By Robert Hall, MD, Chief Medical Officer, Optum Workers’ Comp and Auto No-fault Solutions
A few weeks back, a new patient of mine was accompanied into the examination room by his daughter. Although he was in his mid-50’s, he needed a significant amount of assistance due to decreased balance and unsteady walking. The reason for the referral was to evaluate the cause of his right shoulder and neck pain and hand numbness, which were ultimately found to be due to a pinched nerve. While we were discussing his symptoms, I asked if he had ever been treated for a brain injury. His daughter responded that he had indeed been hospitalized for a brain injury in 2014 following a fall from the top of a canyon. Her father had also sustained multiple orthopedic injuries related to the fall and although his fractures had healed, he continued to have shoulder and neck pain.
With this history presented, I initially assumed his balance problems were related to the fall and a traumatic brain injury suffered at that time. As the visit progressed, I observed that whenever I asked him a question, he was unable to give specific answers and deferred to his daughter to assist with answering my questions.
Proceeding with the examination of his neck and shoulder, I asked if he had any more recent falls that could be contributing towards his decreased balance and worsening his pain. His daughter stated that yes, he had been having problems with losing his balance and falling since being in rehabilitation in late 2015 for his brain injury. At that point, I thought that I must have missed something in the timing of his brain injury as I had recalled the canyon fall occurred in 2014. Upon further questioning, his daughter reported that, while he did, in fact, injure his brain in 2014, he had fully recovered physically, without residual balance problems, but continued to have pain and psychological problems. He had been placed on hydrocodone-acetaminophen, gabapentin, quetiapine, and a skeletal muscle relaxant to treat these conditions. It turns out that in late 2015, he suffered from a medication overdose and stopped breathing. While he was revived from the overdose, he was diagnosed with an anoxic brain injury. Despite several weeks of undergoing intense rehabilitation at one of the top rehabilitation hospitals in the United States, he continued to suffer from severe cognitive and physical deficits.
Anoxic brain injury occurs when the brain does not receive adequate oxygen. As a result, brain cells begin to die. The most vulnerable parts of the brain to decreased oxygen levels are those storing memories and controlling coordination, which explains the common findings of short-term memory loss and balance difficulties following anoxic brain injuries. Other non-overdose causes for anoxic brain injury include cardiopulmonary arrest due to heart attacks and arrhythmias, drowning, and carbon monoxide poisoning. Depending on the length of time without oxygen to the brain, initial symptoms can range from mild confusion to coma in severe cases. While there is no cure for anoxic brain injury, treatment involves intense rehabilitation to help restore (or at least improve) cognitive function, memory, balance, strength, and coordination. The rehabilitation phase can be extremely long and may, in the end, as was the case for my patient, not return the individual to their previous levels of cognitive or physical function.
An ongoing challenge
Often when we hear or think of medication overdose, our thoughts automatically turn to those victims who did not survive resuscitative efforts. With the rising use of naloxone (PDF), we can now anticipate an increasing number of individuals will survive the overdose yet sustain injuries with lasting effects. These individuals must now adapt to, and cope with, new levels of ability and functional capacity. Meanwhile, those of us on the front lines managing care must continue to work together to create goal-oriented, lifelong treatment plans such as those presented in the upcoming Traumatic Brain Injury webinar. In situations involving anoxic brain injury, it is important for these plans to consist of memory compensatory strategies, balance and safety equipment (for example, a walker or cane), depression management, and assistance/supervision with mobility and self-care needs (for example, through the use of home health care and other services), as appropriate for the individual patient. By doing so we can promote a healthier outcome.
About Dr. Robert Hall
As Corporate Medical Director, Dr. Robert Hall advises customers and employees on evidence-based clinical and rehabilitation guidelines that optimize pharmacy, home health and durable medical equipment programs, promoting better outcomes for injured workers. He also offers counsel on processes and procedures, identifying and reducing prescription medication misuse and abuse.
A practicing, board-certified physical medicine and rehabilitation physician, Dr. Hall has treated patients in private practice, private and state-run hospitals and out-patient clinics. His areas of focus include electromyography, pain management, musculoskeletal medicine and stroke rehabilitation.
After receiving his Bachelor of Science in Electrical Engineering at The Ohio State University, he continued his medical training and was chief resident in physical medicine and rehabilitation at the university’s medical center. Dr. Hall also serves as an adjunct assistant professor of Physical Medicine & Rehabilitation at The Ohio State University Wexner Medical Center. He has been awarded the distinction of “Best Doctors in America®” since 2009.
About Optum Worker’s Comp and Auto No-fault Solutions
Optum Workers’ Comp and Auto No-fault Solutions collaborates with clients to lower costs while improving health outcomes for the claimants we serve. Our comprehensive pharmacy, ancillary and managed care services, including settlement solutions, combine data, analytics, and extensive clinical expertise with innovative technology to ensure claimants receive safe, efficacious and cost-effective care throughout the lifecycle of a claim. For more information, email us at firstname.lastname@example.org.
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