Diagnosing a traumatic brain injury
- A detailed neurological examination is important and will bring out evidence of brain injury.
- Brain imaging with CAT scan, MRI, SPECT and PET scan may be useful.
- Cognitive evaluation by a Neuropsychologist with formal neuropsychological testing.
- Evaluations by physical, occupational and speech therapists help clarify the specific deficits of an individual.
The Glasgow Coma Scale is based on a 15 point scale for estimating and categorizing the outcomes of brain injury on the basis of overall social capability or dependence on others.
The test measures the motor response, verbal response and eye opening response with these values:
I. Motor Response 6 – Obeys commands fully
5 – Localizes to noxious stimuli
4 – Withdraws from noxious stimuli
3 – Abnormal flexion, i.e. decorticate posturing
2 – Extensor response, i.e. decelerate posturing
1 – No response
II. Verbal Response 5 – Alert and Oriented
4 – Confused, yet coherent, speech
3 – Inappropriate words and jumbled phrases consisting of words
2 – Incomprehensible sounds
1 – No sounds
III. Eye Opening 4 – Spontaneous eye opening
3 – Eyes open to speech
2 – Eyes open to pain
1 – No eye opening
The final score is determined by adding the values of I+II+III.
This number helps medical practioners categorize the four possible levels for survival, with a lower number indicating a more severe injury and a poorer prognosis:
- More in-depth discussion on the Mild TBI Symptoms page.
Moderate Disability (9-12):
- Loss of consciousness greater than 30 minutes
- Physical or cognitive impairments which may or may resolve
- Benefit from Rehabilitation
Severe Disability (3-8):
- Coma: unconscious state. No meaningful response, no voluntary activities
Vegetative State (Less than 3):
- Sleep wake cycles
- Arousal, but no interaction with environment
- No localized response to pain
Persistent Vegetative State:
- Vegetative state lasting longer than one month
- No brain function
- Specific criteria needed for making this diagnosis
- The Ranchos Los Amigos Scale measures the levels of awareness, cognition, behavior and interaction with the environment.
- Ranchos Los Amigos Scale Level I: No Response
Level II: Generalized Response
Level III: Localized Response
Level IV: Confused-agitated
Level V: Confused-inappropriate
Level VI: Confused-appropriate
Level VII: Automatic-appropriate
The following information in BOLD is taken from a report by the Department of Defense-
- 5. What is the difference between a TBI “screening” and a TBI “diagnosis”?
- A TBI “screening” involves asking a series of four questions to determine: If an event occurred that resulted in a blow to the head or exposure to a blast; if so, did the event result in a change in consciousness (dazed, confused, bell rung or knocked out); was the change of consciousness followed by symptoms such as headache, feeling tired, confusion, memory loss after the event; and, if so, which symptoms are present at the time of the screening. Positive answers to all four of these questions indicate a positive screening for TBI. A positive screen identifies a service member for further clinical evaluation. Further medical evaluation should be done to determine if a “diagnosis” of TBI can then be made. Over half of positive “screenings” done some time after an incident which could cause a TBI do not result in a medical diagnosis of TBI when the medical evaluation is done by a doctor.
- A “diagnosis” of TBI is easiest for a doctor to make at the time of the event or shortly afterward as the history of the event and subsequent sequelae is most accurate then. Delayed evaluations may lead to “false negatives” as the service member may fill in gaps of memory based on information given to him by colleagues, giving the appearance that there was no disruption in cerebral function. Conversely, issues of personal gain may lead to embellishment of symptoms over time, thereby creating “false positive” diagnosis.
The statement in BOLD above gives us two reasons that diagnosing TBI for service members is difficult after they return home. The first point the DoD makes is that a TBI could be missed, a false negative as they refer to it, because the people surrounding the service member at the time of the injury could be unaware or ignoring the signs and symptoms of a TBI and reporting that the service member was okay when relating information back as to how the event took place.
The second reason it becomes difficult to diagnose is that if the service member is not diagnosed at the time of injury in a warzone by some of the methods above they may be thought of as “malingering” or faking the injury for personal gain because there are not conclusive ways to diagnose a brain injury long after the initial injury to the brain.
The “editorial” points of diagnosing I want to make today are:
Why does it become the problem of the service member to PROVE he has a traumatic brain injury when he/she gets home from war, if the system is failing them by not having an accurate and consistent method of diagnosis available to them at the time of injury?
Why because a very low percentage of service members may “fake” an injury after the fact, do all the service members have to be put under such scrutiny? Is this attitude negatively affecting the diagnosing of TBI in service members and keeping them from getting the support they need for their TBI? The civilian population is under the same scrutiny. If there are not skull fractures, blood on the brain or some other type of physical evidence, then cases of TBI have to be fought harder to prove. But, usually the records of the injury are more easily obtained than those in the military.
The Commanders in theater (warzones) have to have a culture change from what is known in the sports world as “put me back in coach”. Troop levels at war are an issue for commanders. If one of the troops appears to be okay from the outside even though a mild or moderate brain injury could be affecting their performance, well, we know what happens. There are troops right now serving with 1, 2, 3, 4 and more brain injuries. I have talked with them. Some are considered “mild” but we know now that mild is for salsa and not necessarily the best term to describe brain injury. The short and long term challenges from a mild TBI are coming to light more and more as research shows that concussions, or mild TBI, can cause permanent damage to the brain. Multiple concussions, increase the chances for more permanent damage.
TBI diagnosing and the problems with inconsistencies and the lack of a definitive method of diagnosing after a certain time of the initial injury is a big problem. Research had brought a new blood test that could be an important tool in diagnosing. Time will tell.
Can you imagine someone being told they are faking diabetes? A heart attack? Breast Cancer? Or HIV/AIDS? Tomorrow we will discuss some of the words used about people who have a traumatic brain injury. They are words that cut deeply for a survivor.
Be kind today. You never know what burden someone is carrying by the way they appear to you.
Below are the details of the 31 Day TBI Challenge for CHANGE for Veterans
So, what is our challenge and how can you be part of the CHANGE in partnership with The Arms Forces nonprofit organization?
March is Brain Injury Awareness Month. So our challenge to you is:
1.) Please learn something new about TBI every day. We will be posting information on The Arms Forces Facebook Page daily, so you will be able to become more informed in an easy manner. http://www.facebook.com/TheArmsForces or you can visit our website and read the posts on our NEWS page www.thearmsforces.org/news
2.) Help facilitate CHANGE by partnering with The Arms Forces by assisting us in continuing our efforts for invisibly wounded veterans by collecting your CHANGE daily and at the end of March donating the money to The Arms Forces. (contact information below) Create a jar and label it “The Arms Forces CHANGE for TBI” and put it out where you and everyone will see it. When someone asks you what it is all about, share with them a bit about what you have learned about TBI. Share stories of the people you will learn about through our posts on Facebook and how their lives have been forever changed by their injuries.
3.) If collecting change every day is not your thing, then be a part of the CHANGE by making a donation to The Arms Forces through our website www.thearmsforces.org or by mailing a check. (contact information below)
Our veterans with traumatic brain injury many times are living lonely and unfulfilled lives. When the doctors are done, when the rehabilitation is finished, when the counseling isn’t working anymore, they are trying to reintegrate into life with abilities that have been altered by the physical wounds of TBI. That is where The Arms Forces comes in and reaches out with open arms and assists them with navigating their life. Without passion and purpose, life can seem less meaningful.
My own journey after a severe TBI led me down a very broken road. But, I found a way to go from extreme adversity to JOYFUL RENEWAL. YOU can be a part of helping us create that joyful renewal for our veterans!!
Thank you for being a part of the force of CHANGE known as The Arms Forces!
I appreciate each and every one of you!!
With open arms,
The Arms Forces
PO Box 981
Maumee, OH 43537