate a range of adverse effects on health that can lead to long-term or lifelong disability, reduced life expectancy and substantial economic costs [2]. These potential effects of TBI are summarized below. Effects of TBI on health

Results of a systematic review by an Institute of Medicine Committee published in 2009 [54] found evidence for a range of adverse long-term health outcomes (lasting greater than 6 months) varying by TBI severity (Table 1.3). Evidence was strongest for moderate, severe and penetrating TBI and included associations with epilepsy, Alzheimer’s dementia, Parkinsonism, neurocognitive deficits and premature mortality. Penetrating TBI is unique compared with other mechanisms of closed head TBIs because an object penetrates but does not exit the cranial cavity. This mechanism of TBI has gained importance in the military literature due to the nature of the recent conflicts in Iraq and Afghanistan. The IOM Committee found limited or inadequate evidence for the long-term effects of concussion/mTBI. However, recent well-designed studies suggest that concussion/mTBI may result in some long-term problems. For example, a study analyzing a prospective cohort of preschool children in New Zealand reported that more severe concussion/mTBI was associated with the persistent negative behaviors of attention deficit/hyperactivity disorder and oppositional defiant/conduct disorder [71]. In another study, US military veterans enrolled in the Vietnam Experience Study reporting concussion/mTBI with AOC were at a significant increased risk for long-term psychiatric (e.g., depression), neurological (e.g., impaired tandem gait) and psychosocial morbidities (e.g., underemployment, marital problems) compared with controls [72]. Long-term disability from TBI

The incidence of TBI-related disability refers to an estimate of the number of people in a defined geographic region who have had a TBI during a specified period of time and are expected to have long-term or lifelong disability. Data from the USA in 2003 suggest that 43.3% of hospitalized

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Unprovoked seizures Endocrine dysfunction‡

Sufficient evidence of causality

Growth hormone insufficiency Neurocognitive deficits Alzheimer’s dementia Diabetes insipidus Parkinsonism Psychosis‡‡ Long-term adverse social-functioning§ Premature mortality#

Unprovoked seizures (with LOC or amnesia) Ocular and visual motor deterioration Alzheimer’s dementia (with LOC) Parkinsonism (with LOC) Post-traumatic stress disorder (military populations) Brain tumor

Neurocognitive deficits Alzheimer’s dementia (without LOC) Post-traumatic stress disorder (civilian populations) Long-term adverse §§ social-functioning

Strength of evidence Sufficient evidence of an Limited/suggestive evidence Inadequate/insufficient association of an association evidence of an association

longer than 6 months. hypopituitarism. § Particularly unemployment and diminished social relationships. # Subset of patients admitted into or discharged from rehabilitation centers or receive disability services. ¶ Associated with the affected region of the brain and the volume of tissue lost. †† In the 2–3 year period post-TBI. ‡‡ Compared with pre-injury levels in the 1–3 year period post-TBI. §§ Including unemployment, diminished social relationships, and decrease in the ability to live independently. LOC: Level of consciousness; TBI: Traumatic brain injury. Reprinted with permission from American Psychiatric Association [54].

‡ Primarily

† Lasting

Moderate

Mild

TBI severity

Table 1.3 Institute of medicine summary of the long-term† health effects of TBI by severity and the strength of evidence.

Janak, Pugh & Orman

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Unprovoked seizures Premature mortality

Penetrating

Neurocognitive decline¶ Long-term unemployment

Neurocognitive deficits Diabetes insipidus Growth hormone insufficiency Psychosis†† Alzheimer’s dementia Parkinsonism Long-term adverse social-functioning§ Premature mortality#

‡ Primarily

longer than 6 months. hypopituitarism. § Particularly unemployment and diminished social relationships. # Subset of patients admitted into or discharged from rehabilitation centers or receive disability services. ¶ Associated with the affected region of the brain and the volume of tissue lost. †† In the 2–3 year period post-TBI. ‡‡ Compared with pre-injury levels in the 1–3 year period post-TBI. §§ Including unemployment, diminished social relationships, and decrease in the ability to live independently. LOC: Level of consciousness; TBI: Traumatic brain injury. Reprinted with permission from American Psychiatric Association [54].

† Lasting

Unprovoked seizures Endocrine dysfunction‡

Severe

Brain tumor

Table 1.3 Institute of medicine summary of the long-term† health effects of TBI by severity and the strength of evidence (cont.). TBI severity Strength of evidence Sufficient evidence of Sufficient evidence of an Limited/suggestive evidence Inadequate/insufficient causality association of an association evidence of an association

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Janak, Pugh & Orman TBI survivors will result in long-term disability [73]. Long-term disability was defined broadly to include functional limitations, postinjury symptoms, cognitive complaints and physical and psychosocial health. The probability of TBI-related long-term disability increased consistently as age increased, and was higher among women (49.2%) compared with men (39.8%). Falls (58.4%) and firearms (49.9%) were the two known mechanisms of injury with the highest probability of TBI-related long-term disability. The prevalence of TBI-related disability refers to the number of people in a defined geographic region who have ever had a TBI and are living with symptoms or problems related to the TBI at a specified point in time. This excludes people who have recovered from TBI-related symptoms and problems. The most recent prevalence, also from the USA, estimated that 3.2 million or 1.1% of the US population was living with TBI-related disability in early 2005 [74]. The estimates for the incidence and prevalence of TBI-related disability are limited because they are based on hospital discharges only and do not include disability associated with concussions/mTBIs. To our knowledge, no other countries have measured long-term disability using similar methods. Expected differences across countries are likely due to variability in the amount and quality of acute care, rehabilitation and community-based services. Life expectancy after TBI

Although the literature suggests an increased likelihood of premature death among persons hospitalized with TBI, a 2009 Institute of Medicine Committee report suggested that there is a need for additional studies to confirm this conclusion [54]. In fact, a more recent study accounting for other trauma concluded that there was not an increased risk of death from TBI more than 6 months after a confirmed TBI [75]. Economic cost

The estimated lifetime costs of fatal, hospitalized and nonhospitalized TBI among US civilians who were medically treated in the year 2000 totaled in excess of $221 billion in 2009 dollars [76]. These costs included direct medical costs (6.6%), indirect costs of inability to work (31.3%) and reduced quality of life (62.1%), the latter of which was not included in reports [77]. TBIs caused by motor vehicle incidents accounted for approximately 40% of costs, firearms for nearly 30%, falls accounted for 15% and struck by/against incidents for 6%. Most available studies from other countries reported short-term medical costs as opposed to lifetime costs. However, a cost study in Europe estimated that the lifetime cost due to TBI mortality in 2004 Euro equivalents was

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Epidemiology of traumatic brain injury 375,000 per death based on data from the Swedish Hospital Discharge and Causes of Death Registry [78]. In contrast, the lifetime cost for a TBI death in the USA was estimated at $968,557 (733,770 in 2004 Euro equivalents) in 2000 dollars.

Current issues in traumatic brain injury epidemiology: concussions/mTBIs in athletes & military service members Sports

Sports-related concussions/mTBIs have received increased attention in recent years because of growing concern about the potential for long-term adverse consequences in a small percentage of individuals, perhaps as low as 1 min) may be a predictor of poor outcome (extrapolating conclusions from moderate to severe TBIs) [9]. Failure to regain consciousness after a head injury or deterioration of consciousness in a previously alert individual may be a sign of intracranial hemorrhage (ICH).

Management In the not so distant past concussions were simply blown off and athletes who ‘got their bell rung’ were encouraged to return to play often in the same game even while they were still very symptomatic. Out of a desire to better protect athletes and provide a framework for return to play decisions concussion grading scales arose (such as the Cantu, Colorado and AAN guidelines). These grading scales would use such factors as LOC and duration of posttraumatic amnesia to grade a concussion in severity. The concussion grade and number of previous concussions in a given season would determine

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Sports concussions Table 10.1. Graded return to play protocol. Rehabilitation stage

Functional exercise at each stage of rehabilitation

Objective of each stage

1. No activity

Symptom limited physical and cognitive rest

Recovery

2. Light aerobic exercise

Walking, swimming or stationary cycling keeping intensity