impacts organization, and how the brain reorganizes during recovery. This reorganization affects the patient, as well as the social order in the world.
I have been both humbled and humiliated by the patients I have met over the years and how much they defy medical wisdom at times. After spending three decades with over 250,000 patient encounters whom I have observed, evaluated, and treated, I have developed “Brain Hierarchical Evaluation and Treatment” or in short, the BHET method. The BHET approach utilizes the concept of organizing the subject of brain injury in various dimensions and domains to evaluate and treat patients with brain injury. The information in this book is not new, but I have utilized my experience to help clinicians, patients and their families, and the public find a more organized and efficient way to evaluate and treat TBI and concussion. This approach is evidence-based as well as clinically relevant. While this book questions and occasionally, objects to many of the current approaches used by clinicians, administrators, caregivers, and families, it utilizes research data available in the medical literature, my experience, and the experience of my colleagues in designing the BHET method. This first volume addresses how the brain works normally, following injury, and during recovery. The second volume will address the prognosis, outcomes, and the various methods of managing and treating TBI and concussion.
The BHET method is based on an understanding of the complexity of the human nervous system: its design, structural and physiological organization, and its adaptive and preservative capabilities after an injury. As the title suggests, “From Head to Tail” defines the inner workings of the nervous system, from its most complicated functions and structures, defined as “head behavior”, to its simpliest and primitive reflex behaviors, known as “tail behavior”.
As a neurologist with specialized training in neurological rehabilitation and neurological trauma, I have examined and treated TBI/concussion patients in the emergency room, trauma center, intensive care unit, acute care hospitals, inpatient neurological rehabilitation centers, outpatient rehabilitation centers, sub-acute facilities, and in out-patient settings. As the former Medical Director of Neurological Rehabilitation at Jackson Memorial Hospital and in my current roles as Medical Director at the University of Miami Miller School of Medicine Sports Medicine Concussion Program, Medical Director of Kendall Regional Medical Center Intermediate Brain Injury Unit, and Managing Director of the Design Neuroscience Center, I feel honored by this opportunity to serve this population of patients. I have seen first-hand the destruction of the hierarchical organization of the nervous system and observed with interest the recovery and restoration process of the structural, physiological, and corresponding functional hierarchical organization. BHET results from the knowledge I acquired in neuroscience, with major guidance from the experience of others, training from my teachers, my experience in the business, and in actually treating patients by utilizing the science presented by medical literature and some trial and error. BHET is an approach that has worked for patients with brain injury of all types, although the focus of this work is mostly on concussion and TBI.
“A Silent Epidemic” – Traumatic Brain Injury (TBI) and Concussion
ACCORDING TO THE Brain Injury Association of America, “every 21 seconds, a person gets a traumatic brain injury (TBI) in the United States”. World Health Organization (WHO) predicts that by 2020, TBI will be among the top three conditions that cause death and disability (Hyder 2017).
A comprehensive review of TBI published in The Lancet Neurology estimated that more than 50 million cases are annually recorded worldwide. The review further stated that half of the world’s population will experience one or more TBI over their lifetime (Feign 2013, Maas 2017). Humphreys (2013) provided lower estimates of 10 million TBI worldwide on an annual basis.
There is a wide range of annual incidence reports in the USA for the number of people with TBI/concussion, with a significant amount of underreporting noted. The number of incidence reports ranges from 1.7 million to 3.8 million persons annually (Bazarian 2005, Ropper 2007, Halsted 2010, Arbogast 2016, CDC 2016, Faul 2010). By comparison, 2% of the population are living with disabilities resulting from TBI (CDC, 2011).
TBI is one of the most-often overlooked conditions, even though it constitutes a major economic burden on the healthcare system. It is the leading cause of injury-related death and disability worldwide (WHO 2006, Majdan 2016, Faul 2010, CDC 2010). In 2003, over 2.8 million persons with TBI/concussion visited the emergency departments of American hospitals. Mild TBI accounts for around 80% of the cases, moderate TBI for about 10%, and severe TBI for approximately 10% of the cases (Faul 2010). A similar breakdown of incidences based on the severity has been noted worldwide.
In our industry, we commonly utilize the Glasgow Coma Scale (GCS) score, developed by Teasdale and Jennett in Glasgow, UK (Teasdale 1974). The GCS measures the level of consciousness as a tool to classify patients based on the initial severity at the time of presentation. This scale, widely used in the field of brain injury, is highly predictive about who with moderate to severe TBI will survive (Steyerber 2008, Saatman 2008). According to Laskowski, “it (GCS) does not necessarily reflect the underlying cerebral pathology because different structural abnormalities can produce a similar clinical picture” (Laskowski 2015).
For persons with milder forms of TBI that are generally classified as concussion, utilizing this scale as a predictor of long-term outcomes can be misleading. So, don’t be fooled by a high GCS score. Despite having a GCS of 13–15 (a high score is associated with mild injury) patients with concussions can experience more dire consequences from their injury. We have a saying in our industry: “Not all mild brain injury is considered mild”.
The scale utilizes 3 variables, each with the elements presented with a weighted score. A final score is provided after each element is tabulated.
The three variables are as follows:
Table #1 -- GCS Score
| Variables | Weighted Score Range | Severity Based upon Total Scores | |
| One’s ability to talk (vocalize) | 1–4 | Mild | 13–15 |
| One’s ability to open the eyes (visual system) | 1–5 | Moderate | 9–12 |
| One’s ability to mobilize the extremities (motor response) | 1–6 | Severe | Less than 8 |
| Maximum Total Score | 15 | Minimum Score | 3 |
Based on the compiled tabulated score, the lowest and worse score is a 3, where the patient is totally comatose. The best score is 15, where the patient may be symptomatic but fully awake and functioning or can be completely normal. Mild TBI/concussion is generally attributed to a score of 13–15, moderate between 9–12, and severe is 8 and below.
Around 52% of severe brain injury survivors are moderately to severely disabled at 1 year after the injury, and around 43% of the patients hospitalized and discharged develop long-term disabilities (Thornhill 2000, Selassie 2008).
Defining the severity of a TBI/concussion is complex and involves assessing the disability measures, community and psychosocial functioning, neurological impairments, and quality of life measures. Having a severe TBI in the acute phase of the injury, as defined by the GCS, is predictive of negative long-term consequences, however, this is not necessarily the case in all patients.
With regard to mild TBI (concussion), approximately 15% of the patients with cerebral concussions have persistent symptoms for more than 3 months, demonstrate increased rates of disability, and need to use the healthcare system (McCrory 2017, Mechtler 2014, Bigler 2008).
TBI affects the young disproportionately and accounts for as much as 30% of the deaths caused
