As of Jan. 1, 2025, the Centers for Medicare & Medicaid Services (CMS) is officially recognizing traumatic brain injury (TBI) as a chronic condition. While this change currently only applies to enrollees in a Medicare Advantage plan (generally for patients over age 65 or those who have a disability lasting more than two years), it’s a large step toward medical institutions treating TBI as a persistent ailment, rather than a temporary injury.
For decades, conventional wisdom has held that lifelong TBI conditions were mainly experienced by patients who sustained a severe head injury or multiple concussions, i.e., chronic encephalopathy in football players or military veterans. Without underlying factors, these patients could effectively recover with only a loss of cognitive function. Recent studies, however, have shown a moderate to severe TBI can cause a ripple effect throughout the body, resulting in cardiovascular and other chronic conditions long after the acute injury has resolved.
Shanti Pinto, M.D., M.S.C.S
Shanti Pinto, M.D., M.S.C.S, Associate Professor of Physical Medicine and Rehabilitation at UT Southwestern, has spent much of her career treating TBI patients and studying their comorbidities. Through the Peter O’Donnell Jr. Brain Institute, she is currently Co-Project Director for the North Texas Traumatic Brain Injury Model System, a consortium of 16 centers tasked by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) with researching the long-term effects of TBI. With one of the largest cohort studies of moderate to severe TBI, the program enrolls individuals during inpatient rehabilitation and has them complete follow-up interviews one, two, five, and then every five years afterward to evaluate the ongoing physical and mental deficits from their injuries. With interviews dating back to 1989, this cohort also provides one of the largest time frames for studying the long-term effects of TBI.
During her clinical practice and research, Dr. Pinto has seen firsthand how TBI can follow a patient years after they’re released from initial treatment, causing issues aside from cognitive difficulties. “I think there's still this big perception of brain injury as ‘It happened. It's an isolated event. You’re a few years out from it. You should be over it by now,’” says Dr. Pinto. “I think that's a perception in the community that needs to change.”
Cardiovascular Conditions and Increased Mortality Risk
For part of their research, Dr. Pinto and her colleagues focused on self-reported cases of cardiovascular conditions in TBI patients, including hypertension, congestive heart failure (CHF), myocardial infarction (MI), and stroke. Researchers matched a sample of participants from the NIDILRR-funded TBI Model System to a control sample from the National Health and Nutritional Examination Survey (NHANES). The final sample size of 4,690 pairs included only individuals over the age of 18 who participated in surveys between January 2015 and March 2020; that sample was further separated into groups under or equal to age 50 and greater than age 50.
Compared with the control group, TBI patients were more likely to report instances of hypertension and stroke, regardless of age, though the risk was higher in the younger cohort. Individuals younger than 50 had 1.39 times the risk of hypertension and 3.41 times the risk of stroke. Those older than 50 had a 1.13 times greater risk of hypertension and a 1.5 times increased risk of stroke after TBI. The risk of both hypertension and stroke was greater in the first five years post-injury than after five years.
Their research showed TBI patients were less likely to report a history of heart failure or heart attack, but Dr. Pinto attributes this to survivorship bias. “Oddly, we found a lower rate of heart attacks and heart failure,” she says, “but the limitation with this study is that it's all self-report, and you have to be alive to report.” In their study, over 20% of patients older than 50 did not survive one year post-injury, compared with only 4.5% of those younger than 50. Those older than 50 were also more likely to die due to heart disease than those younger than 50.
Dr. Pinto’s team is finalizing a systematic review and meta-analysis that found individuals with TBI were drastically more likely to die from cardiovascular conditions. “Looking at the entire literature, we found about a three times higher rate of death due to cardiovascular disease in patients with TBI compared to the general population,” says Dr. Pinto, “which is shocking and something you don't think about.”
Other Comorbidities Require More Research
Additionally, researchers have found comorbidities associated with TBI that can increase the severity of these conditions. Sleep-disordered breathing, particularly obstructive sleep apnea (OSA), is commonly reported by individuals with TBI. OSA not only increases the risk for cognitive and cardiovascular problems but has been linked to chronic pain even five years after a TBI incident. More research is needed to determine if addressing sleep disorders can help alleviate chronic pain, however.
Dr. Pinto and her collaborators are especially interested in studying the correlation between TBIs and autonomic nervous system (ANS) dysfunction, as it may help explain the cardiovascular conditions. “This hasn’t been studied in TBI,” she says, “but we know in the general population that elevated inflammation leads to heart disease, and altered on and off nervous system dysfunction, with the sympathetics being up, leads to cardiovascular disease. We see both of those in TBI.”
One of the most well-publicized issues associated with TBI is a tendency toward mood disorders. Following a TBI, patients often become depressed, anxious, or prone to angry outbursts. This not only impacts their ability to find work or continue supporting themselves but can affect interpersonal relationships and, in turn, the care patients receive. Patients can lose their support network or have their treatment reduced due to apparent noncompliance, which makes it even more difficult to address any other comorbidities.
Earlier Screening, Better Care
Increased awareness of TBI as a chronic condition could lead to more screening, particularly for patients who might ordinarily not receive it. Earlier screening may also help future researchers assess whether certain conditions are linked to specific types or locations of injuries. According to Dr. Pinto, “A lot of the research in TBI coming from the trauma and neurosurgery side tends to be during that really acute phase, and then their outcomes are like six months, maybe a year, out. And so, from a rehab standpoint, we're the only ones really capturing that longitudinal cohort in a really robust manner.”
With the new CMS designation, TBI joins the ranks of other chronic ailments such as congestive heart failure, Alzheimer’s disease, and stroke, allowing patients access to additional services and better care. It’s a large step toward bringing more awareness to TBI as a chronic condition, but putting this concept into practice presents another hurdle, says Dr. Pinto. “We don't really know how well this is going to go in practice and what actually needs to be shown to justify that the patient is still having symptoms from their TBI. So, I'm hopeful that this leads to our patients getting better access to care, because a big issue is the lack of access and fragmentation of care.”