Ramon Diaz-Arrastia, MD, PhD, Presidential Professor of Neurology, Associate Director for Clinical Research at the Center for Neurodegeneration and Repair and Director of the Traumatic Brain Injury Research Center; Danielle Sandsmark, MD, PhD, Assistant Professor of Neurology, Anesthesiology and Critical Care and Neurosurgery; and Megan Moyer, CRNP, MSN, discuss TBI research and care at Penn Medicine.
Q&A about TBI
What is TBI?
Traumatic brain injury (TBI) is a traumatically induced physiological disruption of brain function, induced by mechanical energy impacting the head. These injuries typically occur from falls, traffic accidents, interpersonal violence, or participation in sports. TBI is manifested by either loss of consciousness, alteration of consciousness or mental status, or focal neurologic deficits, which may or may not be transient.
TBI is a leading cause of morbidity and mortality worldwide. It remains the leading cause of death and disability among young people in developed countries. In the United States, 2.5 million emergency department visits, 300,000 hospitalizations, and 50,000 deaths are attributed to TBI. Nearly 5 million Americans live with TBI-related disability. Leading causes of TBI in the U.S. include falls (40%), unintentional blunt trauma (16%), motor vehicle crashes (14%), and assaults (11%). TBI is generally classified as mild, moderate and severe based on the initial Glascow Coma Score (GCS) assessed in the emergency department. Mild TBI is most commonly seen, encompassing about 90% of all cases. Most patients who experience a mild TBI make an excellent recovery, however a sub-set of patients – approximately 15-20% -- continue to experience disabling post concussive symptoms that can interfere with return to work or social activities. Moderate and severe TBI, while less common, are more likely to result in long-term disability. Less than 20% of patients with severe TBI make a full recovery.
What type of patients do you care for at Penn?
We take care of all patients with TBI at Penn. In the emergency department, patients are evaluated soon after injury, and assessed for the need of neurosurgical interventions, which can be life-saving. Patients who need neurosurgical interventions, as well as a larger number who require close monitoring and supportive care, are admitted to the Neurological Intensive Care Unit (NICU) at Penn. Patients with systemic injuries where the brain injury is not predominant are treated by Penn trauma or orthopaedic surgeons. Upon discharge, some patients who require in-patient rehabilitation are admitted to Good Shepherd Penn Partners (GSPP).All patients, whether discharged from the emergency department or the hospital, require follow-up.
The TBI Outpatient Clinic at Penn focuses on follow-up of patients discharged from the hospital after being admitted for a brain injury. We also provide subspecialist neurological expertise for the subset of patients with mild TBI who did not require hospitalization but who experience persistent TBI symptoms lasting more than a few weeks after their injury. Typically, these patients suffer from a variety of symptoms which may include:
- Visual disturbances
- Memory problems
- Mood changes
- Difficulty concentrating
- Sleep disturbances
Although only 15-20% of patients with mild TBI experience residual problems, they represent a large burden of disability.
The TBI Outpatient Clinic also provides in-depth neurological expertise for patients who experience long-term consequences of TBI, often years after the initial injury. TBI has recently been recognized as a lifelong chronic health condition that begins at the time of injury and often has chronic effects that may persist for life.
What is your philosophy on patient care?
The goal of the TBI Outpatient Clinic is to evaluate patients’ headaches, memory problems, mood problems, or sleep disorders. We use state-of-the-art neurodiagnostic and neuropsychometric tests and manage pharmacological and non-pharmacological treatments aimed at relieving symptoms and optimizing function. We collaborate closely with Penn colleagues in Neurosurgery, Physical Medicine and Rehabilitation, Neuropsychology, Psychiatry, and Physical and Occupational Therapy to care for patients who need such services.
Why do patients with TBI benefit from your care?
Most symptoms which produce disability after TBI can be effectively managed through tailored pharmacological and non-pharmacologic treatments. However, choosing the correct treatments requires expert neurological evaluations, in addition to appropriate imaging and diagnostic testing. Inappropriate treatments can delay recovery or even exacerbate symptoms. Finally, counseling and education about the nature and consequences of injury is an important component of recovery.
What types of research will you be involved in at Penn?
TBI remains an unmet medical need. The Neurology TBI Research Initiative is devoted to improving patient outcomes through clinical research. We currently have several clinical trials that are open for recruitment, starting in the acute period after injury and continuing into the subacute and chronic stage.
When should TBI patients see you?
Patients discharged from the hospital after being admitted for a TBI should see us in the outpatient clinic within 2 - 4 weeks after injury. Patients who did not require hospitalization, but have persistent neurologic symptoms lasting more than 4 weeks after injury which fail to respond to treatments prescribed by primary care providers or general neurologists, should also be evaluated by TBI specialists.
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