Brain injury breakthroughs and their claims consequences

The American Congress of Rehabilitation Medicine (ACRM) 2022 annual conference showcased many emerging trends in brain science and rehabilitation. I review some of the main innovations below and attempt to predict the extent to which any of these might individually or collectively alter the management of traumatic brain injury (TBI) claims.

Diagnostics

New techniques are emerging for detecting brain injury by testing for adverse neuropathology or biomarkers:

Diffusion tensor tractography (DTT) is a magnetic resonance imaging (MRI) technique that measures the diffusion rate of water in brain fibre tracts. Specialist automated fibre quantification (AFQ) software calculates values for 20 major fibre tracts known to correlate with clinical and functional outcomes. American trials of fibre tract profiling have shown variations between a control group and brain injury patients.
Functional near-infrared spectroscopy (fNIRS) can be used to measure hemodynamic response (i.e. cerebral blood flow). A Cypriot study showed higher haemoglobin levels and blood volume amongst brain injury patients attempting categorisation tasks, which is indicative of the greater effort that they required compared to a control group.

Fibre tract profiling is a complex process that is only offered by a subset of clinicians who are trained in the specialist software, compared to the wider pool of neuroradiologists qualified to interpret conventional MRI or computed tomography (CT) scans. By contrast, fNIRS works via head-mounted electrodes and therefore has the practical advantage that it can be undertaken in the consulting room without the time, expense and potential claustrophobia of whole-body scanning equipment.

My impression is that neither will become commonplace in TBI claims, for as long as mainstream radiology (alongside proven clinical indicators such as post-traumatic amnesia) remains the gold standard for diagnosis and itself continues to develop better imaging technologies.

A biomarker-led approach could potentially have applications for ‘subtle’ or mild TBI claims, where it is frequently argued by claimants that damage is sub-radiological, although a stronger research base is probably required to meet legal standards of proof. The Cypriot fNIRS study, for example, acknowledged the need to additionally compare hemodynamic response as between different psychometric indices and genders.

Development

The conference profiled some research trials of newer brain therapies:

Repetitive transcranial magnetic stimulation (rTMS) is a neuromodulatory tool that has historically been used to treat depression, by artificially stimulating activity in regions of the brain controlling mood. Stanford University has been testing its potential for improving executive function following TBI.
Stanford University is also collecting pilot data on the effectiveness of low intensity focused ultrasound pulsation (LIFUP) to treat post-traumatic headaches by targeting the caudate brain structure to reduce pain reactivity and enhance meditation effects. There is a treatment gap, because over 40% of sufferers do not respond to medication, and mindfulness and meditation can be effective alternatives, but are difficult for TBI patients to learn.
A provider of hyperbaric oxygen therapy (HBOT) discussed the neuropathology of concussion and reviewed various studies suggesting post-concussive improvements in cognition and behaviour following HBOT, which he attributed to organic effects including oxygenation of brain tissue, stimulation of cell proliferation for neuroplasticity, reduction of neuroinflammation, restoration of transmembrane mitochondrial potential, and promotion of brain angiogenesis.

The initial rTMS results are mixed and further clinical trials are ongoing. No results are available yet for LIFUP, but the pilot will collect data on outcome measures including daily pain scales and functional connectivity (via neuroimaging). HBOT has a stronger research base, but comes with significant practical limitations, including geographical access to treatment centres, a usual protocol of daily sessions for two to three months in duration, and the associated expense of intensive and prolonged treatment.

Data

I observed a general conference trend of data analytics being deployed to benchmark rehabilitation progress and ultimately predict long-term functional outcomes.

The Traumatic Brain Injury Model System (TBIMS) programme began in 1987 to improve care and outcomes following TBI and currently comprises 16 TBIMS centres in the United States. Their TBIMS database contains information on over 18,000 TBI patients for up to 30 years post-injury. It offers the potential to assimilate and model likely outcomes from different types or severity of TBI. For example, a data set of over 2,200 patients categorised as suffering disorders of consciousness on admission to rehabilitation shows that the majority recovered consciousness and almost half regained functional independence.
The Paediatric Brain Injury Consortium (PBIC) takes a similar approach to data sharing. Eight providers have combined for a bigger sample size and development of consistent outcome measures. Their analysis of Functional Independence Measure for Children (WeeFIM) scores has identified various demographic and injury characteristics associated with poorer functional recovery after inpatient rehabilitation:
- Younger age at injury.
- Increased time from injury to rehabilitation admission.
- Lower WeeFIM scores at rehabilitation admission.
- Longer delays in reaching key recovery milestones such as time to follow commands.
- Duration of post-traumatic amnesia.
- Male gender.
- Certain mechanisms of injury.

Comment

Patients, clinicians, healthcare providers and bodily injury compensators all have a clear mutual interest in maximising returns on rehabilitation investment. It is to be hoped that initiatives such as TBIMS and PBIC will originate data-led feedback on the most effective strategies for TBI management and, as their data set matures, facilitate increasingly reliable predictions of eventual function and daily lifestyle.

The opportunity for predicting outcomes has obvious applications for claims professionals when attempting to quantify damages potential or fix early reserves for TBI claims, especially for longer-tail liabilities such as paediatric injuries, when otherwise the lead-time for a clinical prognosis may be counted in years.

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