TBI Updates

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					University of Washington Traumatic Brain Injury Model System
Department of Rehabilitation Medicine

TBI Updates
The newsletter of the UWTBIMS

Volume 2, Number 3
May 5th, 2004


   • TBI: Medical Expenses and the Law

   • Legal Resources for TBI Survivors

   • UW TBI Model System Participates in TBI Video
     Conference Series

   • Recent Staff Presentations

   • Recent Staff Publications

   • Updates on current TBI studies

   • Who’s Who at UWTBIMS: Chuck Bombardier, Ph.D.

   • How to Contact Us

              TBI: Medical Expenses and the Law

    Medical Bills: Our first advice is not to worry about it too much.
If your loved one is in a coma, at least in the United States, they will not be
denied care, at least not until the acute stage is over. While that doesn't mean
you won't have financial hardship ahead, at this point, care will continue,
regardless of how the bills get paid. At least in the United States, people
with severe brain injuries are not denied acute care. In fact, the people who
set hospital and insurance rates understand that and all of the rest of us pay a
little more, on the chance that this kind of care is needed for someone who
doesn't have the ability to pay. If you are getting hassled about medical bills
while someone is still in a coma, basically tell them not to bother you that
you have more important things to worry about.
Now that having been said, getting medical bills paid may become a
priority. If the person is in a coma has a family or spouse to support, then
finding a source to pay these bills will help to reduce the financial hardship

   The first place to have medical bills paid in most cases, is your own
                         medical insurance policy.
While there will typically be deductibles associated with this policy, after
the deductible, $250 to $1000, and the copay (20% up to $5,000 typically)
they should cover all acute care costs. Unfortunately, with the advent of
HMO's and managed care, getting the proper care from your medical
insurance company may require you to be an "advocate." The term advocate
is used to mean you may have to ask for services, use persuasion, be firm
and persistent, argue with them if need be, cajole them and as a truly last
resort, threaten them. While every insurance policy is different, the medical
insurance company’s obligation to pay for necessary care may be much
broader than may appear on the surface.
One suggestion from an insurance professional, who is now a caregiver, is to
try to get a case manager appointed. A case manager is usually a health care
professional (like a nurse) who has the authority to make decisions that
make sense both for the patient, and also to lessen the long-term burden on
the insurance company. For example, providing some in-home care, may not

be authorized by the policy, but may be much cheaper than the alternative of
a nursing home, which is covered.

                             Med Pay Coverage
If the survivor was injured in an accident, there is a significant probability
that what we will refer to as "Med Pay Coverage" is also available. Med Pay
coverage is additional insurance to cover medical bills related to the
accident. Such a policy may be on the car that the survivor was riding in, any
other car owned by the survivor or a member of his or her household, or on
the place where the person was injured, such as in a fall. In some states,
where there are no-fault or personal injury protection laws ("PIP") the Med
Pay coverage may pay all the bills, but this differs from state to state.
It is a good idea to have an attorney review all insurance policies held by any
member of the injured person's household, including umbrella policies,
disability policies, homeowner's and even all policies on credit cards owned
by the person. It may be that medical pay coverage is included in such

                             Medical Assistance
With children, not covered by insurance, and adults who do not have
substantial assets, medical assistance may be available. Medical assistance is
available to someone who qualifies for SSI benefits from the Social Security
Administration. SSI, as opposed to SSDI, is available to people who do not
have a substantial work history (have not paid in social security taxes in
enough quarters) but who need assistance because their income and
resources are below the minimum level. To understand more about
qualifying for social security, contact your local social security office or go
to their website.
If the survivor is eligible, medical assistance should pay all acute care costs,
and substantial amounts toward long-term care and rehabilitation. Medical
assistance waivers, which are becoming more widely available, can
sometimes be utilized to get medical assistance to cover things not typically
covered by the program.

                            Workers Compensation
In most states, if the injury occurred at work, workers compensation is
obligated to pay all related medical bills, especially for acute care costs. But
as workers comp benefits are being trimmed to make states more
competitive to recruit industry, it may be harder to get comprehensive
benefits. An attorney may be required to encourage the insurance company
pay all that is necessary for long term care and rehabilitation.

                           Personal Injury Actions
One final way to get medical bills paid is through a lawsuit, against someone
who is legally responsible for the injury. And if you have a viable action, the
survivor may recover many times the medical bills in lost wages as well. To
recover in a personal injury action, the survivor must prove that someone
else wrongfully caused the injury. It is important to realize that not all
injuries are wrongfully caused.

The critical mistake in too many personal injury cases is that an insurance
adjuster convinces the survivor or his family to settle for a relatively modest
sum, before the full extent of injury or entitlement is clear. If an insurance
adjuster is there early in the process, seemingly generously offering to pay
all medical bills, don't sign anything. When faced with the pressure of
catastrophic medical bills, the promise to pay all the bills may sound
wonderful. Regardless of how much they try to endear themselves to you,
the insurance adjuster is not your friend. He is not offering to pay medical
bills out of the goodness of his heart, but to avoid paying substantially more.
The insurance adjuster's job is to pay as little as he can. An early offer to pay
bills is tantamount to an admission that they realize they are responsible to
pay far more. Don't sign anything until you have at least consulted with an
attorney. Most personal injury attorneys will not charge for the initial

Lawyers can be of great assistance to the survivor in recovering benefits to
which he or she may be entitled. While it is possible to find your way
through the multi-layered process to maximize a recovery without an
attorney, it makes sense to at least talk to an experienced attorney to see
what they could do for you. Be careful in your selection of an attorney. Ask
for references and indications that the attorney has experience with brain

              Legal Resources for TBI Survivors
Traumatic Brain Injury and Spinal Cord Injury are often caused by events
that deserve legal scrutiny. In this analysis and advocacy arena, lawyers play
an important role in the TBI/SCI recovery process. This demands the
synthesis of medicine, rehabilitation and the law. It is important to work
with an attorney who, through interest, education, and training, has
developed a special expertise in representing clients with TBI or SCI.

Issues often arise with regard to the cause of the injury, the medical
necessity or appropriateness of certain medical and rehabilitative treatments,
and the real impact on the lives of the survivor and family. The lawyer's role
is to deal with these issues on behalf of the family as an advisor,
investigator, communicator, advocate, negotiator and gladiator. To do this
effectively, the neurolaw attorney must be knowledgeable about the
biomechanics of neurotrauma, neuroanatomy, neurophysiology,
neurochemistry, neuropsychology, neurorehabilitation, and the special needs
that accompany brain injury and spinal cord injury. The central goal of the
neurolawyer should be to improve the quality of life for TBI/SCI survivors
and their families. To this extent, the neurolawyer is an important member of
the team of professionals involved in the care and treatment of TBI/SCI

The importance of choosing the right attorney in a brain injury case cannot
be overstated. Head injury, toxic exposure, whiplash or other insults that
result in injury to the brain greatly increases the complexity of an already
very complex personal injury claim. In such cases the right attorney can
mean the difference between a fair settlement and one that is wholly
inadequate. In real terms, the difference between such attorneys can add up
to a win or a loss for you.

It is also important to understand attorney fees for these types of cases.
Generally, lawyers work on a percentage-fee basis. That is, the lawyer will
keep a percentage of any monetary settlement made in a personal injury
case. This is often as much as one-third of the settlement. Despite the
substantial fee, lawyer services are often important.

For more information about head injury, and personal injury lawyers, call
the Head Injury Hotline at: 206-621-8558. You can also visit the Head

Injury Hotline website at The Head Injury
Hotline website contains numerous links to law firms in the Seattle area who
are experienced in dealing with TBI related litigation. To check out your
lawyer, or to file a complaint contact: your local Bar association or contact
the American Bar Association, 750 N. Lake Shore Dr., Chicago IL 60611,
telephone: 312-988-5000; internet:; email:

Other Legal Resources A personal injury law firm who was instrumental in
helping BIAWA with their downtown Seattle Big Mural Project. The Brain Injury Information Page provides information
about brain injury, concussion, coma and head injury, for TBI survivors,
spouses and caregivers. This page features articles, information and graphics
about traumatic brain injury. Great resource for families and professionals. Article discusses brain
injury causes, outcomes, and provides definition of terms.

Advocacy Resources Washington State Protection and Advocacy System. Washington Coalition of Citizens with disabilities promotes
equality and choice of people with disabilities through advocacy,
collaboration and programs. TASH promotes equity, quality and social justice for people
with disabilities. Disability Information Resources provides links to
advocacy resources, disability and business technical assistance centers, and
legal resources. A grassroots federal legislative action center
sponsored by the American Bar Association. The official Washington State Legislature web site.

      UW TBI Model System Participates in TBI Video
Dr. Kathy Bell will be leading a discussion entitled “Mild TBI: Current
Thoughts on Diagnosis and Management” on May 6th from 12:00pm-

2:00pm in the Turner Auditorium (Room #D209) at the University of
Washington Medical Center. (Ask for directions at the hospital front desk)
Dr. Bell will discuss what actually happens with a concussion. The
presentation will focus on the neurophysiological and pathological changes
that occur with concussion, natural history of recovery, associated medical
conditions, and treatment. The event is open to anyone with an interest in the
treatment and care of TBI survivors, and will include a question and answer
session following the presentation. Community-based providers, state
agency personnel, family members, and the general public who work with or
have an interest in traumatic brain injuries are encouraged to attend. The
session is free. For more information, please contact Aaron (UW TBI Model
System Study Coordinator) at 206-731-5196.

The presentation is part of an interactive five-week series presenting
nationally recognized speakers covering topics on traumatic brain injury
research, education and prevention. The series is coordinated by Telehealth
Idaho Virtual Grand Rounds and broadcast live throughout Idaho. Sponsored
in part by the Idaho State Traumatic Brain Injury Grant (HRSA Grant #H21-
MC0006801). The UW TBIMS presentation is sponsored in cooperation
with the Department of Social Health Services, Aging & Disabilities Service
Administration, Lead Agency-Washington State Traumatic Brain Injury
Grant. (HRSA Grant # H21-MC000620200). Other presentations in the
series include :

April 15th: “The Program Without Walls: Innovative Approach to State
Agency Vocational Rehabilitation of Persons with Traumatic Brain Injury”
By Wayne A. Gordon, Ph.D. Mount Sinai School of Medicine, TBI Model

April 22nd: “Personal Futures Planning” By Robin Greenfield, Ph.D. Center
on Disabilities and Human Development- University of Idaho- Boise Center

April 29th: “Educating Students with Brain Injuries: Sorting out the myths
and facts for effective identification, assessment and teaching” By Marilyn
Lash, M.S.W. Lash and Associates Publishing/Training, Inc.

May 6th: “Mild TBI: Current Thoughts on Diagnosis and Management: By
Kathleen Bell, MD. University of Washington, TBI Model Systems

May 13th: “CDC Funded Traumatic Brain Injury Surveillance Projects” By
Angela L. Marr, MPH, Public Health Advisor, Centers for Disease Control
and Prevention

Visit our on-line resource page for a list of helpful websites for
             TBI survivors, families, and friends at:


                   Recent Staff Presentations

Bob Frasier Ph.D., CRC presented "Neurological Vocational
Rehabilitation,” 1st Annual Pacific Northwest Regional Brain Injury
Conference 2003. Sponsored by the Brain Injury Association of Oregon,
Portland, OR on October 3, 2003.

Jason Doctor Ph.D. presented "Workshop on the Difficulties and Future of
QALY Research,” Sponsored by the Insituto Valenciano de Investigaciones
Economicas (Valencian Institute of Experimental Economics),
Departamento de Fundamentos del Analysis Economico, Universidad de
Alicante, Biar (Alicante), Spain on October 3-4, 2003.

Kathleen Bell, M.D. presented "Pharmacology of Treating Depression in
TBI,” Department of Rehabilitation Medicine Grand Rounds, University of
Washington, Seattle, WA. on October 13, 2003.

Janet Powell, Ph.D. presented "Occupational Therapy and the Post-
concussive Syndrome Patient,” University of Washington, Seattle, WA on
October 23, 2003.

Bob Frasier Ph.D., CRC presented "TBI Rehabilitation: Assessment and
Placement Models,” University of British Columbia, Graduate Certification
in Vocational Rehabilitation, Vancouver, BC on November 26, 2003.

Kathleen Bell, M.D. presented "Concussion,” Edmonds School District

Sports Medicine Class, Mountlake Terrace, WA on December 13, 2003.

                      Recent Staff Publications

Bell, K.R., Esselman, P., Garner, M.D., Doctor, J., Bombardier, C.,
Johnson, K., Temkin, N., & Dikmen, S. (2003). The use of a worldwide web-
based consultation site to provide support to telephone staff in a traumatic
brain injury demonstration project. Journal of Head Trauma
Rehabilitation, 18, 504-511.

This paper describes a Web site where experts give advice to general health
care providers and telephone care providers about caring for people with
brain injury. The University of Washington brain injury team recently
developed a Web site like this for a research study. The study was looking at
whether telephone follow-up was helpful after people leave the hospital.
They found that the Web site was convenient for the telephone staff to use
and improved client confidence in their recommendations. It was also an
excellent way to train less experienced staff. A similar set-up could be used
to improve services for people who do not live close to specialized treatment
centers. For example, it could be used to help people who live in rural areas.
Local health providers could use the Web site to contact experts and get
advice for their patients.

Bell, K.R., & Williams, F. (2003). Use of botulinum toxin type A and type B
for spasticity in upper and lower limbs. Physical Medicine & Rehabilitation
Clinics of North America, 14, 821-835.

This paper summarizes the research that has been done on treating limb
spasticity with Botulinum toxin injections. There has been more research on
using Botulinum toxin to treat spasticity in the arm than in the leg. This
research has found that Botulinum toxin is likely to be effective in treating
spasticity in the arm and hand. The outcomes when treating leg and foot
spasticity are more varied. The larger size of leg muscles makes it more
difficult to get good results. This is especially true if the spasticity is over a
large area. However, Botulinum toxin may be effective in treating smaller
areas of spasticity in the legs and feet, especially if it is combined with other

treatments. The authors recommend that each situation be carefully analyzed
before Botulinum toxin is used.

     Updates on Current Brain Injury Studies at UW
The University of Washington Traumatic Brain Injury Model System began
a new study in April of 2003 called “The Effect of Community-Based
Exercise on Symptoms of Depression in Persons with TBI”, led by
Kathleen R. Bell, M.D. This project is studying the effects of aerobic
exercise on depression and anxiety in persons who have had a mild to
moderate TBI in the previous 1-5 years. The study offers a supervised 10-
week exercise program to participants along with education and motivational
components. To date 21 individuals have participated in the study. Early
results are encouraging, as participants seem to gain a number of benefits
from the exercise classes. The study is now enrolling subjects for future
classes. If you are interested in participating in the study, or for more
information, contact research coordinator Aaron Scrol at or 206-731-5196.

The Magnesium Sulfate Study is being conducted to determine if treating
head injured patients with magnesium sulfate will improve medical, mental,
and psychological recovery. In particular, we are studying the ability to
return to daily life, live independently and return to work or school as done
before the head injury occurred. We are also assessing magnesium sulfate's
ability to reduce the risk of developing seizures (epilepsy) as well as to
improve survival rates after a traumatic brain injury. We currently have 444
subjects, with plans to enroll 500.

The fMRI Study of Executive Function in Traumatic Brain Injury is
now in the second of five years for the study. The UW is working alongside
Baylor and Emory University on this study. The study is using functional
Magnetic Resonance Imaging to obtain pictures of the brain as it performs
executive function tasks. Executive functions, frequently impaired in more
severe traumatic brain injury, include abilities such as working memory,
planning, and flexibility in problem solving. In addition, the researchers are
conducting a second study using fMRI to examine the effects of
methylphenidate (also known as Ritalin) in improving working memory in

people with traumatic brain injury. More specifically, the goals of this study
are to see if Ritalin improves memory and what parts of the brain may be
responsible for improvement. Up to date, 28 subjects have participated in
the first study, while 12 subjects are participating in the second Ritalin

TBI and Depression Study: Researchers in the Department of
Rehabilitation Medicine at Harborview Medical Center are seeking people
with traumatic brain injury (TBI) to participate in a federally funded
research study about depression. Major depression is not just sadness or a
normal reaction to traumatic events. It is an illness that can affect sleep,
energy, thinking and appetite as well as mood. About 1 in 20 Americans
(over 11 million people) develop major depression every year. However,
some research suggests that major depression may affect about one out of
three persons with recent TBI. Major depression may occur more frequently
in people with TBI because the injury changes the delicate balance of
chemicals in the brain. We hope that early identification and treatment of
depression after TBI might improve recovery from and adaptation to this
type of injury.

                   Who's Who at the UW TBIMS:
                     Chuck Bombardier, Ph.D

Chuck Bombardier is a clinical psychologist and an Associate Professor in
the Department of Rehabilitation Medicine within the University of
Washington School of Medicine. For more than 10 years he has specialized
in the acute rehabilitation of persons with traumatic brain injury, spinal cord
injury, and stroke.
Chuck has a wide range of research interests. Among them are:
   o Studying the effects of alcohol and drug abuse in persons with TBI,
     Spinal Cord Injuries and Multiple Sclerosis.
   o Depression in persons with neurological conditions.
   o Exercise/health promotion among persons with disabilities.

Chuck is the Co-Principle Investigator on the Northwest Regional Spinal
Cord Injury Model System grant and a co-investigator on the University of

Washington TBI Model System grant. He is also currently the chief
researcher on a NIH grant studying the prevalence and treatment of
depression following TBI. This grant includes a double-blind randomized
clinical trial of sertraline (Zoloft) versus placebo for treating depression after
Chuck has directed may federally funded grants or projects, and he has
published in the areas of:
   o Predicting functional outcomes in persons with chronic medical
   o Adjustment to chronic medical conditions
   o Neuropsychological impairments in persons with alcohol problems
     and TBI
   o Preventing alcohol problems among persons with TBI.

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