Traumatic Brain Injury and the Tool Use to Help Prevent It
PSY 625: Biological Bases of Behavior
Instructor: Dr. Roxanne Behaire
February 5, 2018
Specific Aims
Traumatic brain injury (TBI) effects more than 1.7 million people each year with 75 to 85% fitting into the mild category. As this number doesn’t include individual seen in private practices or by their primary doctor, it is underestimated. (Shenton, 2012) It has become known as a “silent epidemic” (Shenton, 1) and the attention in its regards have heighten due to the rising number of individuals suffering from TBI as well as the effects it has had on soldiers throughout the years. Often time mild TBI goes undiagnosed as it is harder to detect using the typical computed tomography (CT) as it will not put abnormalities, so the brain will appear to be normal. In such events mTBI will typical rectify itself with in a few days to a few weeks. However, when the recovery takes up to 3 months, the could be cause for concern as it could lead to permanent disabilities known as post-concussive symptoms (PPCS) or more commonly known as post-concussive syndrome (PCS). This disability will cause symptoms such as headaches, fatigue, blurred vision as well as cognitive disorders.
The specific aim for this proposal is to bring to light the effectiveness of the angiograms we are using as a preventive measure. Determine if the scales we are using to measure the intensity of TBI are working and to provide information on new treatment and medication that could help to elevate traumatic brain injury altogether. As well as evaluation any new treatment that could help to eliminate TBI.
Background
Of all the neurologic disorders, Mild traumatic brain injury (mTBI) is one of the most common. Traumatic brain injury will affect nearly 10 million individual worldwide each year. Of with about 2 million are American, making it the most prevalent of all neurological disorders. Although most patient who suffer from mild traumatic brain injury recover within a few weeks or months and without any specific intervention (Alexander, 1). There is an overwhelm amount of people in the U.S. who suffer from TBI that is severe enough to be hospitalized, will be result in fatality, or will not recovery from their injuries. Approximately 15% (70 to 90 thousand) of those who survive TBI will develop long term disabilities that result in costly medical and rehabilitation care. This total is equivalent to the amount of individuals who suffer from Parkinson’s disease, multiple sclerosis, Guillain-Barré syndrome and myasthenia gravis combined each year. And like myasthenia gravis, mTBI effect men in their early 20’s and 30’s more so than any other gender or age group. Which means that those affected by it will potentially be afflicted this disability for a great part of their lives.
Children can also be affected by mild traumatic brain injury, it is also referred to as a concussion. These injuries to their brains are mostly sustained from sports and recreational activity, shaken baby syndrome and motor vehicle accident with flexion extension injuries. The symptoms of a concussion typically are more refined as hours to days elapse, so the severity of the injury cannot be determined at the time of the injury. Because of this often time the outcome of these injuries (especially in babies) result the leading cause of death or disabilities ranging from physical, cognitive, emotional and behavioral deficits in the United States.
Outside of the impairments that limit the daily functions of the patient’s everyday life. The survivor of TBI will have to endure substantial cognitive dysfunctions, i.e. memory loss, poor response inhibition, distractibility and will not be able to form and store new memory. “These attributes are not limited to severe and moderate TBI cases, but patients with mild TBI that suffer from post-concussion symptoms with cognitive impairments comorbid with other neuro-behavioral symptoms such as emotional alterations,” (Bondi, 1) will also experience these disturbances.
“Postgraduate teaching in neurology doesn’t mirror the high prevalence of this disorder – i.e. most residents probably do not get proportionate instruction in the diagnosis and management of mTBI”. (Alexander, 1). This is due to the following reasons: treatment of the acute phase of mTBI is typical provided by neurologist, most patient recover on their own, persistently symptomatic patients in anguish due to mild traumatic brain injury are often times thought to be lazy, unpleasant litigates, because of unclear psychological issues, that isn’t cured by the typical treatment, because when compared to other disorders, mTBI isn’t academically fascinating and there’s not an academic reward from the patients of mTBI. This could be due to the fact that the clinical phenomenology of mTBI is rationally comprehensive in neuropathology. While the deficiencies due to neurologic injury can be manifestation of impairment, the recovery time can usually be predicted. More times than not the treatment for mild traumatic brain injury works and the risk factor for developing prolonged symptoms detected, and with the correct treatment, can stop chronic disability from developing.
However, treatment for TBI is limited and continued research is critical. There has been several models developed for experimentation purposes, hoping to better understand the pathophysiology and neurological condition that causes TBI. These models are used primarily “to induce brain injury replicating features and outcomes that are seen clinically” (Bioni 1). One of the original ways to detect the severity of mild traumatic brain injury, (mTBI) which is “defined by the acute injury characteristics and not by the severity of the symptoms at random points after trauma”(Alexander). Those characteristic are as follows: head trauma due to force, how long the patient was unconscious, (usually seconds to minutes), or if there was no loss of consciousness, and by the use of the Glosgow Coma Scale (GCS) in an emergency room. The GCS it must be based on a score of 15 to be considered mild. A score of 13 or 14 is due to confusion and will be considered post-traumatic amnesia, (PTA). Those suffering from PTA will not have focal signs.
Diffuse axonal injury (DAI) is the primary neuropathology of TBI. Diffuse is caused by unaligned forces that generate in the brain by unexpected deceleration. These forces can result in tearing of the brain’s long connecting nerve fibers (axon) this happens when the brain shift and rotate inside the skull. “The combination of characteristic deficits in everyday activities and apparently normal performance on clinical tests can convince clinicians that the patient is exaggerating. Tests of divided attention and working memory may be abnormal for weeks. Initial complaints will include forgetfulness, neck pain, headache, and dizziness. DAI severity expectations should be based on the mechanism of injury, duration of coma, and duration of PTA. Treatment of persistent post-concussive syndrome should target the identifiable components of the disorder.” (Alexander, 1).
Significance
Because the anemograms we are using to detect TBI will not always actually read mTBI as a condition in patient. Resulting in sever cognitive disabilities. It is import for research to continue to not only promote awareness of this disorder that was at one time thought to be serve. As the greater the awareness is about the risk involved with mTBI, the more likely funding will be made available to provided better ways to diagnose, treat and prevent all forms of TBI.
In for years, the tools used to detect TBI were the Abbreviated Injury Scale (AIS). This scale is used to determine the clinical severity of TBI. GCS measures loss of consciousness and posttraumatic amnesia. And AIS “classifies each injury by body region according to its relative importance.” It uses a scoring systems of 6 point ordinal scale. A computed tomography (CT) which is used in hospitals to identify subtle brain injuries like diffuse axonal injury or mirco-hemorrhage. When using a computed tomography (CT) it is harder to diagnose mild TBI, as the brain will appear normal and about only 10% of CT can detect mild TBI. MRI can detect 30% of common abnormalities in mTBI.
However, in more recent years other treatment methods have been discovered that many help in limiting the severity of and assist in revering TBI. Staying in down this vain, and in order to drastically reduce the amount of individual that server from TBI it is important to continue to fund studies that will be a better defender of this disability.
Proposed Study
Participants:
In order to conduct this study 60 participants who have suffered or currently suffering from all categories of traumatic brain injury will be randomly selected. They will be divided into 3 groups of 20 according to the classification of the traumatic brain injury they have incurred (i.e mild, moderate and sever traumatic brain injury). Each individual would have to compete an evaluation form to determine if they have had any kind of medical or clinical treatment in the past or are currently taking medication. Each participate will need to complete a consent for experimental testing.
Each test will be conducted by physician’s or x-ray technicians trained in each specific area. This will ensure that each test is corrected conducted and read and eliminate risk of injury to the participants. Each participant will meet with the staff that will be responsible for the experimental and observational studies. The will be provided with an informational packet and a roundtable discussion will provide the participants with details of the study and allow them to ask any questions or voice any concerns they may have regarding the risk and or safety of this study.
Procedure:
Test will be conducted first using the computed tomography (CT) or magnetic resonance imaging (MRI) depending on the time frame the injury occurred. Each abnormality (i.e. gray – or which is composed mostly of neuronal cell bodies, glial cells and capillaries. And white matter – which are believed to reflect stretched or sheared axon bundles which are abnormal micro-structures) will be record, as well as if the brain appeared normal. After a week’s time, each participate shall be assessed by the Glasgow Coma Scale (GCS) to measure the functional capacity of their TBI. The white matter will be reviewed for lesions. For individuals who are suffering from severe diffuse axonal injury (DAI), clinical observation will be recommended and those participants will be observed for 6 months to 1 year to see if any improvement in functionality after trauma occurred.
Individuals who aren’t suffering from DAI, will be allowed to go home, they will complete a self-evaluation. They will record data of the day to day activities and provide information on their ability to comprehend materials that were read to them, that they read on their own and what they may have heard. This will show if there are any signs of cognitive dysfunction. This test will conclude after 3 weeks. If the participants find that they are not able to complete the task, they shall report back to the study lab immediately for, further observational evaluations. If consent was given, brain on chip
Hypotheses & Analysis:
This study is expected to find the best way to determine if an individual is suffering from TBI. It will evaluation the tools used to help detect mTBI at its onset in order to elevate ongoing cognitive disorders. It will examine new treatment options such as brain on chip and cerebral micro-dialysis to conclude if the change in molecular biomarker which are caused by TBI, and what drugs are best to assist in reversing or preventing TBI altogether taking some of the burden off of the healthcare system as well as providing a better since of life for those who have suffered from TBI.
Budget Justification
Funding would be necessary in order to employ assistants to recruit participants, packets that will be provided and the round table discussion presenter. Funding will also be necessary for the x-ray technicians and physicians they will be on staff to conduct the study. 15% of the funding will be allocated to the inpatient observations.
Each subject shall receive funding for participation of $70.00 each as well as supplemental payments for any medical treatment, in house treatment stays and reimbursement for mileage outside of 10 miles to reach the study lab. Funding will also be needed for any technical equipment that may be used to record data i.e. computers and/or testing equipment use in hospital.
(See Appendix A:Budget Details)
Annotated Bibliography
Alexander M. P Neurology (1995), 45 (7) 1253-1260; DOI: 10.1212/WNL.45.7.1253
Bogoslovsky, T., Gill, J., Jeromin, A., Davis, C., & Diaz-Arrastia, R. (2016). Fluid Biomarkers of Traumatic Brain Injury and Intended Context of Use. Diagnostics, 6(4), 37. http://doi.org/10.3390/diagnostics6040037 States,
This research article outlines the major factors in clinical practice to help measure the extent of TBI is one main be suffering from. Provided the effectiveness of the the Glasgow Coma Scale (GCS) and Abbreviated Injury Scale (AIS) when used to determine the clinical severity of TBI. Given an account of the percentage of TBI a CT and or a MRI will detect when used to determine common abnormalities in mTBI.
Bondi, C. O., Semple, B. D., Noble-Haeusslein, L. J., Osier, N. D., Carlson, S. W., Dixon, C. E., … Kline, A. E. (2015). Found in translation: understanding the biology and behavior of experimental traumatic brain injury. Neuroscience and Biobehavioral Reviews, 58, 123–146. http://doi.org/10.1016/j.neubiorev.2014.12.004
Cesar Reis, Yuechun Wang, Onat Akyol, Wing Mann Ho, Richard Applegate II, Gary Stier, Robert Martin, John H. Zhang Int J Mol Sci. 2015 Jun; 16(6): 11903–11965. Published online 2015 May 26. doi: 10.3390/ijms160611903
Provides excellent information as to why it is important to detect TBI early on. Shed light on new treatments such as brain on chip and cerebral micro-dialysis can help with the changes in molecular biomarkers caused from TBI. The researcher provides updates on new treatment i.e. stem cell-base and nanotechnology based as well as drugs that also reacts favorably in reversing or preventing TBI.
Muschelli, J., Ullman, N. L., Mould, W. A., Vespa, P., Hanley, D. F., & Crainiceanu, C. M. (2015). Validated Automatic Brain Extraction of Head CT Images. NeuroImage, 114, 379–385. http://doi.org/10.1016/j.neuroimage.2015.03.074
Rapp, P. E., Rosenberg, B. M., Keyser, D. O., Nathan, D., Toruno, K. M., Cellucci, C. J., … Bashore, T. R. (2013). Patient Characterization Protocols for Psychophysiological Studies of Traumatic Brain Injury and Post-TBI Psychiatric Disorders. Frontiers in Neurology, 4, 91. http://doi.org/10.3389/fneur.2013.00091
Shenton, M., Hamoda, H., Schneiderman, J., Bouix, S., Pasternak, O., Rathi, Y., … Zafonte, R. (2012). A Review of Magnetic Resonance Imaging and Diffusion Tensor Imaging Findings in Mild Traumatic Brain Injury. Brain Imaging and Behavior, 6(2), 137–192. http://doi.org/10.1007/s11682-012-9156-5
Provides an extensive account of the percentages of people suffering from Traumatic brain injury (TBI) each year. Gives an overview of the many causes of TBI and why it has gained more attention throughout the years. The author focuses on the different reasons as to why mild TBI (mTBI) remains undetected and what could happen if the usually recovery time of a few day to a week, elapses into 3 months.
Toledo, E., Lebel, A., Becerra, L., Minster, A., Linnman, C., Maleki, N., … Borsook, D. (2012). The Young Brain and Concussion: Imaging as a Biomarker for Diagnosis and Prognosis. Neuroscience and Biobehavioral Reviews, 36(6), 1510–1531. http://doi.org/10.1016/j.neubiorev.2012.03.007
Appendix A: Budget