New Developments in the Diagnosis and Treatment of Mild to Moderate Brain Injury

I recently had the opportunity to meet with Dr. Anthony Feinstein, Director of the Mild to Moderate Traumatic Brain Injury Clinic at Sunnybrook and Women’s Health Sciences Centre in Toronto. The Clinic’s mandate is the early detection and early treatment of patients with mild to moderate traumatic brain injury. Dr. Feinstein and a member of the research team kindly demonstrated some of the research projects currently underway at the Clinic. In light of the fact that June is Brain Injury Awareness month, I am taking the opportunity to stray away from a purely accident benefits focus, in order to describe the treatment model and some of the exciting research of Dr. Feinstein and the TBI Clinic.

The TBI Clinic at Sunnybrook is now three years old. The aim of the Clinic is to see all patients within days to weeks of injury. Each patient undergoes a standardized assessment, which is repeated at each subsequent visit. The patient sees a physiatrist, a neuropsychiatrist, an occupational therapist and a physiotherapist. Further, a patient attending the clinic receives a detailed neuropsychological assessment six months following their injury. All data are entered into the database and the Clinic can chart the course of each patient’s recovery, or otherwise, over the course of time. This evidence-based approach is a unique model of patient care, taking into account not only the physician’s assessment of the patient’s progress but also the patient’s own self-appraisal.

On average, 180 plus patients per year visit the Clinic with about 50 percent of patients given follow-up appointments. Presently, the Clinic’s database contains over 600 patients with longitudinal data on approximately half of them. The Clinic works closely with the ER physicians, trauma department, neurosurgeons, orthopedic surgeons, and neuroradiologists. Given the presence of all of these disciplines within Sunnybrook, the Clinic can readily access brain imaging, including MRI, CT and SPECT.

The Clinic’s research initiatives centre on assessing neuroimaging abnormalities in patients with mild to moderate traumatic brain injury. They use state of the art imaging software to detect functional brain abnormalities. They also combine SPECT analysis with similarly detailed MRI brain data, the latter designed to detect structural abnormalities within the brain of patients who have suffered a mild traumatic brain injury. This study, which is currently running and is due for completion towards the end of 2002, offers the possibility of defining the diagnostic usefulness of SPECT and MRI in patients who have sustained a mild traumatic brain injury.

A second research initiative has focused on improving detection of patients with mild traumatic brain injury within the Emergency Department. It is well recognized that many patients with mild traumatic brain injury escape detection and are left to fend for themselves. This frequently leads to the patient experiencing difficulties within the home and at work and without access to treatment. Dr. Feinstein and his researchers have introduced the Galveston Orientation and Amnesia Test into Sunnybrook’s ER, with the hope of increasing awareness of mild traumatic brain injury amongst ER physicians.

A third study is looking at potential genetic markers of outcome following traumatic brain injury. All Clinic patients over the age of 65 are requested to provide a blood sample for genetic screening at six months following injury. Correlates are then sought between their cognitive and emotional outcome and the presence of the APOe4 gene.

Other on-going projects in the clinic include a study looking at the role of gender in predicting outcome following a head injury, a study exploring the impact of litigation on symptom expression following a head injury, and an important treatment study investigating whether a particular treatment model can enhance outcome following mild head injury. The Traumatic Brain Injury Clinic publishes its data from various research projects and presents their findings at national and international meetings. Through its work, the Clinic also hopes to encourage other hospitals with trauma facilities to adopt their approach with respect to detection and treatment of patients with mild to moderate head injury.

Most motor vehicle accident victims who suffer mild to moderate brain injury are restricted to limited no-fault accident benefits of $100,000 for medical and rehabilitation expenses, limited to a period of ten years. Accordingly, the earlier a mild to moderate brain injury is recognized and treated, the more likely an accident victim will derive benefit from the limited funds available for medical and rehabilitation expenses. The patient care model and the research of Dr. Feinstein and the TBI Clinic are encouraging for all victims of mild to moderate traumatic brain injury.

Anthony Feinstein, MPhil, PhD, MRCPsych, FRCP(C)
Wendy Moore Mandel, Partner