The Arnold Law Firm

Brain Injury as a Chronic Disease

Individuals living with a brain injury are referred to as brain injury survivors. But that term does not address the reality of brain injury. Cancer survivors are survivors because it is believed they are cured, and they indeed have outlived their disease. Many individuals who sustain a traumatic brain injury recover 100 percent. They have truly survived their injury. However, each year in the United States more than 125,000 individuals who sustain a traumatic brain injury become disabled.
Disease is defined in the Free Online Dictionary as representing a “deviation from or interruption of the normal structure or function of any body part, organ or system that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology and prognosis may be known or unknown.”

The insurance industry prefers the term “sickness,” which is defined as: “illness, disease of condition of a covered person which first manifests itself after the effective date of the policy and which this policy is in force for such person. Sickness includes any complications of recurrences that relate to such sickness while the policy is in force of the person.”

Traumatic brain injury should not be treated as an event or as a final outcome -- the insurance industry's sickness -- but rather as the beginning of a disease process. Despite the fact that people with traumatic brain injuries survive the injury, the effect is that of a disease.

A 2004 study on mortality one year post injury among individuals with a moderate to severe traumatic brain injury found those individuals were twice as likely to die as a similar non-brain injured cohort and had a life expectancy reduction of seven years. Even individuals with mild traumatic brain injuries have been found to have a small but statistically significant reduction in long-term survival.

The nature by which a brain injury can impact other organs is not known, but clearly there is an indirect effect.

NEUROLOGIC DISORDERS

  • Epilepsy:  Traumatic brain injuries are a major cause of epilepsy, accounting for 5 percent of all epilepsy in the general population. Traumatic brain injury  is the leading cause of epilepsy in the young adult population. As the time from injury to the time of the first post TBI seizure may be as long as 12 years, there is a need for heightened awareness of the development of epilepsy on the part of the patient, family and treating medical personnel.
  • Vision: Visual disturbances are common after a traumatic brain injury, occurring in 30-45 percent of individuals. Optic atrophy can begin shortly after the brain injury and lead to a marked decreased acuity and blindness.
  • Sleep: Sleep complaints are common following traumatic brain injuries. Subjective complaints of sleep disturbances have been reported in 70 percent of outpatients. Hypersomnia is associated with decreased cognition and decreased productivity, and certainly with a greater risk for accidents. National Highway Traffic Safety Administration data showed that approximately 56,000 auto crashes annually were cited by police officers where driver drowsiness was a factor.
  • Alzheimer’s Disease: Although the cause of Alzheimer’s is unknown, numerous studies have shown that a brain injury may well be a risk factor for the development of Alzheimer’s disease. A large study of World War II veterans found that any history of head injury more than doubled the risk of developing Alzheimer's, as well as the chances of developing non-Alzheimer’s dementia. They also found that the worse the head injury, the higher the risk. Even individuals with no known cognitive impairment after their injury have a risk of an earlier onset of dementia due to Alzheimer’s disease.
  • Chronic Traumatic Encephalopathy: At one time referred to as dementia pugilistica or “punch drunk,” CTE is a distinct neuropathological entity caused by repetitive blows to the head and was at one time deemed to be a disease seen only in old retired professional boxers. CTE is an insidious disease beginning with deterioration in concentration, memory and attention, eventually affecting the pyramidal tract resulting in disturbed gait, coordination, slurred speech and tremors. The sporting world has recently been shaken by autopsy-confirmed findings of CTE in retired professional football players (Omalu et al., 2006).
  • Neuroendocrine: A traumatic brain injury is associated with a host of neuroendocrine disorders. Hypopituitarism is found in approximately 30 percent of individuals, over a year post injury, with moderate to severe injuries. Growth hormone (GH) deficiency/insufficiency is found in approximately 20 percent of moderate to severe traumatic brain injury victims. This deficiency is associated with an increased risk of osteoporosis, hypercholesterolemia and atherosclerosis. These patients have a significant increase in mortality from vascular disease. Hypothyroidism is found in approximately 5 percent of individuals post traumatic brain injury. Associated signs and symptoms are weight gain, dyspnea, bradycardia and intellectual impairment. A recent study has shown a connection between hypothyroidism in females and the development of Alzheimer’s disease. Gonadotropin deficiency is found in approximately 10-15 percent of individuals post traumatic brain injury. Adult males will note decreased libido, muscle mass and strength. Hypogonadal women will develop secondary amenorrhea and increased risk for osteopenia.
  • Incontinence: Traumatic brain injury frequently affects the cerebral structures that control bladder storage and emptying functions, resulting in a neurogenic bladder. In one study individuals admitted to rehabilitation centers after a traumatic brain injury, one-third were incontinent of bowel. Twelve percent were incontinent at discharge, but 5 percent were still incontinent at the one year follow-up. Another review of medical complications in individuals with moderate to severe traumatic brain injuries found that 14 percent had fecal incontinence over one year post injury. Fecal incontinence is not only socially devastating, but it will have medical consequences, including skin breakdown, pressure ulcers and skin infections. Urinary incontinence is also a problem. One review of records on patients admitted to a rehabilitation unit within six weeks of
    injury found 62 percent were incontinent and 18 percent remained incontinent at six months. Urinary incontinence is associated with the development of frequent urinary tract infections and decubitus ulcers.

PSYCHIATRIC DISEASE

  • Many individuals with a mild traumatic brain injury, and the overwhelming majority of those who survive a moderate to severe injury, are left with significant long-term neurobehavioral complications. The costs to society in terms of lost productivity, as well as the costs for medical treatment are enormous. In addition to the aggression, confusion and agitation seen in the acute stages, a traumatic brain injury is associated with an increased risk of developing numerous psychiatric diseases, including obsessive compulsive disorders, anxiety disorders, psychotic disorders, mood disorders and major depression. A traumatic brain injury clearly may cause decades long, and possibly permanent, vulnerability to psychiatric illness.

SEXUAL DYSFUNCTION

  • Sexual dysfunction is a major ongoing problem in the traumatic brain injured population. Studies have shown 40-60 percent of individuals complain of sexual dysfunction after a traumatic brain injury. Transient hypogonadism is common acutely following a TBI, yet it persists in 10-17 percent of long-term survivors. Beyond just the fertility and psychosocial issues presented by hypogonadism, muscle weakness and osteoporosis may have a significant impact on long-term function and health with consequences exacerbated by immobility of long durations following a traumatic brain injury.

MUSCULOSKELETAL DYSFUNCTION

  • Spasticity is characterized by an increase in muscle tone that will result in abnormal motor patterns. This spasticity may well interfere with an individual’s general functioning, and limit self care, mobility and independence in the activities of daily living. Untreated, spasticity will eventually lead to muscle contractures, tissue breakdown and skin ulceration.
  • Skeletal dysfunction: The incidence of fractures in a traumatic brain injury is approximately 30 percent. Patients with fractures, especially fractures of the long bones, are at risk for heterotopic ossification (HO), which may not develop for as long as three months post injury. HO is defined as “the development of new bone formation in soft tissue planes surrounding neurologically affected joints,” and has an incidence of 10-20 percent following a traumatic brain injury. If left untreated, HO will eventually lead to abnormal bony fusions (ankylosis) and subsequent functional limitations.

Online resources: Conceptualizing Brain Injury as a Chronic Disease
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John Hughes,
Mar 31, 2010, 10:56 PM