Recovery May Take Time

While many clinical decisions are made within weeks of traumatic brain injury, recovery may occur up to a year later

Closeup of the hands of two people wearing white lab coats examining medical images of a patient’s brain.
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A new study has found that many people with moderate to severe traumatic brain injury (msTBI) achieve favorable outcomes over the course of their first year of recovery, moving from a deep coma to being able to live independently for at least eight hours per day within a year.

Understanding the long-term dynamics of recovery is vital, the study authors said, as many critical decisions that impact outcomes, including withdrawal of life-sustaining treatment, are made by clinicians within a few weeks of injury.

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Moderate to severe traumatic brain injury is a major cause of death and disability in the United States, with an average of 166 related deaths per day, according to the CDC.

The study was part of Transforming Research and Clinical Knowledge in TBI (TRACK-TBI), one of the first efforts to collect and examine data on the long-term course of msTBI from the time of injury to the chronic phases of recovery.

The study team included researchers from Harvard Medical School, the Medical College of Wisconsin, and the University of California, San Francisco. Their findings were published July 6 in JAMA Neurology.

“This paper adds to the growing body of evidence that many of our past assumptions on recovery from severe traumatic brain injury need to be reexamined,” said Joseph Giacino, co-first author of the study and professor of physical medicine and rehabilitation at Harvard Medical School.

“The rush to judgment we often see in the early days after injury may be placing arbitrary limits on patients’ remarkable potential to recover and on the rehabilitative treatments that may help them,” said Giacino, who is also director of the Spaulding Rehabilitation Hospital Neurorehabilitation Laboratory.

“For the thousands of people and families impacted each year we need to ensure we are providing every chance possible to achieve the best recovery possible,” he said.

When the researchers examined the outcomes for 484 participants with msTBI at 12 months post-injury, they found that approximately half of the participants with severe TBI and three-quarters of those with moderate TBI recovered the ability to function independently at home for at least eight hours per day.

Among the sample as a whole, participants frequently demonstrated major functional gains between two weeks and 12 months post-injury.

Among participants who remained unconscious in a vegetative state at two weeks, 77 percent recovered consciousness and 25 percent were fully oriented by 12 months, which means that they could accurately report their name, the date, and the location.

“These findings should not be misinterpreted to imply an overly optimistic picture of outcomes after moderate to severe traumatic brain injury because a high proportion of participants were left with considerable disabilities,” said Michael McCrea, co-first author of the study, professor of neurosurgery and co-director of the Center for Neurotrauma Research at the Medical College of Wisconsin.

“However, these data further inform the natural history of recovery after moderate to severe traumatic brain injury and indicate that a sizeable subset of these patients can achieve meaningful improvement in life function over the first year after injury. These findings wield important translational implications for early clinical management of patients with moderate to severe traumatic brain injury,” he added.

“Severe impairment in the short term did not portend poor outcomes in a substantial minority of patients with msTBI. When discussing prognosis during the first two weeks after injury, clinicians should be particularly cautious about making early, definitive prognostic statements suggesting poor outcomes and withdrawal of life-sustaining treatment in patients with msTBI,” the authors concluded.

“While a substantial proportion of patients die or suffer lasting disability, our study adds to growing evidence that severe acute impairment does not portend uniformly poor long-term outcome,” said senior author Geoffrey Manley, professor and vice chair of neurological surgery at UCSF and chief of neurosurgery at Zuckerberg San Francisco General Hospital.

“Even those patients in a vegetative state–an outcome viewed as dire–may improve, since this is a dynamic condition that evolves over the first year.”

The study was funded by the U.S. National Institutes of Health, National Institute of Neurologic Disorders and Stroke (grant U01 NS1365885) and supported by the U.S. Department of Defense (grant W81XWH-14-2-0176). Patient travel and stipend expenses were supported by One Mind.

Adapted from a Spaulding news release.