By Mark S. Williams, DC, MBA, DACBOH, Medical Director – Group Benefits, The Hartford
Like most medical conditions, brain injuries present with a wide range of severity and related impairments. Unlike many of these other conditions, however, the ability to quantify and manage brain injuries is not well understood. This is particularly true with the less severe brain trauma known as mild traumatic brain injury (mTBI). With rising rates of incidence and related medical costs, this condition needs to be considered carefully.
According to the American College of Rehabilitation Medicine, traumatic brain injury (TBI) occurs when external force to the head or body alters brain function. The greatest number of these injuries by far are categorized as “mild” (mTBI). Also known as “concussion”, mTBI is defined by the American Congress of Rehabilitation as “involving no or only a brief (less than 30 minutes) loss of consciousness and period of posttraumatic amnesia (less than 24 hours)”, although there remains a lack of a universally accepted diagnostic criteria.
The absence of any trauma-related findings on brain imaging is a hallmark of this category of brain injury. There are no current guidelines that recommend advanced imaging (e.g. CT, MRI) beyond the acute period unless symptoms are not improving to rule out pathology that may have been less apparent when acute or the presence of other possibly related conditions. Further confounding the clinician’s expectations, recovery can be uncomplicated or it can result in prolonged symptoms. It is estimated that 1 in 5 of those with this diagnosis report symptoms beyond 1 month.1 These symptoms commonly consist of altered mental status, headache and malaise and can be subtle and transient, making diagnosis and treatment complicated to say the least. Biomarkers of brain trauma are being developed, but none have been validated for clinical use at this time.
So, a provider might be faced with a scenario involving a reported injury that may or may not have been witnessed, little consensus on the diagnostic criteria of mTBI, a lack of supporting imaging or biomarker evidence, and with symptoms that are difficult or impossible to verify. Then, the claim handler or analyst is asked to evaluate such issues as coverage, compensability and/or benefits. Not an ideal position for either party. Compounding this, consider that the patient/claimant is navigating unfamiliar medical care, typically with non-specialized training in management of TBI, as well as pursuing a workers’ comp system or disability insurance claim. There are plenty of challenges for all involved in these cases.
Most symptoms related to these injuries resolve and return to work within 1-2 weeks, more than half by 1 month. Unsurprisingly, as with most subjectively-based impairments, medical care (and costs) tend to run high while 20% of patients and providers seek validation of symptoms and appropriate treatment beyond six months. Post-traumatic headaches occur in more than 50% of cases, and 80-90% resolve within 3 months. The strongest predictors of extended durations include having a high number of symptoms prior to the event and having had prior mental health problems like pre-existing depression and anxiety. Prior mTBI’s may be a predictor, but evidence is mixed.
Claim handlers or analysts, should expect to find supportive information in the medical record. There should be a plausible mechanism of injury established. Does the sequence of events described demonstrate head or body trauma that could explain a brain injury? The presence of altered mental status is important, so there should be investigation around loss of consciousness, loss of orientation or amnesia of events before and/or after the trauma. There also needs to be questioning around confounding factors like substance use/abuse, presence of prior emotional or developmental conditions (e.g. depression or ADHD).
When validating any mTBI-related impairment, there should be evidence of treatment for the subjective complaints. For example, headaches would be expected to have medical or physical medicine treatment with some impact to symptom severity. Fatigue complaints can have many causes and should be assessed for possible adverse medication responses, sleep disorders and thyroid disease. Visual examinations are needed to validate vision problems and vestibular complaints should be examined by simple clinical tests before specialist referrals are made.
Persistent cognitive complaints should be evaluated carefully. Pre-existing diagnoses of attention deficit or other learning disability can be responsible for cognitive complaints and job accommodations may be helpful for returning to work. Screening for depression and anxiety are critical in any prolonged mTBI diagnosis. Mood symptoms are common after mTBI2 and post-injury symptoms are highly correlated with prolonged recovery. Neuropsychological testing should be considered in these instances.
Instrumental activities of daily living (IADL’s) such as driving, housecleaning and finance management may be impacted and their ability to accomplish these tasks are critical to the understanding of function. Analysts should probe these areas carefully to assess reported impairments.
Most people do not seek treatment and those who do are typically seen initially by their primary provider or the emergency department. Referrals are usually made to rehabilitation providers and neurologists, but less commonly to brain trauma specialists. These are generally group practices and are good resources of information, when available, and where most efficient care is more likely to be obtained.
These recommendations include some of the most up to date medical consensus3 on this complex condition. Research continues and consensus will evolve, but this will likely remain a difficult clinical and claim entity for some time.
(Dr. Williams writes on topics of interest to the community. He notes that this article is provided for informational purposes only and is not provided as specific medical advice, or for diagnosis or treatment, nor is it direction on how to handle or adjudicate individual claims.)
About Dr. Williams
Dr. Mark S. Williams is a chiropractic physician and medical director with The Hartford Insurance Company. He received his Doctor of Chiropractic from Logan College of Chiropractic. He is board certified in occupational health and applied ergonomics and has worked in the disability and workers’ compensation insurance industry since 2000. He has earned a MBA from the University of Southern Maine and a BS in Human Biology from Logan College of Chiropractic. He is a member of the American Chiropractic Association Council on Occupational Health. He serves as chair of the advisory committee for the ACA Opioid Task Force and is also a committee member of the Medical Issues, as well as the Disability and Return to Work Committees of the International Association of Industrial Accident Boards and Commissions (IAIABC).
1Bloom B, Thomas S, Ahrensberg JM, et al. A systematic review and meta-analysis of return to work after mild traumatic brain injury. Brain Inj 2018;32:1623-36
2Iverson GL, Gardner AJ, Terry DP, et al. Predictors of clinical recovery from concussion: a systematic review. Br J Sports Med 2017;51:941-8
3Silverberg, ND, Iaccarino, M, et al. Management of Concussion and Mild Traumatic Brain Injury: A Synthesis of Practice Guidelines. Archives of Physical Medicine and Rehabilitation 2019