Research

The Cost of Undiagnosed TBIs and Potential Solutions

In recent years, traumatic brain injuries (TBIs) and concussions have become a popular topic of conversation throughout the sports world. What sparked this dialogue was diagnosis and early death of several ex-pro football players who were later diagnosed with chronic traumatic encephalopathy (CTE), a degenerative brain disorder associated with repetitive head trauma. Studies have found a link between CTE and suicidal behavior, dementia and declines in memory, executive function and mood.

The problem is that this conversation has not yet reached the levels necessary to understand just how mis- and under diagnosed TBIs really are.

Rate of undiagnosed TBIs

Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. According to the World Health Organization (WHO), Traumatic brain injury (TBI) will surpass many diseases as the major cause of death and disability by the year 2020.

The magnitude and prevalence this condition imposes on society makes TBI a pressing public health and medical problem. This includes:

● 230,000 people hospitalized

● 50,000 deaths

● 80,000 to 90,000 injuries that resulted in long-term disability

Mild Traumatic Brain Injury

Researchers speculate that the number of undiagnosed mild brain injuries in the United States is much greater than often thought. Mild TBIs are hard for both doctors and survivors to diagnose, but studies show that often in both sports and the military reporting may be intentionally stifled.

One study found nearly 60 percent of all TBIs were undiagnosed in a sample of individuals admitted to hospitals following the 9/11 terrorist attacks. Because hospitalizations resulting from falling debris were the most common injury, many TBIs went undiagnosed.

The study indicates that situations involving multiple traumas, invisible head trauma is often missed.

Estimates of undiagnosed TBIs outside the research community are strikingly unavailable. None of the US Government, military, healthcare or educational organizations have published estimates to date. Lack of reporting reflects a concern identifying individuals with these injuries may present a far larger public health concern than some are ready to admit.

Why is This Such a Big Problem?

In recent years, mild traumatic brain injury) also known as concussions) has emerged as a major public health concern. Of the 1.5 million Americans whose TBIs are documented by medical professionals, 85 percent are considered mild TBIs (mTBI). These injuries once were considered a “rite of passage”, especially in contact sports.

Now, we are starting to understand the potential cognitive, physical, emotional, and social consequences. Despite increasing awareness, a large portion of mTBIs go undiagnosed due to a lack of educational awareness, reporting, under-diagnosis, and misdiagnosis. The prevalence of undiagnosed mTBIs poses a significant public health threat, especially with identified links between head injury and mental illness, substance abuse, and criminality.

The Financial, Physical and Emotional Cost of Undiagnosed TBIs

Led by Professor David Menon from the Division of Anaesthesia at the University of Cambridge and Professor Andrew Maas from Antwerp University Hospital and University of Antwerp, Belgium, an International commission is working to reduce the global burden of traumatic brain injury. The commission targets policy makers, funders, patient organizations, as well as health-care professionals.

Using data from 300 international clinicians and researchers, many of whom are part of the International Initiative for Traumatic Brain Injury Research, they provide clinical and research priorities with recommendations to reduce the global burden of TBI. Some of their findings include:

● $1 of every $200 of annual global output is spent on some impact of TBIs

● TBIs impact 50 million people every year

● More than half the world's population will suffer a TBI over their lifetime

● TBIs are the leading cause of mortality in young adults, a major cause of disability across all ages

● There is an increased risk of late-life dementia

● TBIs cost the global economy US $400 billion annually

What the commission has uncovered is just how catastrophic this global epidemic is becoming.

What Do We Need to Know About TBIs

The first commonly asked question is what exactly causes a TBI? Whiplash or a sudden jolt or a physical blow to the head causes a coup contrecoup effect in the brain. This means that the brain is forced roughly inside of the skull. Depending on the velocity of the impact, the brain may even reverberate into the opposite side of the skull. Depending on the area of the brain that meets the inside wall of the skull this will determine the damage to the brain.

Some of the risk factors for TBIs include:

● Falling, especially in young children and older adults

● Participating in a high-risk sport, such as football, hockey, soccer, rugby, boxing or other contact sport

● Participating in high-risk sports without proper safety equipment and supervision

● Being involved in a motor vehicle collision

● Being involved in a pedestrian or bicycle accident

● Being a soldier involved in combat

● Being a victim of physical abuse

● Having had a previous concussion

Long-term complications if untreated

When we look at the long-term implications of untreated TBIs, the list is extensive.

These symptoms are broken into five categories: physical, cognitive, sensory, perceptual, and social-emotional. Physical deficits are things like sleep disorders, appetite changes or chronic pain. Some examples of cognitive impact are problems with memory, attention or focus. Sensory symptoms would be experiencing difficulty with things like hearing, smell or taste. Symptoms in the perceptual category would be when someone has trouble perceiving things like temperature or pressure. Lastly, social-emotional issues would be when a person who has a TBI struggles socially, emotionally or behaviorally.

COMMON PEDIATRICS CAUSES

Playground Injuries

Recent studies indicate that children are suffering traumatic brain injuries at an increasing rate. Researchers found increasing numbers of TBI diagnoses in children after sustaining an injury on playground equipment. Researchers from the National Center for Injury Prevention and Control studied injury state that between 2005 and 2013, kids under 14 experienced a significant increase in children going to the emergency room for traumatic brain injuries. Boys accounted for 58.6 percent of the TBIs identified and 50.6 percent of children with TBIs were between the ages of five and nine.

Contact Sports

Head impacts and concussions caused by contact sports are a rapidly growing epidemic among young athletes. When left undetected, concussions can result in long-term brain damage and some even prove fatal. In order to protect young athlete’s brain health, mental cognition and ability to succeed, it is imperative for coaches, players and parents to be are aware of the inherent dangers and how to properly perform concussion evaluations.

Detailing the magnitude of this problem, the following important information should be considered regarding contact sports and brain health:

● There were 3,800,000 concussions reported in 2012, double what was reported in 2002

● Emergency room visits doubled for concussions in kids 8 to 13 years old, while concussions rose 200 percent in the last decade in kids 14 to 19

● 33 percent of all sports concussions occur at practice

● 39 percent of cumulative concussions are shown to increase catastrophic head injury that leads to permanent neurological disability

● After football - ice hockey and soccer pose the most significant risk for concussions

● 1 in 5 high school athletes will sustain a sports concussion during the season

● 33 percent of high school athletes who have a sports concussion report two or more in the same year

● 4 to 5 million concussions occur annually, with rising numbers among middle school athletes

● 90 percent of most diagnosed concussions do not involve a loss of consciousness

Without medical professionals available to assess head impact or impact measurement data, athletes are left vulnerable and ill-equipped without information.

Return to School After a TBI

Adding to the difficulty with youth TBIs is early return to school. A 2004 cross-sectional study, included a group of 67 school-age children with TBI (35 mild, 13 moderate, 19 severe) and 14 uninjured matched controls. Parents and children were interviewed and children were evaluated 2 years post injury. Researchers used several assessment tools, including students classroom performance, the Children’s Memory Scale (CMS), the Wechsler Intelligence Scale for Children–third edition UK (WISC-III) and the Wechsler Objective Reading Dimensions (WORD).

What they found was that upon return to school, a third of teachers were unaware of the TBI. Special arrangements were made for 27 percent of children and special educational needs were identified for 16 children. Only six children received specialist help upon their return to school. A staggering two thirds of children with TBI had difficulties with school work, including half with attention/concentration problems and 39 percent with memory difficulties.

What’s more is children in the severe TBI group had a mean full-scale IQ significantly lower than controls. Half of all students had a reading age 1 year below their chronological age, one third were reading 2 years below their chronological age.

Schools rely on parents to inform them about a TBI, and rarely receive information on possible long-term results. At hospital discharge, health professionals should provide schools with information about TBI and possible long-term impairments, so that children returning to school receive appropriate support.

TBI IN THE ADULT POPULATION

Children are not the only group experiencing TBIs at an increasing rate. Adults ranging from young adulthood to the elderly population are experiencing brain injuries at an alarming rate.

Recent studies indicate that fall-related TBIs among the elderly are responsible for an estimated 141,998 emergency department visits, 81,500 hospitalizations, and 14,347 deaths in the United States each year. The expectation of poor outcomes in the elderly often leads to treatments being withheld or prematurely stopped resulting poorer outcomes.

TBI and the Prison System

There is a silent epidemic occurring in the United States prison system. Researchers looking at the cost of incarceration uncovered some startling trends. In a study by Matt Ferner he found that the cost of incarceration in the US is more than $1 trillion. He found that half of that burden falls upon the families, children and communities of the incarcerated. It costs the U.S. government about $80 billion a year to operate federal and state prisons. What Ferner and other researchers found is that TBIs play a pivotal role in the cost of the modern prison system.

In a 2003 study researchers determined that 87 percent of a county jail population reported a history of head injury. Studies like these have uncovered the unrecognized problem of inmates living with traumatic brain injury (TBI)-related problems. It complicates their management and treatment while incarcerated and upon released these problems pose challenges in readjusting to life in the community.

TBIs and Alcohol and Drug Use

When looking at the major causes of adult TBIs, it is necessary to look at the relationship between alcohol and drug use and TBIs. Alcohol and drug abuse is a common and welldocumented problem among persons who have sustained a traumatic brain injury (TBI).

Recent studies have shown that before injury, persons who sustain a TBI have higher rates of alcohol abuse than their peers. Unfortunately those who consume alcohol after a head injury are at an increased risk for seizures, a more severe TBI classification, higher rates of depression and a decreased risk of benefiting from rehabilitation.

HOW TO PROPERLY ASSESS A TBI

An important first line of defense is to properly identify and diagnose a TBI. Survivors of a TBI often face symptoms that can last a few days or for the rest of their lives. By educating medical professionals, parents, coaches, and the general public TBIs can be assessed and treated more quickly. There are a number of tools that can be used to identify a brain injury.

ASSESSMENT METHODS AND TESTS FOR IDENTIFYING TBIS

Glasgow Coma Scale

The Glasgow Coma Scale (GCS) is usually applied by first responders and by hospital emergency room doctors when an accident victim has lost consciousness for up to a minute or more. The 15-point test assesses a person's ability to follow directions, move their eyes and limbs and quality of speech coherence.

While the GCS is an excellent diagnostic test there are a couple of limitations. The first is that it is often not applied when someone has not lost consciousness. Considering the fact that many TBIs occur without a loss of consciousness this becomes problematic.

Additionally, GCS findings can sometimes be skewed by the increase of adrenaline in the brain after a traumatic experience. This can alter the findings of the scale.

Imaging Options to Assess a TBI

Computerized tomography (CT) scan is usually the first performed in an emergency room for a suspected traumatic brain injury more likely when a patient demonstrates a low Glasgow Coma scale. Magnetic resonance imaging (MRI) uses powerful radio waves and magnets to create a detailed view of the brain.

In the past many medical professionals were remiss to use imaging as a diagnostic tool for TBIs. While they can sometimes miss a TBI, more doctors are using these tools to assess a TBI.

It is important to note that imaging does have limitations in this scope. They can miss microscopic white matter injury associated with a Diffuse axonal injury, which is a brain injury with lesions in white matter over a widespread area. Studies indicate that in these types of injuries conventional head CT and MRI are unable to accurately diagnose mild TBI patients.

COST OF IMAGING AND TESTING

For people with limited insurance coverage the cost associated with these tests might limit their ability to undergo proper assessment. CT scans of the brain can cost between $500 and $900 and MRI’s can range from $2000 to $3600. Hospital costs can be significant, which may keep some people from pursuing medical treatment.

Is There a Solution to this Problem?

When all of the data succinctly highlights that TBIs are both undiagnosed and costly, both economically and socially we have to ask ourselves as a nation - what can be done to fix this problem?

First, education on this topic is critical. As more people know about the signs, symptoms and diagnosis of TBIs, more people will get the proper diagnosis. Second, which imaging can be an effective tool in making a diagnosis, medical professionals should be able to rely on inexpensive tests like the Glascow Coma Scale to make a quick and inexpensive diagnosis. Third, there are steps we can take a society to ensure that the rate of TBI does not continue to grow.

Protecting our youth when they play sports, properly diagnosing the incarcerated population and better drug and alcohol treatment are just a few ways we can work to decrease the impact of TBIs on our society.

CONCLUSION

Traumatic Brain Injuries are a complex injury with a variety of symptoms and outcomes. With more and updated data indicating the massive number of both diagnosed and undiagnosed Traumatic Brain Injuries, the impact on the person and their family can be devastating.

Because symptoms may not be apparent at the time of injury diagnosis is often missed by the patient, family and doctors. The person can look perfectly normal and family and friends often notice changes in behavior before the injured person realizes there is a problem.

1. Medical emergency first responders’ general medical doctors and allied health professionals failed to recognize mild head concussions as a possible brain injury.

2. Medical referrals for neurological testing was only for individuals who had lost consciousnesses.

3. Neurological testing is priced from$1100 to $5,000.

4. Highly personally invasive and time consuming up to four hours.

5. Online neuropsychological is convenient cost effective as being able to complete multiple tests of several months to monition social psychological changes.

6. Rehabilitation goals could be set and monitored.

© 2019. Christian King, B.Soc.Sci, is a socioligist and counsellor. Brain Injury Centre.