Cognitive Assessment and Rehabilitation for Traumatic Brain Injury (TBI)

A recent initiative from the Congressional Brain Injury Task Force highlights an important issue affecting millions of Americans living with traumatic brain injury (TBI): the lack of long-term TBI rehabilitation care for most people, including those with health care insurance.

A letter from the office of U.S. Rep. Gabrielle Giffords to HHS Secretary Kathleen Sebelius advocating an end to the TBI “treatment gap”, by defining rehabilitation care as part of the essential benefits package included in the Patient Protection and Affordable Care Act, is being championed by U.S. Rep. Bill Pascrell (Chair of the Congressional Brain Injury Task Force).

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Congresswoman Giffords is currently being treated at TIRR Memorial Hermann Medical Center, one of the top TBI rehabilitation centers in the nation. Acute TBI rehabilitation costs more than $8,000 a day at a center like TIRR, and even long term post-acute TBI services can cost more than $1,000 per day.

An important part of the TBI rehabilitation discussion also includes the more than 350,000 military service members who have sustained blast-related TBI injuries in Iraq and Afghanistan. The Pentagon and Veterans Administration are struggling to effectively assess and treat a wide range of symptoms associated with “non-impact” TBI.

Two relevant questions for this discussion are:

What are the available cognitive assessment and testing tools for TBI, and how do we provide affordable long-term TBI rehabilitation care?

There are several options available in the market for TBI assessment. Concussion testing and management for school sports teams is a hot topic in state legislatures right now, and the NFL in particular has been grappling with lax concussion testing standards in the past few years. Axon Sports and ImPACT are two concussion testing systems that also could have useful applications for mild TBI. (See the cognitive screening and assessment guide for more information.)

For acute TBI assessment, portable EEG systems in TBI triage units show some interesting and practical utility. BrainScope and NeuroVigil are two companies that provide portable EEG systems.

Regarding cognitive testing and TBI assessment in the US military, the Automated Neuropsychological Assessment Metrics (ANAM) tool has been funded and championed by the Pentagon for use as a pre-deployment cognitive assessment tool. As I discussed in a previous article, ANAM has several advantages as a general purpose cognitive screen, but it may not be suitable for blast-related TBI assessment.

In addition, recent testimony from Lt. Gen. Eric Schoomaker, Army Surgeon General, that ANAM is about as reliable as a “coin flip”, doesn’t bode well for continued use of ANAM.

The Department of Defense faces a classic “build it in-house” or buy off-the-shelf dilemma. A general cognitive assessment tool that is also diagnostically sensitive to blast-related TBI probably doesn’t exist yet. There are, however, several commercial cognitive testing tools for TBI that could be re-purposed for the (somewhat) unique requirements within DoD. A shortlist of companies include CNS Vital Signs, CogState, Cambridge Cognition (CANTAB), Brain Resource (WebNeuro), HeadMinder (CSI), and Neurotrax (Mindstreams).

Moving on to long-term TBI rehabilitation, the “treatment gap” between acute TBI care (measured in days-weeks) and long-term rehabilitation (measured in months-years) reflects the clash between the desire of the health insurance industry to limit open-ended treatment costs and the reality that many TBI injuries do in fact require years of rehabilitation services.

Demanding that health insurers always provide unlimited TBI rehabilitation coverage is a non-starter. Reliable health insurance requires solvent insurers. At the same time, the pretense from the health insurance industry that only a few days or weeks of TBI rehabilitation produces miraculous results needs to be disavowed. Long term rehabilitation is the norm.

A potential middle ground comes from a TBI rehabilitation team at Walton Rehabilitation Health in Augusta, GA. The Walton team has modified the Rusk Institute of Rehabilitation brain injury protocol (readers can contact me for a copy of the protocol) to reflect the more limited resources in a “small town” rehabilitation setting.

One of the main points the Walton team made was setting a Patient:Staff ratio of about 2:1, combined with an intensive outpatient model that requires a significant six month commitment from both patients and staff. This group outpatient model for TBI rehabilitation (which also has a strong focus on emotional self-regulation training) can be an effective and economical model for long-term TBI care.