Concussion: Traumatic Brain Injury from Head to Tail

By Kester J Nedd DO

Clinicians and patients can no longer wait for answers to fundamental questions regarding how to properly evaluate and treat concussions and traumatic brain injuries.

Doctors, those suffering, and their loved ones have questions that need to be answered, including:

• When will someone emerge from a coma?
• Can the fear of going out in public be overcome?
• Will problems pertaining to memory and anger management go away?
• Will the individual be able to work again?

Dr. Kester J Nedd, a board-certified neurologist, draws on his years of experience treating patients suffering from head injuries to answer these questions and many more.

Filled with real stories of patients, this first volume explores how this modern epidemic is often misdiagnosed or left untreated. Unsound definitions, rules of engagement, and limited scientific evidence has caused us to lose generations of people who suffered the fate of this condition.

The author shares a new and transformative evaluation method, known as Brain Hierarchical Evaluation and Treatment- the BHET method. The book outlines the hierarchical organization of the brain “from head to tail” and highlights what happens to the brain after an injury and how it responds.

• Language: English
• Publisher: Archway Publishing
• Release date: May 27, 2020
• ISBN: 9781480886964

Kester J Nedd DO

Dr. Kester J Nedd has helped thousands of patients with traumatic brain injury over his thirty-year career. A board-certified neurologist, he is a neurological rehabilitation and concussion traumatic brain injury specialist at the University of Miami Miller School of Medicine and the Design Neuroscience Center in Miami. As an expert in sports concussion, Dr. Kester Nedd is involved in treating current and retired athletes and is on the forefront of issues related to concussion from sports, military conflicts, road traffic accidents, and other injuries.

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Copyright © 2020 Kester J Nedd, DO.

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CONTENTS

Introduction

Part I         Defining the Issues

Chapter 1     Tragedy in an instant

Chapter 2     From Head to Tail … What is the BHET Method?

Chapter 3     A Silent Epidemic – Traumatic Brain Injury (TBI) and Concussion

Chapter 4     Concepts and terms that better define TBI/concussion in the context of the BHET Method

Part II       Features of Cerebral Concussion and TBI

Chapter 5     Key Elements that Define Concussion

Chapter 6     What really happens during a concussion?

Chapter 7     What constitutes an injury?

Chapter 8     Clash of cultures in the field of brain injury

Chapter 9     The Walking Wounded – Missing the diagnosis

Chapter 10   It’s About Time we pay attention!

Chapter 11   Wake up America and Wake up World!

Chapter 12   Conformational Intelligence – Another Point of View

Chapter 13   Time is Brain

Part III       The BHET Concept

Chapter 14   Understanding BHET? From head to tail…

Chapter 15   The Basis for BHET

Chapter 16   Pillars of the BHET methodology

Part IV       Understanding the Anatomical & Physiological Domain

Chapter 17   The Metaphysical Basis of the Human Nervous System Organization – Starting with the Microanatomy and Physiology

Chapter 18   The Human Nervous System – Anatomic Hierarchical Organization – Gross Anatomic Sub-Dimensions

Chapter 19   Cerebral Cortex (Telencephalon) — The Head Behavior Structures – Gross Anatomic Sub-dimension (BHET Level 1).

Chapter 20   Diencephalon – The Lower Head structures – A Gross anatomic Sub-dimension – (BHET Level 2)

Chapter 21   Brain Stem and Cerebellum – BHET Level 3

Part V       When things go wrong

Chapter 22   Disruption of the Cellular Organization and the On and Off switching mechanisms - A physiological dimension

Chapter 23   The Energy Sink

Chapter 24   Energy and Balance

Chapter 25   Mechanical Forces that Hurt the Brain

Chapter 26   What is the Story of CTE?

Part VI     Time, stage and severity domain in the context of the central nervous system hierarchy

Chapter 27   Relationships between Three Dimensions – Time, Stage and Severity of Injury

Chapter 28   Determining Brain Disorganization – Utilizing the TSS Domain (Scoring System)

Part VII     The brain as a computer – the input process and output domain (IPO domain)

Chapter 29   How messages get in? The nervous system functioning as a keyboard (input dimension)

Chapter 30   The Nervous System as a Microprocessors – The Processing Dimension

Chapter 31   The Nervous System as an Output Device – The Output Dimensions

Chapter 32   Ranking Input, Output, and Processing

Part VIII     The basis for signs and symptoms domain

Chapter 33   A Cluster Versus Hierarchical Approach

Chapter 34   A jigsaw puzzle – The signs and symptoms domain

Chapter 35   Obtaining a Clinical History (Symptoms Dimension)

Chapter 36   Critical Clinical Exam Factors (Signs/Clinical Dimension)

Chapter 37   Organizing the Signs and Symptoms Domains in a Meaningful Way

Chapter 38   Putting Jack Thomas’ Case in Perspective – A Multidimensional Approach

Part IX       Cognitive and neurobehavioral domain

Chapter 39   The Cognitive Dimension

Chapter 40   Cortical Function/Cognitive Dimension (Disorders of Attention, Concentration, and Processing Abilities)

Chapter 41   Higher Cortical Function/ Cognitive Dimension – Memory 101 from Head to Tail

Chapter 42   How the Brain Handles Retrieval

Part X         Making sense! Issues to consider in TBI/

concussion

Chapter 43   Associate Learning – The Most Powerful Form of Learning in Living Organisms

Chapter 44   Executive Functions – Higher Cortical Function/Cognitive Domain

Chapter 45   Information Processing -- Higher Cortical Function/Cognitive Domain

Chapter 46   Communication -- Higher Cortical Functions/Cognitive Domain

Part XI         Neurobehavioral dimension

Chapter 47   Neurobehavioral Conditions in TBI/Concussion

Chapter 48   What is the tendency of the brain?

Chapter 49   A Bright Future Ahead?

Credits

INTRODUCTION

WHILE READING THIS book, if not already aware, you may realize that you or someone you know has suffered a traumatic brain injury (TBI) or concussion, in many cases without full knowledge that this condition exists. TBI is occurring at a rate much higher than previously believed and is now classified as one of the worst silent medical epidemics of our times. Poor surveillance systems worldwide, underreporting, and an improper definition of what constitutes an injury to the brain are all reasons for the limited focus on this condition. So, wake up, world, let’s pay attention!

The human brain is the one element in the universe that can both preserve and destroy mankind as we know it. It is a highly organized structure with over a hundred billion nerve cells (neurons) and about a thousand trillion connections between those nerve cells. This highly organized structure is the most important computer processor known to the universe, which defines who we are and what others perceive us to be. As highly organized as it is, the human brain can be damaged or destroyed by external forces in an instant.

The Brain Hierarchical Evaluation and Treatment (BHET) methodology has been developed by a board-certified neurologist, Dr. Kester J. Nedd, who has been treating persons with TBI and concussion in the USA for over 3 decades. Through his career, Dr. Nedd has had over 250,000 patient encounters with individuals who had a TBI or concussion. Dr. Nedd is an associate professor in the Department of Neurology at the University of Miami Miller School of Medicine and is the Medical Director of the USports Concussion Clinic, along with formerly being the Medical Director of the Neurological Rehabilitation and Intermediate Head Injury Unit at Jackson Memorial Hospital in Miami. At the time of publication of this book, Dr. Nedd was serving as Medical Director and Managing Partner of Design Neuroscience Center in Doral/Miami Florida, a center of excellence in TBI and concussion.

This work simplifies the complex subject of TBI and concussion, a subject that has been recently popularized by the media in conjunction with consumers and certain healthcare professionals. In its attempt to provide answers for complex unresolved questions, the BHET method deviates from the current linear approach in favor of a multi-dimensional approach. BHET is a transformative approach for the evaluation and treatment of patients by considering the hierarchical organization of the brain and how this hierarchy is impacted by injury and during recovery. It redefines the nature of TBI and concussion in the context of signs and symptoms, some of which are often missed in conventional intervention while also utilizing case reports of patients to illustrate important clinical principles. Based on the experience of Dr. Nedd and his colleagues, this method questions the current approaches and offers evidence-based, practical solutions that can be utilized by clinicians, patients and their families, the legal system, media, researchers, social scientists, medical professionals, individuals involved in the sports world, students, and policymakers when considering TBI and concussion.

PART I

Defining the Issues

CHAPTER

1

Tragedy in an instant

PEOPLE WITH CONCUSSION and/or traumatic brain injury (TBI) and their loved ones know the reality of facing a radical change in an instant. Can you imagine being a fully functional human being, caring for your family, holding down a job, or performing as a student in school, then suddenly not being able to do any of these at a level you were previously able to perform?

Meet Mario (Case #1), a 24-year-old dental student from Venezuela, an avid sportsman who lived for the thrill and exhilaration that only a few experience while participating in extreme sports. Mario suffered a form of TBI that is rarely seen – second impact syndrome (SIS). I came across Mario and his family when they were desperately in search of a neurologist who had experience caring for individuals with severe TBI. About 10 days after suffering a cerebral concussion while wakeboarding, Mario returned to the sport while having persistent dizziness, vertigo (sensation of spinning), and headaches. He received medical care from a neurologist following his first cerebral concussion and was told that the CAT scan of his brain was normal, even though his condition was labeled as a cerebral concussion. Unfortunately, when he returned to the sport, he suffered a second injury as he was thrown off the wakeboard moving at a high speed. For the second time, his head impacted against the water, which when traveling at a high speed, feels equivalent to an impact against a brick wall. Mario’s friend lifted Mario out of the water and onto the boat, realizing he was limp and unable to help himself. His friend noted that he was minimally conscious but still breathing. On his way to the shore, Mario had a grand mal tonic-clonic seizure with intense violent jerking movements involving both sides of the body. When the paramedics arrived on the shore, he was intubated (a tube placed in his windpipe through his mouth) and placed on a ventilator – a device that facilitated his breathing. He was taken to a local hospital and the initial CAT scan of his brain showed diffuse cerebral edema (brain swelling) and a small right subdural hematoma (bleeding under the coverings of the brain). At the hospital, he was minimally responsive to pain, able to spontaneously move his extremities, but not able to communicate. Within a few hours of arrival at the hospital, he became totally unresponsive. His neurological exam showed a dilated pupil on the right eye. A dilated pupil that does not react to light especially on one side is usually indicative of compression of the third cranial nerve in the brain. The third cranial nerve is responsible for the contraction of the pupil when the eye is exposed to light. Further, a dilated pupil is generally an ominous sign of brain herniation from swelling or the effect of a mass, such as a subdural hematoma, causing the shifting of the brain from one side to the other. The effect of the edema and of the mass (subdural hematoma) also known as mass effect, caused the shift in Mario’s brain, which resulted in compression of the third nerve. Since this change was considered a neurological emergency, a follow-up CAT scan of the brain was carried out, which showed increased diffuse swelling of the brain with a shift of the brain from the right to the left, due to the massive expansion of the subdural hematoma on the right.

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Mario was taken into surgery, and a decompressive craniectomy (removal of a portion of the skull) was performed to drain the subdural hematoma and reduce the pressure in the brain. This gave the brain room to expand due to the swelling process, a sign of severe brain injury.

It was clear that Mario had SIS, a condition rarely diagnosed in TBI. But when diagnosed, SIS is most common in concussion and TBI due to sports-related injuries.

Despite having symptoms after the first injury, Mario was cleared by his neurologist to return to the sport. It was even more devastating that after a further review of the original CAT scan of the brain from his first injury, an area of contusion (brain bruise) in the right hemisphere of the brain was revealed. This area of contusion on the very first CAT scan was not picked up by the neurologist or the neuro-radiologist. As a result, he was cleared to return to the sport. Mario returned to wakeboarding before he had a chance to fully recover from the original injury, which along with the second injury caused his brain to suffer extreme swelling.

Mario’s brain injury was severe enough to result in a major disruption of his brain’s hierarchical organization, causing him to be in a comatose state for over one year. After six years of caring for Mario and observing the effects of TBI and concussion in many of my patients, while also; witnessing up close the natural history of how the nervous system recovers following injury, I was inspired to develop this work.

Imagine for one moment that the human brain has over 100 billion neurons (nerve cells) which create over 1,000 trillion connections. It is estimated that the brain, as a supercomputer, can process one trillion bits per second and has a memory capacity that can vary from one to one thousand terabytes of data. This extraordinary system has been compared with the Library of Congress, which has over 19 million volumes equivalent to 10 terabytes of data.

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The complexity of such a system as it sits in our skull is unfathomable.

On a metaphysical level, it is an entire galaxy.

To paraphrase an expression, It took years to build Rome, but it was destroyed in a day. As a corollary, it took years for the human brain to evolve to its current state of sophistication and years following conception and birth to organize such a brain to perform what we now know as human behavior.

Yet, this highly organized structure can be destroyed in an instant!

CHAPTER

2

From Head to Tail … What

is the BHET Method?

WHEN CONSIDERING THE field of traumatic brain injury (TBI) and concussion, I am reminded of lyrics by Jimmy Cliff, a famous reggae artist who said, There are more questions than answers, and the more I find out is the less I learn. Despite years of scientific research on brain injuries, the experience of highly trained clinicians, and the support of families and foundations, we face the disadvantage of several unanswered questions.

According to Kenzie et al., TBI can be referred to as the most complicated disease of the most complex organ of the body.

The Brain Hierarchical Evaluation and Treatment (BHET) method challenges the current methods employed to evaluate and treat persons with TBI, while also providing an explanation for the hierarchical disorganization and subsequent reorganization that occurred in Mario’s brain and the over 50 million victims worldwide who are also affected by this condition each year.

BHET further provides the basis for carrying out treatment through various dimensions and domains to understand this very complex condition. The treatment and outcome will be covered in Volume II of this series.

Given the recent attention gained by the field of concussion and TBI, clinicians and patients are at a stage where they can no longer wait for answers to fundamental questions regarding how to properly evaluate and treat these conditions. The questions about the outcome of a specific health concern form the basis for what we believe subsequently and how we act: When will someone emerge from a coma? Can I overcome the phobia of going out in public? Is the dizziness and vertigo (spinning sensation) permanent? Why can’t I multitask and not be distracted? What about the problems pertaining to memory and anger management … will they ever go away? Will I ever be able to enjoy a good night of sleep? Should I stop this medication that I am using for seizures? Can I ever drive again? What about my sexuality? What about the restoration of my rights as an individual and will I ever be able to work again?

While the issues of concussion and TBI have been popularized in the modern media, there remains a lack of understanding among all stakeholders regarding the longitudinal issues in time and space that confront society related to this kind of injury. Brain injury as a concept is unlike any other condition, in that it impacts the computer-like processing system that directs the physiology of our bodies and how they operate, who we are, and what others perceive us to be. In fact, it is not merely about the health care provider and the patient; it involves a web of societal concerns, including the family unit, our policymakers, the legal system, funding sources, research interest, media, and our social organization. Those affected by this condition know very well the challenges it poses to our quality of life, economic stability, and social order.

Very few physicians have been interested in learning about TBI/concussions due to the limited understanding of the brain and the complexity of the science, the patients, and the issues. While extensive research has been done in the field, the results of TBI/concussion research have been hampered by imprecise classification, methodological inconsistencies, measurement issues, and uncertainty about underlying pathophysiology according to a paper published by Erin Kenzie and colleagues in 2017 (Kenzie 2017).

As of 2014, the total estimated cost incurred for failed clinical trials in TBI/concussion in the USA is over 1.1 billion dollars (ASPE 2014). In terms of the treatment, as of 2016, over 30 major clinical pharmaceutical trials to treat TBI have been conducted, and they have all been considered to have failed (Hack 2016).

As a treating neurologist for over three decades, I see a level of disorganization in our field, which has caused chaos among the stakeholders. I believe this disorganization is fundamentally due to our lack of understanding in how the brain is truly organized, how injury impacts organization, and how the brain reorganizes during recovery. This reorganization affects the patient, as well as the social order in the world.

I have been both humbled and humiliated by the patients I have met over the years and how much they defy medical wisdom at times. After spending three decades with over 250,000 patient encounters whom I have observed, evaluated, and treated, I have developed Brain Hierarchical Evaluation and Treatment or in short, the BHET method. The BHET approach utilizes the concept of organizing the subject of brain injury in various dimensions and domains to evaluate and treat patients with brain injury. The information in this book is not new, but I have utilized my experience to help clinicians, patients and their families, and the public find a more organized and efficient way to evaluate and treat TBI and concussion. This approach is evidence-based as well as clinically relevant. While this book questions and occasionally, objects to many of the current approaches used by clinicians, administrators, caregivers, and families, it utilizes research data available in the medical literature, my experience, and the experience of my colleagues in designing the BHET method. This first volume addresses how the brain works normally, following injury, and during recovery. The second volume will address the prognosis, outcomes, and the various methods of managing and treating TBI and concussion.

The BHET method is based on an understanding of the complexity of the human nervous system: its design, structural and physiological organization, and its adaptive and preservative capabilities after an injury. As the title suggests, From Head to Tail defines the inner workings of the nervous system, from its most complicated functions and structures, defined as head behavior, to its simpliest and primitive reflex behaviors, known as tail behavior.

As a neurologist with specialized training in neurological rehabilitation and neurological trauma, I have examined and treated TBI/concussion patients in the emergency room, trauma center, intensive care unit, acute care hospitals, inpatient neurological rehabilitation centers, outpatient rehabilitation centers, sub-acute facilities, and in out-patient settings. As the former Medical Director of Neurological Rehabilitation at Jackson Memorial Hospital and in my current roles as Medical Director at the University of Miami Miller School of Medicine Sports Medicine Concussion Program, Medical Director of Kendall Regional Medical Center Intermediate Brain Injury Unit, and Managing Director of the Design Neuroscience Center, I feel honored by this opportunity to serve this population of patients. I have seen first-hand the destruction of the hierarchical organization of the nervous system and observed with interest the recovery and restoration process of the structural, physiological, and corresponding functional hierarchical organization. BHET results from the knowledge I acquired in neuroscience, with major guidance from the experience of others, training from my teachers, my experience in the business, and in actually treating patients by utilizing the science presented by medical literature and some trial and error. BHET is an approach that has worked for patients with brain injury of all types, although the focus of this work is mostly on concussion and TBI.

CHAPTER

3

A Silent Epidemic – Traumatic

Brain Injury (TBI) and Concussion

ACCORDING TO THE Brain Injury Association of America, every 21 seconds, a person gets a traumatic brain injury (TBI) in the United States. World Health Organization (WHO) predicts that by 2020, TBI will be among the top three conditions that cause death and disability (Hyder 2017).

A comprehensive review of TBI published in The Lancet Neurology estimated that more than 50 million cases are annually recorded worldwide. The review further stated that half of the world’s population will experience one or more TBI over their lifetime (Feign 2013, Maas 2017). Humphreys (2013) provided lower estimates of 10 million TBI worldwide on an annual basis.

There is a wide range of annual incidence reports in the USA for the number of people with TBI/concussion, with a significant amount of underreporting noted. The number of incidence reports ranges from 1.7 million to 3.8 million persons annually (Bazarian 2005, Ropper 2007, Halsted 2010, Arbogast 2016, CDC 2016, Faul 2010). By comparison, 2% of the population are living with disabilities resulting from TBI (CDC, 2011).

TBI is one of the most-often overlooked conditions, even though it constitutes a major economic burden on the healthcare system. It is the leading cause of injury-related death and disability worldwide (WHO 2006, Majdan 2016, Faul 2010, CDC 2010). In 2003, over 2.8 million persons with TBI/concussion visited the emergency departments of American hospitals. Mild TBI accounts for around 80% of the cases, moderate TBI for about 10%, and severe TBI for approximately 10% of the cases (Faul 2010). A similar breakdown of incidences based on the severity has been noted worldwide.

In our industry, we commonly utilize the Glasgow Coma Scale (GCS) score, developed by Teasdale and Jennett in Glasgow, UK (Teasdale 1974). The GCS measures the level of consciousness as a tool to classify patients based on the initial severity at the time of presentation. This scale, widely used in the field of brain injury, is highly predictive about who with moderate to severe TBI will survive (Steyerber 2008, Saatman 2008). According to Laskowski, it (GCS) does not necessarily reflect the underlying cerebral pathology because different structural abnormalities can produce a similar clinical picture (Laskowski 2015).

For persons with milder forms of TBI that are generally classified as concussion, utilizing this scale as a predictor of long-term outcomes can be misleading. So, don’t be fooled by a high GCS score. Despite having a GCS of 13–15 (a high score is associated with mild injury) patients with concussions can experience more dire consequences from their injury. We have a saying in our industry: Not all mild brain injury is considered mild.

The scale utilizes 3 variables, each with the elements presented with a weighted score. A final score is provided after each element is tabulated.

The three variables are as follows:

Table #1 -- GCS Score

Based on the compiled tabulated score, the lowest and worse score is a 3, where the patient is totally comatose. The best score is 15, where the patient may be symptomatic but fully awake and functioning or can be completely normal. Mild TBI/concussion is generally attributed to a score of 13–15, moderate between 9–12, and severe is 8 and below.

Around 52% of severe brain injury survivors are moderately to severely disabled at 1 year after the injury, and around 43% of the patients hospitalized and discharged develop long-term disabilities (Thornhill 2000, Selassie 2008).

Defining the severity of a TBI/concussion is complex and involves assessing the disability measures, community and psychosocial functioning, neurological impairments, and quality of life measures. Having a severe TBI in the acute phase of the injury, as defined by the GCS, is predictive of negative long-term consequences, however, this is not necessarily the case in all patients.

With regard to mild TBI (concussion), approximately 15% of the patients with cerebral concussions have persistent symptoms for more than 3 months, demonstrate increased rates of disability, and need to use the healthcare system (McCrory 2017, Mechtler 2014, Bigler 2008).

TBI affects the young disproportionately and accounts for as much as 30% of the deaths caused by injury to young people under 45 years of age. This makes it the single most common cause of death and disability for individuals under the age of 45 (Faul 2015).

The most common causes of TBI/concussion include road traffic incidents or accidents (RTI), falls, sporting injuries, and interpersonal violence.

What is interesting about TBI/concussion is that the causes have evolved over time in keeping with our changing lifestyles, human interactions, world order, and technology. A major study on the incidence and occurrence of TBI worldwide reported on the Global Burden of Disease Study in 2016 revealed that the two leading causes of TBI were road traffic accidents and falls. The increase in the incidence of TBI between 1990 and 2016 can be attributed to the increase in population density, population aging, and the increased use of motor vehicles, motorcycles, and bicycles (GBD 2016).

Road traffic accidents increasingly affect the youth in low–middle-income countries, and this ties in with the male preponderance of the condition (Maas 2008). Developing nations are more significantly affected by this condition due to defective roads, the lack of or limited enforcement of laws that promote safety, and defective equipment.

Alcohol and substance abuse also play an important role in such cases. The highest rates of TBI in Latin America and the Caribbean result from road traffic incidents (RTI) and violence (Murry 1996). RTIs are the most significant contributor to the economic costs associated with TBI in Latin America (Hijar 1999). Further, violence is the second largest cause of intracranial injury in the Latin American region as well as a principal cause of death in Brazil, Columbia, Venezuela, El Salvador, and Mexico (Briceno-Leon 2005).

A study covering a quarter of a million people in Ontario, Canada, showed that the long-term risk of individuals who have a concussion committing suicide is three times the general incidence. When the concussion occurs over a weekend, the risk is even higher (Frallick 2016).

While motor vehicle accidents remain the major cause of TBI in high-income countries (HICs), there has been a relative increase in age-related TBI due to falls in HICs. This has been evidenced by the growth in the oldest segment of the elderly population and in the pediatric age group. Falls in the elderly are the major cause of TBI due to aging factors resulting in the loss of balance and motor control and the medical conditions of the elderly (Brazinova 2016, CDC 2015, Peters 2015, CDC 2010).

The increased incidence of injury related to sports has been noted and this in part is due to better education and higher self-reporting (CDC 2011, Hootman 2007, Lincoln 2011).

Military conflicts being a major cause of injuries have placed war-torn Syria as the country with the highest incidence of TBI in recent times (GBD 2018).

The direct costs incurred due to TBI in the USA have been estimated at $13.1 billion per year. An additional $64.7 billion is lost because of missed work and lost productivity. The total medical costs range from $63.4 to $79.1 billion (Salassie 2008, Coronado 2011).

These cost estimates mostly cover direct costs, such as that spent on acute care, hospitalization, acute, and sub-acute rehabilitation. However, these numbers are believed to be an underestimation because they do not cover certain indirect long-term costs such as neurobehavioral management and the impact on families and social order. Worldwide, direct and indirect costs related to TBI borne by the global economy are estimated at approximately $400 billion per year.

CHAPTER

4

Concepts and terms that better

define TBI/concussion in the

context of the BHET Method

OVER THE YEARS, the pressure to implement well-defined research methodologies combined with our misunderstanding of how the brain works, is injured, and how it recovers has forced us to standardize what many experts believe to be unsound definitions of what a concussion and/or a Traumatic Brain Injury (TBI) is. In fact, we now know that some of our conclusions regarding a brain injury and its impact have been sometimes wrong or misleading. These unsound definitions have caused us to have generations of people with missed cases of concussion and TBI. Imagine playing American Football in the 1960s, 1970s, 1980s, 1990s and even in early 2000. In many cases, you would not be considered to have suffered a concussion or TBI without loss of consciousness (LOC). LOC was a key part of defining a concussion, and this remained the case for many years. While LOC continues to be a factor in the definition, one needn’t have experienced LOC to have suffered concussion or TBI. We now know that most persons who suffer a concussion do not in fact experience LOC. I have seen patients with gunshot wounds to the head with a bullet traversing the frontal lobe of the brain with what we know to be a severe TBI requiring major neurosurgical intervention and yet not have experienced LOC. In a study performed with 343 individuals with concussion, more than 80% did not experience LOC and 95.6% had Glasgow Coma Scale (GCS) scores of 15/15 on presentation to the Emergency Department (ED). A score of 15 represents the best possible score following an injury (Pensford 2019).

A study published by the University of Pittsburgh Medical Center for Sports Medicine determined that only 2 out of 107 athletes with concussion suffered LOC, indicating that approximately 98% of persons with concussion in their program did not suffer LOC. According to Kenzie et al. (2017), LOC during concussion has been evidenced at 14%.

Even today, I hear some of my colleagues in neuroscience say that you must have LOC to be considered as having a concussion or TBI. How sad and uninformed! Several ex-football players who participated in hitting exercises whom I see as patients today tell me that if they did not experience dizziness, spinning sensation, feeling of being in a fog, or daze, they were considered a softy. What they did not know at the time is that every time they experienced these symptoms, yet another cerebral concussion was heralded. What we now know is that repeated hits to the head as that witnessed in American Football can lead to long-term consequences, including conditions such as chronic traumatic encephalopathy (also known as (CTE), a form of Dementia commonly seen in athletes with repeated hits to the head (McCrory 2017). Increasingly, data shows that even players with multiple hits to the head who are not considered to have suffered concussion (sub-concussive hits) can suffer long-term consequences such as CTE, a degenerative disorder of the brain caused by TBI and concussion (Moore 2017, McAlister 2017, Gardner 2015, Washington 2016).

Concussion occurs when mechanical forces affect the brain in such a manner that the physiological hierarchical organization and the associated functioning of the brain are disrupted to the extent that the patient experiences signs and symptoms which we now know are characteristics of concussion. These signs and symptoms include the following:

• Physical: fatigue, sleep disturbance, dizziness, spinning sensation, headaches

• Cognitive: mental fog, memory and attentional impairment, word-finding problems, communication problems

• Neurobehavioral: anxiety, depression, panic attacks, low self-esteem, fear, racing thoughts, short fuse, obsessive-compulsive tendencies

At its core, concussion have much to do with an imbalance between energy availability and its utilization throughout the brain or in certain parts of the brain (Giza 2001).

Following concussion/TBI, the delicate hierarchically organized structure of nerve cells or neurons working in an array becomes impaired and disorganized. These structures are responsible for the orderly production of energy to ensure the proper function of the brain. After injury, the brain remains impaired until there is recovery or reorganization of these neurons.

Applying the GCS criteria, approximately 80% of all TBI/concussion cases are classified as mild head injuries (Bazarian 2005, Rutland 2006). Data from various studies have shown that approximately 70–90% of all traumatic brain injuries are considered concussions (Cassidy 2004, Numminen 2011). In most cases, concussion symptoms last for a few days but rarely beyond 10–30 days (McCrory 2013, Broglio 2014).

Patients whose symptoms last for more than 30 days experience more physical, cognitive, and neurobehavioral signs and symptoms (O’Neil 2013, Williams 2015, McCrea 2003, Nelson 2016). When concussion symptoms last longer than 3 months following the initial injury, the condition is labeled as post-concussion syndrome. In this case, there are usually neurophysiological and neuropathological injuries to the brain structures, causing the disorganization and disruption of brain and body cycles, as well as functioning (Silverberg 2011).

Patients with repeated concussions tend to suffer greater long-term effects of concussion and/or TBI.

For the purpose of this book, concussion is defined as a milder form of TBI where the patient may or may not experience an alteration in or loss of consciousness for a brief period of time that is generally less than 30 minutes and may have the associated signs and symptoms but no focal neurological deficits. Focal neurological deficits generally involve an impairment in the neurological function of one or more parts of the body after an injury (e.g., weakness on one side of the body). The term Traumatic Brain Injury will be reserved for the more severe forms of injury, where there is one or more of the following: significant alteration in or loss of consciousness generally for more than 30 minutes; focal neurological deficits; or abnormal findings on CAT scan or routine MRI related to the injury. Abnormal CAT and MRI scans are rarely seen in concussion, depending upon how concussion is defined in various studies.

Between 5–15% of concussed patients will have trauma-related positive findings on MRI (Ellis 2015, Morgan 2015).

More recent sequences (techniques) in MRI, such as diffusion tensor imaging (DTI), can show abnormal findings in concussion patients that were not previously documented using the CAT scan or the regular MRI sequences (Arfanalkis 2002, Niogi 2008, Wilde 2008).

We now have both anatomic and physiological tools to evaluate one’s brain function after an injury, and while many of these tools are yet in their early stages of development, they tell us quite a bit about how the brain actually works, when an injury occurs, and what happens during recovery. Positron emission tomography (PET) scans and functional MRI (fMRI) are promising, as they look at the metabolism of glucose to reflect the functioning of distinct areas of the brain. The fMRI utilizes cognitive paradigms during imaging to look at the functioning networks and their connections to various areas (nodes) of the brain to determine their relationship while performing certain tasks (Medaglia 2017).

While there are limitations in these methods, they are valuable in the detection of injury and in understanding the patterns of recovery when compared to a normal functioning brain.

Recently, various pronouncements have been made about the identifiable markers of concussion/brain injury, which are found in blood and cerebrospinal fluids and that can be measured in the laboratory following an injury. Undoubtedly, findings such as these will ultimately change the definition of concussion and TBI. What we now know is that the definition of concussion will continue to evolve as we learn more about the science of brain injury.

Note that traumatic brain injury or TBI and brain injury are often used interchangeably to describe all forms of injury, including severe traumatic brain injury and concussion. Concussion and cerebral concussion are also used interchangeably.

Words and Concepts that Truly Define the Hierarchical Brain

Defining certain concepts and categorically organizing such concepts in a meaningful way to effectuate diagnosis and treatment and predict outcomes is what BHET is all about. While there are various approaches to evaluate and treat TBI/concussion, the BHET method espouses that there can indeed be a right and wrong way to evaluate and treat persons who carry the diagnosis of TBI or concussion.

Structural Anatomy: Relates to the physical structures of the nervous system that are both microscopic (also referred to as histological anatomy) and macroscopic that can be seen with the naked eye (also referred to as gross anatomy).

Physiology: Deals with the biology of how all living organisms work in relation to physical and chemical processes.

Cognitive or Neurocognitive or Neuropsychological Functioning: Deals with the cognitive function of humans that allows us to behave in certain ways that express who we are, what we believe, what is important to us, and how we relate to each other. It involves how we communicate, understand, express emotions, learn, memorize, perceive, process information, and relate to others and the world around us.

Neurobehavioral Functioning: Relates to how we react to who we are, what we perceive others to be, and how we respond to a situation. For example, anger, depression, anxiety, paranoia, and obsessive-compulsive tendencies are more neurobehavioral and can occur as a result of physical and neurocognitive factors, the environment, injury, or genetic defects that impact our physiological, functional, and our structural order.

Psychosocial: Looks at how the psychological factors and the social environment impact the physical health and mental wellness of an individual and their ability to function in society.

The hierarchical approach takes into consideration the following concepts:

1. Understanding the normal working of the brain and the working of the brain following injury – Having knowledge of the normally working brain enables a comparative understanding of the levels of disorganization that occur following injury and the subsequent reorganization that occurs during the recovery process. Anatomical, structural, and physiological disorganization produces a certain symptoms complex. Patients are not only treated according to the level of signs (what the professional finds) and symptoms (what the patient experiences) but also based on an understanding of the anatomical, structural, and physiological disorganization that disrupts the hierarchical order of functioning. This disruption can produce a complex set of symptoms reported by the patient and signs noted by families, caregivers, and through a meticulous evaluation performed by qualified clinicians. In doing so, BHET focuses on determining the level and severity of injury at every stage of the recovery process in terms of the hierarchical organization. BHET utilizes realistic evaluation methods to properly classify those conditions.

2. Treatment Concepts – The simple principles of what to treat first, where to start, how one sign or symptom relates to another, what athe triggers of a sign or symptom are, how to proceed with and when to end a treatment modality, are all critical issues in TBI/concussion. It is essential to establish the order and sequence of administering a treatment modality after the condition has been properly staged and classified. Once the level of disruption is established, there is generally an attempt to match the available treatment modalities to the patient based upon the level established. While the levels cannot always be neatly defined, any effort to classify the disorder into a hierarchy will go a long way towards treatment planning. BHET also provides sensible, logical, and whenever possible consensual and evidence-based tangible treatment modalities that generally produce positive results. This facilitates an approach that determines what should be evaluated and treated in the appropriate sequence and manner for effective recovery. This model utilized to treat TBI has the level of hierarchical organization and reorganization following TBI/concussion as its focus. Addressing those issues utilizing the BEHT method has made the concepts meaningful. Clinicians must resist the urge to start treatment when they have no idea what they are treating but feel the urge to do something because of the suffering reported by patients and their families. Such issues of treatment will be addressed in the second volume of this book series.

BHET provides a framework that can be utilized for making critical decisions about staging, prognostication, and treatment. This book was designed to bridge a significant chasm that exists among the various healthcare professionals and between health professions and the lay public. By taking this very complex area of neuroscience that utilizes case histories and models, BHET makes it easy to understand this complex condition.

A major point of failure with clinicians treating TBI is their limited understanding of the hierarchical organization of the brain before and after injury and the subsequent recovery path that the brain follows during recovery. I have personally seen patients be harmed because of this misunderstanding. In fact, certain treatment modalities are often administered at the wrong time or stage of recovery because of a misunderstanding of the brain’s hierarchal organization and the process by which such disorganization is restored following injury. BHET was developed based on my experience as a neuroscientist working in the field of brain injury with a team of colleagues who I have come to respect and admire. In developing this method, I have been able to utilize my experience in leadership and business, the practice of neuroscience, knowledge of the human condition, and my understanding of how the nervous system works, in order to conceptualize and implement BHET.

PART II

Features of Cerebral

Concussion and TBI

CHAPTER

5

Key Elements that

Define Concussion

ONE OF THE best definitions provided for concussion is based on a consensus statement provided at the 4th International Conference on Concussion in Sports held in November 2012 in Zurich. This very progressive definition evolved from the changing evidence that we now have on concussion. The definition is as follows: "Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic, and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:

1. Concussion may be caused by a direct blow to the head, face, neck, or elsewhere on the body with an ‘impulsive’ force transmitted to the head.

2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.

3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury, and as such, no abnormality is seen on standard structural neuroimaging studies.

4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged" (McCrory 2013).

BHET defined: Concussion occurs when mechanical forces affect the brain in such a manner that it disrupts the structural and physiological hierarchical organization and the associated functioning of the brain to the point that the patient experiences signs and symptoms that we now know are characteristic of concussions. In TBI/concussion, signs are what the healthcare providers find and symptoms are what the patients report.

These signs and symptoms include the following:

• Physical or somatic – fatigue, dizziness, spinning sensation, headaches, sleep disturbance, and lack of energy. Headache is the most commonly reported symptom in TBI/concussion, followed by dizziness, vertigo, and fatigue. A hallmark reported somatic symptom suggesting a disruption in the brain cycle is difficulty falling asleep and staying asleep.

• Cognitive – mental fog, memory and attentional impairment, and word-finding and visual perception problems. The hallmark feature of TBI/concussion is the inadequacy in executive functions, manifested by diminished insight, speed of processing, trouble with social graces, and in one’s ability to shift from one set of cognitive tasks to another.

• Neurobehavioral – anxiety, OCD, depression, low self-esteem, disinhibition (loss of filter), fear, short fuse, and personality changes that could include aggression, emotional lability (inappropriate laughter or crying), impulsivity (lack of impulse control), and irritability (Riggio 2009).

• According to Riggo (2009), neuropsychiatric or neurobehavioral symptoms actually are correlated with the severity, type, and duration of the somatic symptoms. This issue of which comes first the chicken or the egg, i.e. the physical somatic symptoms causing the cognitive and behavioral symptoms or vice versa is critical to understand TBI and concussions and how to treat such conditions.

Signs and symptoms in the immediate and chronic phases Immediate:

• Impaired attention – vacant stare,