SUMMARY OF CHANGES
BETWEEN THE CURRENTLY EFFECTIVE RULE 17, EXHIBIT 10-TRAUMATIC BRAIN INJURY MEDICAL TREATMENT GUIDELINES AND ADOPTED

Below is a Summary of Major Substantive Changes between the 2006 Traumatic Brain Injury Medical Treatment Guidelines and the Adopted  2012  Medical Treatment Guidelines. The changes that are listed below comprise mainly the following:  interventions/diagnostic procedures not addressed previously; procedures and other issues no longer addressed in proposed rule; Some explanatory statements in the narrative designed to be more specific to TBI or treatment protocols/parameters are provided. The reader should refer to the Adopted Traumatic Brain Injury Medical Treatment Guidelines (as adopted November 21, 2012) for specific and complete substantive and non-substantive changes.  

SECTION	Page # [of proposed]	SUBSTANTIVE CHANGE	
General Comments		Language has been updated according to changes in the medical literature

Throughout the guidelines, language regarding whether certain medications/devices are FDA approved was inserted, along with medical evidence to provide guidance to providers on off-label use.

All sections include an increased number of evidence statements, discussion of literature, emphasis on outcomes and function, and considerations for provider

Incorporation of narrative related to return-to-work and delayed recovery issues more specific to individuals with TBI, rather than just the general population.
	
Section C.  TBI Philosophy of Care	5-6	Additional narrative provided regarding the terminology of concussion, post-concussive syndrome, and complicated mild TBI	
	7	Discussion on the need for caution when returning individual with MTBI to work and other activities between 3 and 14 days post-injury.  The need for a gradual increase of activity based on improvement and/or resolution of symptoms is emphasized. 	
	7	Adoption of the International Classification of Functioning, Disability, and Health (as opposed to the Nagi scheme of disablement) which recognizes the interaction between health condition and: body function and structures; activity; and participation.  
	
	8	Increased detail provided on the course of recovery for Mild Traumatic Brain Injury and Moderate/Severe TBI	
	10-12	TBI Model Systems of Care adjusted to reflect current trends along the care continuum for individuals with TBI.   	
	12-16	Insertion of  disciplines commonly involved in the treatment of individuals with TBI:  behavioral analyst (master’s level);  clinical pharmacist; driver rehabilitation specialist; independent live-skill trainer; board-certified music therapist; neuro-otologist; otolaryngologist; neuropsychiatrist; rehabilitation nurse.	
	19	Additional narrative on precipitating event	
Section D.  Initial Diagnostic Procedures	21	Insertion of developmental history, assessment of Activities of Daily Living (ADL) function,  and legal history as recommended information to obtain during initial examination procedure.

Insertion of pain that the individual might have and to document all body parts involved.	
	26-27	Insertion of CT angiography and brain acoustic monitor as vascular imaging tests.	
Section E.  Follow-up Diagnostic Procedures	30	Insertion of information on diffusion tensor imaging, susceptibility-weighted imaging, magnetic transfer imaging.	
	31-34	Personality/Psychological/Psychosocial Evaluation:  This section greatly expanded to include further detail on aspects of:   history of the injury; health history; psychosocial history;  mental status; assessment of danger to self or others; psychological test results (if performed),  pre-existing psychiatric conditions; distinguishing pre-existing symptoms, traits, or vulnerabilities from current symptoms.  	
	35	Electroneuronography language correctly inserted [errata previously done]	
	38	Insertion of optical coherence tomography	
	40	Insertion of correct language for electrocochleography [errata previously done]	
	42-44	Return-to-Work (RTW) Assessment:   This section greatly expanded and slightly renamed (Special Tests for RTW) to include further detail on the benefits and components of a high-quality RTW evaluation/assessment, such as monitoring, physical skills related to job placement,  and the importance of specific objectives.  As with other Division medical treatment guidelines, FCEs may be done initially to determine baseline status; and 2) for case closure when the patient is unable to return to the pre-injury position and further information is desired to determine permanent work restrictions. Prior authorization required for FCE’s performed during treatment.	
Section F.  Acute Therapeutic Procedures – Non-Operative	45-46	Resuscitation:   Narrative related to sedation and neuromuscular blockade, hypotension and hypoxia, unnecessary prophylactic hyperventilation deleted

Hyperventilation stated as generally not recommended

Narrative on nutrition deleted.

Medications for acute therapeutic procedures expanded to include the following:  hyperosmolar agents, prophylactic anti-convulsants, progesterone.

Hypothermia: This section expanded to include a more in-depth discussion of available literature, complexities of determinants of outcome, side-effects. 

Hyperbaric Oxygen Therapy- addressed and (not recommended)

The Non-Operative sections have been re-organized and delineated to include the following sub-sections (although components are included in currently effective MTG):  They are:
•	Acute Therapeutic Procedures, Non-operative
•	Initial Treatment Considerations
•	Neuromedical Conditions in Moderate/Severe Brain Injury
•	Rehabilitation
•	Vision, Speech, Swallowing, Balance, and Hearing
•	Return-to-work, Driving, and Other	
Section G.  Therapeutic Procedures Non-operative-Initial Treatment Considerations	 48-49	Behavior:   Expanded version that discusses latest literature, components of behavior and treatment analysis. 	
	52	Narrative on Assistive Technology inserted	
	p. 55 – 67	Medications and Pharmacological Rehabilitation:  This section greatly expanded with several types of medications addressed. Includes specific discussions regarding medication issues related to affective disorders, behavior/aggression, and cognitive enhancers.  

Detailed descriptions of the cognitive enhancers include the following:
•	Amantadine
•	Bromocriptine
•	Carbidopa/L-Dopa
•	Dextroamphetimine and mixed amphetamine salts
•	Donepezil
•	Methylphenidate
•	Modafinil/Armodafinil
•	Rivastigmine

A table of indications for cognitive enhancers has been inserted.  

Hypnotics and Sedatives:  not normally recommended but may be used temporarily in sleep disturbances.

Non-steroidal anti-inflammatory drugs:  This language inserted to be consistent with other Division Guidelines

Skeletal Muscle Relaxants and Opioids:   Briefly mentioned with a reference to the Chronic Pain Medical Treatment Guidelines

Headache algorithm has been updated to reflect recent literature.  
	
	68	Botulinum toxin injections generally not recommended for cervicogenic or other headaches.
	
Section I. Non-operative Therapeutic Procedures – Rehabilitation	74 - 79	Interdisciplinary Rehabilitation Programs:   Much additional discussion regarding circumstances, protocols, and conditions in which interdisciplinary rehabilitation benefits the individual with TBI:  including but not limited to the consideration of the ability for the individual with TBI to tolerate and benefit from a specific treatment.   Additional narrative provided on the dimensions that interdisciplinary rehab programs should include.

Information on Residential Rehabilitation (aka transitional living), occupational rehabilitation provided. 
	
	84-85	Narrative on work conditioning, work simulation, inserted (to be consistent with other guidelines).  	
	86	Narrative specific to the benefits/indications of postural control activities for muscle tone inserted.	
	87	Brief mention of pharmaceutical agents for management of spasticity	
Section J. Non-operative Therapeutic Procedures-Vision, Speech, Swallowing, Balance, and Hearing	p. 92-97	Neurotologic Treatment:  This section greatly expanded and re-organized to include the following sub-headings:  treatment of fixed lesions; treatment of recurrent, non-progressive otologic disorders; treatment of progressive otologic disorders.

Steroid perfusion inserted

	
Section K.  Non-operative Therapeutic Procedures-RTW, Driving, & Other	p. 103-106	Return-to-work:   List of special considerations provided when attempting to return and injured worker with MTBI and moderate/severe TBI to work, including ability to perform basic ADLs.  	
	p.  107	Other Treatments addressed:  Hyperbaric Oxygen Therapy-(not recommended); Deep thalamic stimulation (generally not recommended); transcranial magnetic stimulation (not recommended). 
	
Section M.  Maintenance Management	p. 117	Narrative specific to neuromedical management and speech-language pathology added.