Traumatic Brain Injury: Separating the Wheat from the Chaff

Transcription

1 Traumatic Brain Injury: Separating the Wheat from the Chaff Les Kertay, Ph.D., ABPP American Academy of Disability Examining Physicians 27 th Annual ScienAfic Session & Business MeeAng San Antonio, Texas January 10, 2014

2 Outline IntroducAon The evidence base on mtbi AccumulaAng new evidence Prognosis and outcome So now what? 2

3 Les Kertay, Ph.D. Employed Lincoln Financial Group, Insurance SoluAons Private pracace; coaching, consulang, counseling No commercial endorsements or conflicts The opinions and ideas expressed in this presentaaon are those of the author, based on his training and experience. The contents of this presentaaon are not intended to represent the official policies or guidelines of Lincoln Financial Group 3

4 TraumaAc Brain Injury: SeparaAng the Wheat from the Chaff Les Kertay, Ph.D. AADEP January, 2014 INTRODUCTION 4

5 What is a Traumatic Brain Injury? damage to brain Assue caused by external mechanical forces, as evidenced by objecave neurological findings, pos0rauma2c amnesia, skull fracture, or loss of consciousness because of brain trauma. - American Psychological AssociaAon,

6 What is a Traumatic Brain Injury? Severity of injury can be assessed with the Glasgow Coma Scale score or by measuring dura2on of LOC, with each measure adding increased prognosac value. - InternaAonal Neuropsychological Society,

7 Epidemiology 7 Langlois, et al., The epidemiology and impact of traumaac brain injury. J Head Trauma Rehab, 21(5),

8 Causes 13% 9% 28% Falls 11% MVA Fall/Strike 19% 20% Assault Other Unknown 8 Langlois, et al., The epidemiology and impact of traumaac brain injury. J Head Trauma Rehab, 21(5),

9 Causes 9% 36% 38% RTA Fall Violence EsAmates based on Neurological Disorders: Public Health Challenges WHO,

10 Severity GCS PTA LOC Mild < 1 day 0-30 min Moderate to 7 days 30 min - 24 hrs Severe 3-8 > 7 days > 24 hrs 2008 DOD and VA TBI Task Force 10

11 WHO mtbi Operational DeEinition Holm, et al (2005), J Rehab Med, 37(3), Acute brain injury resulang from mechanical energy to the head from external forces that meets the following criteria: 11

12 WHO mtbi Operational DeEinition Holm, et al (2005), J Rehab Med, 37(3), A. Including one or more of the following 1. Confusion or disorientaaon 2. Loss of consciousness for 30 minutes or less 3. Pos0rauma2c amnesia for 30 minutes or less 4. Other transient neurological abnormali2es 12

13 WHO mtbi Operational DeEinition Holm, et al (2005), J Rehab Med, 37(3), B. GCS score of aner 30 minutes post injury C. NOT due to drugs, alcohol, medicaaon, other injuries or treatment for other injuries, other problems, penetraang craniocerebral injury 13

14 What We Knew Barth s 3 Facts 1. There is NO relaaonship between postconcussion syndrome and concussion 2. There is NO relaaonship between prolonged post- traumaac headache and head trauma 3. The AMA, WHO, and AACN reviews concluded that there is NO credible scienafic support for claims of permanent impairment due to mtbi Overwhelmingly, the evidence indicates that recovery from mtbi is rela2vely rapid, and complete 14

15 So Why All the Renewed Interest? 15

16 TraumaAc Brain Injury: SeparaAng the Wheat from the Chaff Les Kertay, Ph.D. AADEP January, 2014 THE EVIDENCE BASE 16

17 Permanent Cognitive Impairment in mtbi? The stronger studies, u2lizing appropriate control groups and controlling for confounding factors, suggest that post- concussion symptoms are largely resolved within three months to a year - WHO Task Force on mtbi, Carroll et al.,

18 Permanent Cognitive Impairment in mtbi? The symptoms of mtbi generally resolve in days to weeks, and leave the pa2ent with no impairment - AMA Guides to the Evalua2on of Impairment, 6 th Edi2on 18

19 Permanent Cognitive Impairment in mtbi? The effect size for mtbi is smaller than the effect sizes associated with either li2ga2on or hypertension - Binder, et al., 1997, A Review of Mild Head Trauma part 1 19

20 Postconcussion Syndrome Caused by mtbi? CausaAon Analysis (AMA Guides to the EvaluaAon of Disease and Injury CausaAon, 2 nd EdiAon, 2014) 1. DefiniAvely establish a diagnosis 2. Apply relevant findings from epidemiological science to the individual case 3. Obtain & assess the evidence of exposure 4. Consider other relevant factors 5. ScruAnize the validity of the evidence 20

21 Postconcussion Syndrome Caused by mtbi? This study illustrates that the presence of postconcussion- like symptoms: (a) are not unique to mild head injury and are commonly found in healthy individuals, and (b) are highly correlated with depressive symptoms. 36%- 76% for any symptoms in the past 2 weeks 3%- 15% for severe symptoms r =.76 correlaaon with BDI scores - Iverson & Lange,

22 Postconcussion Syndrome Caused by mtbi? Non- TBI Claimants mtbi PaAents Headache 77% 42% Dizziness 41% 26% Irritability 63% 28% Memory symptoms 46% 36% ConcentraAon symptoms 71% 25% - Dunn et al. 1995, J Clin Psych, 51: Ingelbrigsten et al. 1998, J Neurology, 245:

23 Postconcussion Syndrome Caused by mtbi? The bo0om line is that PCS symptoms are common in the healthy popula2on, and are more highly correlated with filing claims than with a history of brain injury - Thank you Dr. Bob Barth 23

24 Malingering (Larrabee, 2003) Across a broad range of studies, rates of malingering/ decepaon/inconsistent effort range from 15% to 64% Study Heaton, et al (HRB, MMPI) Trueblood & Schmidt 1993 (< chance) Frederick et al (slope, non- verbal) Youngjohn et al (PDRT or dot counang) Millis 1995 (0 percenale on RMT) Greiffenstein et al (Inconsistencies) Millis et al (Chance or worse on RMT) Meyers & Vollbrecht 1998 (Failure on Digit Span) Grote et al (Failure on VSVT) Rohling et al (Failure on CARB or WMT) TOTAL 11 Studies Base Rate 64% 15% 25% 48% 50% 59% 25% 49% 42% 42% 40% 24

25 Malingering Mittenberg et al., 2002 Cases Reported Adjusted Personal Injury 28.7% 30.4% Disability/WC 30.1% 32.7% Criminal 19.2% 22.8% Medical/Psychiatric 8.1% 8.1% 25

26 Malingering Mittenberg et al., 2002 Cases Reported Adjusted Mild TBI 38.5% 41.2% Fibromyalgia/Chronic Pain 34.7% 38.6% Pain/Somatoform 31.4% 33.5% Neurotoxic 26.5% 29.5% Depression 14.9% 16.1% Moderate/Severe TBI 8.8% 8.8% 26

27 Review Barth s 3 Facts 1. There is NO relaaonship between postconcussion syndrome and concussion 2. There is NO relaaonship between prolonged post- traumaac headache and head trauma 3. The AMA, WHO, and AACN reviews concluded that there is NO credible scienafic support for claims of permanent impairment due to mtbi Overwhelmingly, the evidence indicates that recovery from mtbi is rela2vely rapid, and complete 27

28 TraumaAc Brain Injury: SeparaAng the Wheat from the Chaff Les Kertay, Ph.D. AADEP January, 2014 BUT THEN AGAIN 28

29 So Why All the Renewed Interest? 29

30 Contrary Evidence At one year severity was not related to late disability, which occurred in almost half of each group (mild 47%, moderate 45%, severe 48%) Accords with some other studies that show relaavely high rates of persisang poor recovery - McEwen et al Disability in young people and adults one year aner head injury: A prospecave cohort study. Bri2sh Medical Journal. 30

31 Contrary Evidence - NFL case study by itself cannot confirm a causal link between professional football and CTE. However, it indicates the need for comprehensive cogni2ve and autopsy- based research on longterm postneurotraumaac sequelae of professional American football. - Omalu et al., Neurosurgery, 57:

32 Contrary Evidence - NFL 32

33 Contrary Evidence - Military Of 2525 soldiers, 124 (4.9%) reported injuries with loss of consciousness, 260 (10.3%) reported injuries with altered mental status, and 435 (17.2%) reported other injuries during deployment. Of those repor2ng loss of consciousness, 43.9% met criteria for post- trauma2c stress disorder (PTSD), as compared with 27.3% of those reporang altered mental status, 16.2% with other injuries, and 9.1% with no injury. - Hoge, et al NEJM mtbi in US Soldiers returning from Iraq 33

34 Hoge, et al Soldiers with mild traumaac brain injury, primarily those who had loss of consciousness, were significantly more likely to report poor general health, missed workdays, medical visits, and a high number of somaac and postconcussive symptoms than were soldiers with other injuries. However, aeer adjustment for PTSD and depression, mild trauma2c brain injury was no longer significantly associated with these physical health outcomes or symptoms, except for headache. 34

35 Accumulating Evidence Risk factors for increased severity: Age > 40 Previous head injury, brain illness Previous other illness Repeated trauma and increased age appear to be associated with increased likelihood of long- term sequelae for prior head injury 35

36 Caution Many studies (e.g., McEwen) ask for self- reported comparisons to premorbid funcaoning and assignment of causaaon (GOS) Insufficient well- controlled studies Use of ill- defined syndromes Reliance on circular reasoning Failure to account for PTSD (military personnel) Correla2on is not causa2on 36

37 TraumaAc Brain Injury: SeparaAng the Wheat from the Chaff Les Kertay, Ph.D. AADEP January, 2014 PROGNOSIS 37

38 Outcome in TBI The default outcome is improvement that is rapid, thorough, and enduring 38

39 Sbordonne et al. (1995) 20 paaents who sustained sever TBI at least 5 years prior to the study were evaluated by structured interview and observaaon These data suggest that pa2ents who sustain severe TBI con2nue to make gradual improvements in their func2oning for at least 10 years post- injury 39

40 Miller & Stern (1965) 100 consecuave cases of severe TBI, evaluated average of 11 years post injury For 38 of the adults, when evalua2on that had been provided 2-3 years aeer the injury had produced conclusions that there was serious doubt about whether the pa2ent would ever work again, the long term follow up revealed that approximately 74% were working 40

41 Throughout other studies, consistently approximately 70-75% of those experiencing severe TBI are employed on long- term follow up, despite a high incidence of con2nued symptoms at 1 year post injury 41

42 Rogan, Fortune & Prentice (2013) 70 subjects with Moderate to Severe brain injury of various causes, averaging 70 months post injury Results showed that greater levels of post- trauma2c growth were associated with greater use of adap2ve coping strategies (r..597), lower levels of distress (r..241) and stronger beliefs about treatment- induced controllability of the effects arising from brain injury (r.. 263). Only adap2ve coping strategies gave a unique and sta2s2cally significant contribu2on to post- trauma2c growth 42

43 TraumaAc Brain Injury: SeparaAng the Wheat from the Chaff Les Kertay, Ph.D. AADEP January, 2014 SEPARATING WHEAT FROM CHAFF 43

44 This is the mtbi paradox: Pa2ents with severe head injuries can make full recoveries, while others with no premorbid risk factors and mild injuries experience long- term nega2ve consequences (Klimek, 2011) 44

45 But Just Because You re Paranoid 45

46 Analyze a Brain Injury Claim 1. Determine severity A. 90% are mild by definiaon B. Records from the day of injury C. Document the natural history of the claim 2. Review by a competent neuropsychologist A. Documented sources of informaaon B. Evaluate formal effort tesang C. Evaluate internal consistency D. Consistency analysis 46

47 What Can Neuropsychological Testing Do (& Not Do)? Not Do Assess cogniave impairment due to head injury if no head injury is documented Localize injury Prove causaaon Do ObjecAvely assess whether there is any cogniave impairment Provide alternaave hypotheses ObjecAvely assess effort Note: sta2s2cal significance does not equal clinical significance 47

48 Risk, Capacity, Tolerance Risk: NONE The brain does not become injured or get worse with ac2vity. Capacity: MAYBE Func2onal tes2ng or a trial of supervised work ac2vity may be helpful in determining work ability. Tolerance: AT ISSUE These symptoms are not measurable or verifiable and are infrequently a basis for physician cer2fica2on of work absence sa2sfactorily addressed by work autonomy, in which the pace and rate of work are modified Klimek, Working with common neurologic problems. In AMA Guides to the EvailuaAon of Work Ability and Return to Work, 2 nd EdiAon.

49 mtbi Management Protocol 49 Holm, et al (2005)

50 Do TBI s Have Long- term Sequelae? 50

51 Contact Information Les Kertay, Ph.D., ABPP Licensed Psychologist website: blog: facebook: dr.les.kertay phone: