Traumatic brain injuries can occur in nearly every industry and are notoriously difficult to predict on the provider side and the carrier side. While treatment differs from patient to patient, injured workers in particular need support to cope with the variety of symptoms, some of which can be devastating. Louisiana Comp Blog discussed TBI with Dr. Kevin Bianchini, PhD, ABPN, of Jefferson Neurobehavioral Group and got his perspective on the Louisiana workers’ compensation system and the challenges that come with treating work injuries.
Comp Blog: How did you choose neuropsychology as a professional focus? What drew you to the field?
Bianchini: I graduated with my Bachelor’s degree from St. Joseph’s University in Philadelphia in psychology. I got my Master’s at the University of Tennessee in Knoxville and finished with a clinical PhD from the University of Miami. I was always interested in the brain and brain function, especially as it functions with the endless variety of human emotions and interactions.
In my practice [Jefferson Neurobehavioral Group] we do evaluation more than treatment these days. We’re referred by other doctors to take a look at the patient and assess risk factors for recovery. Most commonly we evaluate patients with pain problems and we determine functional capacity and cognitive impairment. I also do some [traditional] therapy with patients, particularly those with pain issues.
Comp Blog: Can you explain the distinction between mild and moderate TBI and how cases are diagnosed?
Bianchini: The research on severity [of TBI] is always based on the acute injury characteristics. Probably the clearest research was performed by Michael Alexander and published in 1994 in Neurology. Basically, it’s important to differentiate not by the patient’s presentation, since many times you are evaluating them much later after the injury occurred, but by the injury itself and what happened to the patient initially. Those acute characteristics are how you arrive at the mild or moderate distinction. As for measuring the characteristics, most ambulances will record the Glasgow Coma Scale score in which 8-12 is a moderate TBI. There are other methods but the Glasgow Coma Scale is the most commonly used and it is pretty well known. We also take into account how long someone has been unconscious; in the case of mild and moderate TBIs, that would be less than 24 hours all around. Especially for moderate TBI there can be significant variation though, it all depends on the individual.
Comp Blog: What are the typical cognitive impairments that a patient can expect after suffering one of these injuries and for how long?
Bianchini: For a typical mild case, we now know that recovery is expected in days to months. In recent years there has been a development in the literature related to sports concussions. It is a very good body of literature and in many cases these TBIs are witnessed by thousands of people and the injured athletes are attended to immediately by medical personnel. For these athletes with mild concussions, you’re talking about a week to ten days and they can be ready to play again safely. All the protocol in place is there to ensure that activities are being taken on in a safe manner – and that’s the same with injured workers.
As for moderate cases, these patients can have, and many do have, long-lasting neurocognitive and sometimes neurobehavioral problems. This can include difficulties with emotion and cognition in the workplace, which can be challenging for the patient’s return to work. For an injured worker’s treatment, hospital-based rehabilitation and then a transition program is best. I also think that it is better if the rehabilitation program is geared toward brain injury patients and that expertise is there. We want to start rehabilitation as early as possible and, in my view, it goes best when there’s an active approach to rehabilitation. Ultimately though, especially with moderate TBI patients, return to work must be evaluated in terms of safety. An extreme example would be an air traffic controller but, in the same way, a construction worker could put others at risk if they are cognitively impaired.
Comp Blog: What challenges have you encountered treating patients with mild or moderate TBI within the Louisiana workers’ comp system?
Bianchini: Well, unfortunately in the Medical Treatment Guidelines for Louisiana workers’ comp, there’s not a guideline for head injury right now. So for example when we’re trying to get rehab approved, those delays, even in outpatient treatment, can contribute to a poor outcome.
And certainly, there are some problems with exaggeration of symptoms and disability when the patient is seeking compensation. Motivational issues in that regard can be very significant. If you’re a state like Louisiana that wants to use guidelines, a set of guidelines for TBI patients would help; I think it would just give some structure to how adjusters and employers view these claims.
Comp Blog: In your general experience, what are the most significant psychosocial factors that either inhibit or promote recovery from TBI? Are there different significant factors for workers’ comp patients?
Bianchini: Prior psychiatric history is a major risk factor. It is most pronounced in mild TBI because some patients have persistent symptoms – beyond what we would expect the timeline to be – and that can be challenging with a workers’ comp claim. Depression and anxiety are also significant co-morbidities and can create barriers to recovery. About 17-20 percent of the general population has a diagnosable psychiatric condition, so that’s not a lot of TBI patients, but it is a significant minority and you want to differentiate between pre-existing and reactive aspects of that disorder. Also, lower education attainment and educational problems in the past tends to be associated with poorer recovery.
With workers’ comp patients specifically, the layer of financial incentives can become a problem. There’s a lot of good research out there that has found that some patients with financial incentives perform poorly on functional exams and exhibit more symptoms, so we have to be on the look out for that. However, I want to emphasize that not everyone responds to financial incentives the same way. Most patients want to get back to their routine functioning and recover.
Comp Blog: Have the Louisiana Medical Treatment Guidelines for workers’ comp, implemented in July 2011, had any effect on your practice, positive or negative?
Bianchini: A set of guidelines would be helpful for brain injuries just like you have for other areas. In my practice, we do a lot of work in the pain arena, the guidelines for that are laid out and that has been positive.
Comp Blog: Related to the above question: have you found litigation of the comp claim to be an issue with respect to the injured worker’s recovery?
Bianchini: When the comp claim goes into litigation, the structure of the incentives has an effect on the outcome. So if a patient has a third party lawsuit on their hands and the possibility of unlimited damages for that, as opposed to and in addition to their set benefits with the comp claim, that has the potential to be a serious limitation [to recovery and return to work.]
Editor’s Note: Jefferson Neurobehavioral Group was founded in 1996 and provides clinical psychology, neuropsychology, and behavioral medicine services for adults of all ages, adolescents and children in the Gulf South. The practice’s main office is in Metairie and they have additional offices in across Louisiana, in Texas and in Mississippi and Alabama.