The terms “Mild, Moderate and Severe” are derived from several different eras and medical models, one of which is even formula based on the acute care setting and the Glasgow Coma Scale (one of several determinant scales). This author is NOT going to delve into the origins other than to say that the scales, regardless of type or name, have been used to “classifying TBI severity, grades a person’s level of consciousness on a scale based on verbal, motor, and eye-opening reactions to stimuli”. Real life long term effects of a trauma as to outcomes of that trauma have so many variables that the scales “go out the door, as does the patient”. As with all unknowns; the outcomes from the classifications are usually conservative, and are considered with cautiously guarded with pessimism. As a resultant, the military and other institutions have begun to develop new severity guidelines based on loss of consciousness, loss of memory (amnesia), imaging to detectlesions, swelling, etc. and the Glasgow Scale. Unfortunately cutting edge detection is still in development, limited in access and available at only a few sites worldwide. Science is years out from predicting long term effects in behavior, cognition and resultant brain function after trauma with the visual detection methods, let alone having ready access to such equipment in every Emergency Department.
Not only are the definitions of levels of severity changing but the definition of “Traumatic” is subject to review. A Clinical Assessment Working Group comprised of both military and civilian researchers in the field of neurology, neuroscience and neuropsychology have redefined TBI “…as an alteration in brain function, or other evidence of brain pathology, caused by an external force.”A position statement released from the working group reported that “A clear concise definition of Traumatic Brain Injury (TBI) is fundamental for reporting, comparison, and interpretation of studies on TBI. Changing epidemiology patterns, an increasing recognition of significance of mild TBI, and a better understanding of the subtler neurocognitive neuroaffective deficits that may result from these injuries, makes this need even more critical.”According to Dr. Wayne Gordon of the Mount Sinai School of Medicine, who serves in this group: “The new definition incorporates the emerging evidence that signs and symptoms of the injured brain may emerge over time.”
What does this mean to us in lay terms? Severe is still a “severe condition” where a person may lay in a coma, have surgical removal of portions of, or repairs of the brain and/or have significant brain matter altered. The person may have significant detectable damage, open skull trauma or other obvious signs of brain damage. What is now becoming clearer is that ALL OTHER forms of “lesser brain injuries” can have similar influences on the brain: whether it is in the initial stages, going without proper treatment, or no treatment, or multiple “minor” insults, or with accumulative insults and/or events to the brain spanning months or even years.
Some individuals who have sustained “severe brain injuries” enter into their new and altered life with that brain injury especially “well” and can become as productive as can possibly be expected; especially with proper treatment, rehabilitation and supports. Many people, and they are the vast majority, who have sustained the so called “mild – moderate brain injuries” have not improved as well and often times spiral downward, sustain further physical traumas or cumulative insults to the brain, develop psychological complications, etc. More likely than not, these individuals do not receive the proper diagnosis, treatment, therapies and supports. As with all individuals, we are each unique and so goes the saying with brain injury, that injury is unique to the individual.
Thus said when we talk about the long term effects to the brain and the person: “Mild” or “Moderate” brain injury labels diminish as such factors of treatment (poor or lack thereof), additional brain injury or life style choices from the impaired brain. As research continues, case monitoring of the long term effects on people sustaining brain injury and statistical data is gathered; it is seriously doubtful that the “severe – moderate – mild” categories will stand the test of time without better diagnostic tools and historical data.