Dual Diagnosis




Key points







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    Spinal cord injury (SCI) patients should be assessed for a co-occurring traumatic brain injury (TBI) on admission to a rehabilitation program.


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    Incidence of a dual diagnosis may approach 60% with certain risk factors.


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    The National Institute on Disability and Rehabilitation Research (NIDRR) SCI Model Systems started collecting data on co-occurring TBI in 2011 due to the high incidence of a dual diagnosis.


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    Diagnosis of mild–moderate severity TBIs may be missed during acute care hospitalizations of SCI.


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    Neuropsychological symptoms of a missed TBI diagnosis may be perceived during rehabilitation as noncompliance, inability to learn, maladaptive reactions to SCI, and poor motivation.


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    There are life-threatening and/or quality-of-life–threatening complications of TBI that also may be missed if a dual diagnosis is not made.






Introduction


Rehabilitation strategies and expected outcomes for patients having a SCI can be complicated by a dual diagnosis of TBI. The reported incidence of concomitant brain and spinal cord injuries ranges from 25% to more than 60%, especially if the mechanism of injury was a motor vehicle collision or a fall. Other factors that increase risk for a concomitant TBI are cervical level SCI, complete SCI level trauma, and initial trauma associated with alcohol intoxication. The highest rate of concurrent TBI occurs in SCI patients with a C1 through C4 level of injury.


Physical, cognitive, and/or emotional impairments that may result from a TBI pose important challenges in the rehabilitation of a dual diagnosis SCI patient. Physical impairments may include motor or sensory deficits. Motor impairments may involve deficits of strength, balance, and/or coordination. Sensory impairments may include deficits of touch or proprioception sensation and/or deficits of the special senses, such as vision. Cognitive impairments may include deficits of attention, information processing speed, problem solving, learning, memory, and communication. Emotional impairments may include apathy, emotional lability, agitation, aggression, disinhibition, impaired task initiation, anxiety, and depression.


The likelihood of significant physical, cognitive, and/or emotional impairments increases along the spectrum of worsening TBI severity from complicated mild TBI (MTBI) through moderate TBI to severe TBI. In SCI patients with a dual diagnosis of TBI, MTBI occurs most commonly and occurs in approximately 64% to 73% of cases whereas moderate TBI occurs in 10% to 23% and severe TBI in 17% to 23% of cases. The relationship between SCI postrehabilitation functional outcomes and brain injury severities, however, is not necessarily linear, although in general, as expected, the worst outcomes occur with a dual diagnosis of severe TBI. Also, the effect of severe TBI on motor recovery may be greatest in SCI patients having paraplegia rather than tetraplegia, probably due to a ceiling effect on motor recovery potential, although there are cognitive impairments that include memory and problem-solving deficits in both groups. Paraplegic SCI patients with MTBI may have greater difficulties performing certain motor tasks, such as chair transfers, although cognitive deficits in uncomplicated MTBI tend to resolve prior to admission to inpatient rehabilitation. Contusions involving motor brain areas resulting from moderate TBIs may result in contralateral motor deficits that exacerbate weakness resulting from an SCI. In experimental animal models, cortical contusions ipsilateral to a unilateral incomplete SCI at the C5 level enhanced forelimb motor recovery possibly due to the stimulation of plasticity in the contralateral motor cortex, which may have clinical relevance in patients having similar lesions.


Prompt diagnosis of a concomitant TBI in an SCI patient is important for planning appropriate rehabilitation interventions to maximize functional returns and for the prevention, anticipation, and early treatment of possible related medical complications. A diagnosis of TBI, in particular mild and moderate severity TBIs, may be missed during the acute care hospitalization of an SCI patient, especially when there is a need for sedation, intubation, and/or the presence of acute trauma-related life-threatening issues. The symptoms, signs, and possible complications of a co-occurring TBI may not become evident until a patient is already admitted to an inpatient rehabilitation unit. Awareness on the part of the rehabilitation team regarding the potential for a dual diagnosis of TBI in traumatic SCI patients, as well as vigilance for related symptoms, signs, and/or complications, is important to improving both clinical and functional outcomes. Also, it is not uncommon for patients with a known diagnosis of co-occurring TBI with traumatic SCI to be assigned to a specialized TBI or SCI rehabilitation unit depending on which injury may be more severe. Proper treatment and management strategies, however, are necessary for those patients who are admitted to rehabilitation with a known dual diagnosis of TBI/SCI regardless of whether they may be assigned to a TBI, an SCI, or a neurorehabilitation unit. TBI/SCI definition, diagnosis, pathologic features, evaluation, complications, and rehabilitation are discussed.




Introduction


Rehabilitation strategies and expected outcomes for patients having a SCI can be complicated by a dual diagnosis of TBI. The reported incidence of concomitant brain and spinal cord injuries ranges from 25% to more than 60%, especially if the mechanism of injury was a motor vehicle collision or a fall. Other factors that increase risk for a concomitant TBI are cervical level SCI, complete SCI level trauma, and initial trauma associated with alcohol intoxication. The highest rate of concurrent TBI occurs in SCI patients with a C1 through C4 level of injury.


Physical, cognitive, and/or emotional impairments that may result from a TBI pose important challenges in the rehabilitation of a dual diagnosis SCI patient. Physical impairments may include motor or sensory deficits. Motor impairments may involve deficits of strength, balance, and/or coordination. Sensory impairments may include deficits of touch or proprioception sensation and/or deficits of the special senses, such as vision. Cognitive impairments may include deficits of attention, information processing speed, problem solving, learning, memory, and communication. Emotional impairments may include apathy, emotional lability, agitation, aggression, disinhibition, impaired task initiation, anxiety, and depression.


The likelihood of significant physical, cognitive, and/or emotional impairments increases along the spectrum of worsening TBI severity from complicated mild TBI (MTBI) through moderate TBI to severe TBI. In SCI patients with a dual diagnosis of TBI, MTBI occurs most commonly and occurs in approximately 64% to 73% of cases whereas moderate TBI occurs in 10% to 23% and severe TBI in 17% to 23% of cases. The relationship between SCI postrehabilitation functional outcomes and brain injury severities, however, is not necessarily linear, although in general, as expected, the worst outcomes occur with a dual diagnosis of severe TBI. Also, the effect of severe TBI on motor recovery may be greatest in SCI patients having paraplegia rather than tetraplegia, probably due to a ceiling effect on motor recovery potential, although there are cognitive impairments that include memory and problem-solving deficits in both groups. Paraplegic SCI patients with MTBI may have greater difficulties performing certain motor tasks, such as chair transfers, although cognitive deficits in uncomplicated MTBI tend to resolve prior to admission to inpatient rehabilitation. Contusions involving motor brain areas resulting from moderate TBIs may result in contralateral motor deficits that exacerbate weakness resulting from an SCI. In experimental animal models, cortical contusions ipsilateral to a unilateral incomplete SCI at the C5 level enhanced forelimb motor recovery possibly due to the stimulation of plasticity in the contralateral motor cortex, which may have clinical relevance in patients having similar lesions.


Prompt diagnosis of a concomitant TBI in an SCI patient is important for planning appropriate rehabilitation interventions to maximize functional returns and for the prevention, anticipation, and early treatment of possible related medical complications. A diagnosis of TBI, in particular mild and moderate severity TBIs, may be missed during the acute care hospitalization of an SCI patient, especially when there is a need for sedation, intubation, and/or the presence of acute trauma-related life-threatening issues. The symptoms, signs, and possible complications of a co-occurring TBI may not become evident until a patient is already admitted to an inpatient rehabilitation unit. Awareness on the part of the rehabilitation team regarding the potential for a dual diagnosis of TBI in traumatic SCI patients, as well as vigilance for related symptoms, signs, and/or complications, is important to improving both clinical and functional outcomes. Also, it is not uncommon for patients with a known diagnosis of co-occurring TBI with traumatic SCI to be assigned to a specialized TBI or SCI rehabilitation unit depending on which injury may be more severe. Proper treatment and management strategies, however, are necessary for those patients who are admitted to rehabilitation with a known dual diagnosis of TBI/SCI regardless of whether they may be assigned to a TBI, an SCI, or a neurorehabilitation unit. TBI/SCI definition, diagnosis, pathologic features, evaluation, complications, and rehabilitation are discussed.




Definition


A dual diagnosis of TBI with SCI occurs in patients having specific clinical and diagnostic features of both disorders resulting from trauma. The usual causes of the trauma are direct contact forces and/or rapid acceleration/deceleration movements resulting from assaults, crashes, and accidents involving motor vehicles, bicycles, pedestrians, construction, and sports. The SCI may be defined as a traumatic lesion of the spinal cord or cauda equina, which may involve varying degrees of motor and/or sensory deficits. SCI lesions may result in paraplegia or tetraplegia and may be classified as complete or incomplete per the American Spinal Injury Association impairment scale. TBI may be defined as head trauma involving an alteration of consciousness having signs that may include confusion, loss of consciousness (LOC), and amnesia with or without other neurologic deficits.


Brain injury severity is classified as mild, moderate, or severe after a diagnosis is established based on criteria that may include initial Glasgow Coma Scale (GCS) scores, duration of posttraumatic amnesia (PTA), duration of LOC, and neuroimaging findings consistent with intracranial trauma, such as contusions, axonal shear injury, hemorrhages, and encephalomalacia. GCS scores, PTA, LOC, and neuroimaging data are routinely collected by the NIDDR TBI Model System. Standard classifications of TBI severity based on these 4 diagnostic criteria are provided in Table 1 . Assessments of GCS scores, PTA durations, and LOC may be confounded, however, in SCI patients by hypoxia, intubation, sedation, seizures, and/or alcohol or other drug/substance intoxication. Also, brain imaging studies may not be available, or may be initially interpreted as negative, in patients having a primary diagnosis of SCI. Symptoms, signs, and neuroimaging data important in the diagnosis of TBI in SCI patients are discussed in the next section.



Table 1

Standard classifications of TBI severity








































TBI Severity Mild Mild Complicated Moderate Severe
Initial Confusion or AMS Documented or by history Documented or by history Documented or by history Documented or by history
Initial GCS scores 13 to 15 13 to 15 9 to 12 3 to 8
PTA duration <24 h <24 h <1 wk >1 wk
LOC If any, <1 h If any, <1 h Yes Yes
Neuroimaging findings No Yes Yes Yes

Data from Refs.




Diagnosis


Patients having an SCI should be assessed for the possibility of a co-occurring TBI on admission to a rehabilitation program. NIDRR SCI Model Systems started collecting data on associated TBI in 2011 due to the common occurrence of dual diagnosis. A dual diagnosis of SCI with a severe TBI is usually established during acute care and is also usually obvious based on history and initial trauma neuroimaging studies. A dual diagnosis of SCI with a mild or moderate TBI may sometimes be overlooked during acute care especially in the case of co-occurring MTBI. MTBI, which is a synonym for concussion, accounts for as many as 80% of brain injuries that includes the spectrum of mild uncomplicated concussion to complicated concussion bordering on a moderately severe TBI.


A diagnosis of MTBI and moderate TBI may be established during acute care prior to inpatient rehabilitation transfer in patients in which there was documentation of an initial GCS score of 13 to 15 for MTBI or 9 to 12 for moderate TBI, pathology noted on the initial brain CT scan, known LOC, and/or PTA. Due to the subtle nature of the initial symptoms and the often negative findings on emergency department brain CT scans and neurologic examination, however, especially in association with more pressing life-threatening traumatic injuries that include the SCI, diagnosis of an MTBI is often missed. Also, radiologic findings consistent with mild and moderate TBIs, in particular findings of contusions, may be missed in up to 67% of scans, especially when the scans are read by inexperienced radiologists.


Brain injuries, especially concussions/MTBIs, may not become evident until an SCI patient is transferred to an inpatient rehabilitation unit. Individuals having a mild or moderate TBI may present on the inpatient rehabilitation unit with symptoms (listed in Box 1 ). A diagnosis of a mild or moderate TBI may be made on the inpatient rehabilitation unit in symptomatic patients based on review of the patient’s history if there was evidence for confusion or LOC at the scene of trauma or subsequent PTA. Brain MRI studies may reveal findings consistent with TBI in patients with symptoms or clinical signs of brain injury but having otherwise negative brain CT scans.



Box 1




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    Headaches


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    Dizziness


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    Insomnia


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    Imbalance/incoordination


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    Emotional irritability/lability


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    Depression/anxiety


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    Impaired memory


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    Executive dysfunction


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    Behavioral manifestations


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    Focal weakness/numbness


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    Visual Impairments


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    Impaired communication



Possible symptoms of mild and moderate TBIs




Evaluation


It is important for a dual diagnosis to be made in SCI patients having a co-occurring TBI so that the associated physical, cognitive, and behavioral symptoms are treated appropriately and so that the specialized rehabilitation is done accordingly. Cognitive and/or behavioral symptoms from a missed diagnosis of TBI during inpatient rehabilitation may be perceived by interdisciplinary staff, including physicians, nurses, therapists, and case managers, as noncompliance, inability to learn, maladaptive reactions to SCI, and poor motivation. Also there are multiple potentially life-threatening and/or quality-of-life–threatening complications of TBI that also may be missed if a dual diagnosis is not made.


The evaluation should start with a thorough review of acute care records looking for any documentation of LOC, GCS scores, PTA duration, confusion, behavioral issues, seizures and/or abnormal results of any brain imaging studies. Special attention should be given to review of paramedic/emergency rescue reports, acute care emergency department documentation, intensive care unit notes, consultation reports from all specialists, therapy notes, nursing notes, attending physician notes, and any psychology reports. The likelihood of a dual diagnosis may approach 60% when there is history of cervical spine trauma, a motor vehicle accident, or a fall from a significant height. There usually is no clear documentation of durations of LOC or of PTA or GCS scores in most cases of an undocumented TBI diagnosis. PTA duration may be estimated by the interval of time to a patient’s ability to consistently form new memories from day to day. Resolution of PTA usually occurs simultaneously with recovery from confusion/disorientation and is often preceded by the ability to consistently follow simple commands by a few weeks. Initial TBI severity may be determined by PTA durations (see Table 1 ).


Physical, behavioral, and cognitive symptoms and signs of brain injury in SCI patients may also be observed and reported by family members, interdisciplinary therapy staff and/or by the patient.




Neuroimaging


Patients who are having symptoms or signs of a mild or moderate TBI who may have had an initial negative brain CT scan may have abnormalities on brain MRI scans for up to 2 to 3 months after trauma, including findings consistent with areas of axonal shear injury and/or small contusions or hemorrhages. Unilateral or multifocal lesions on MRI, particularly in the temporal or frontal lobes, are associated with neuropsychological symptoms in TBI. Lesions of deep brain structures, such as the thalamus or multiple portions of the corpus callosum, are associated with moderate to severe brain injuries. Isolated lesions of the posterior part of the corpus callosum can occur, however, in MTBI.


Also, diffusion tensor MRI may be useful in showing specific brain motor pathway lesions that could be contributing to motor weakness resulting from TBI in patients with SCI. Awareness of weakness related to TBI may assist clinicians in planning physical and occupational therapy rehabilitation strategies of dual diagnosis patients.


In addition, a brain CT scan is advisable in cases of SCI in which TBI is suspected if there had been no initial brain neuroimaging performed. Brain CT scan imaging is generally more effective than MRI in showing areas of skull fracture and other signs of acute trauma.




Complications


Head/Neck Trauma


Head and neck structures are often injured in association with cervical SCI and/or TBI. Associated head and neck structure injuries may be missed during acute care and initially present during rehabilitation with various symptoms and signs that may require special treatment; sometimes the symptoms of head/neck trauma are the presenting symptoms of the co-occurring TBI.


Fractures at the skull base or frontal bone


Fractures at the skull base or frontal bone may be associated with dural membrane lacerations, which may present as a cerebrospinal fluid (CSF) fistula leak and patient complaint of a chronic running nose or fluid in an ear. Trauma to the frontal bone frequently involves the paranasal sinuses and may result in CSF leakage from the nose (rhinorrhea) and pneumocephalus that may cause headaches; these fractures may also involve the orbit. Fractures involving the middle and posterior skull base often involve the petrous portion of the temporal bone and are associated with risk for facial palsy, hearing loss, and CSF fistulas that leak from the ears (otorrhea). Work-up should include skull radiographs or brain CT scan. Neurosurgical consultation is required if CSF fistula is suspected because there is significant associated risk for the development of an intracranial infection.


Orbital fractures


Orbital fractures may result in diplopia secondary to opthalmoplegia associated with traumatic neuropathies of cranial nerves 3, 4, and/or 6; or due to entrapments of the muscles of eye movement. Diplopia may also occur from vascular trauma or injury of central pathways directly related to brain injury.


Temporal bone fractures


Temporal bone fractures may be associated with traumatic neuropathies of cranial nerves 7 and/or 8 and may present with ipsilateral facial palsy, hearing loss, and/or vertigo. Vertigo/dizziness is also the second most common postconcussion symptom after headache and often occurs in the absence of skull fractures (discussed later).


Vascular trauma


Vascular trauma, such as dissections and fistulas involving the anterior and posterior blood supply to the head and neck, including the extracranial and intracranial branches of the vertebral and carotid arteries, may present with symptoms and signs that include neck pain, unilateral headache or facial pain, and transient or fixed neurologic findings referable to specific brain vascular territories. Trauma is a primary cause of carotid cavernous fistulas and the cavernous sinus syndrome, which may present with diplopia, unilateral facial pain, and/or numbness, Horner syndrome, and unilateral scleral erythema.


Eye injuries


Eye injuries may occur, especially in association with frontal impact head trauma and orbital fractures. Vision impairment may directly result from trauma of eye structures and/or extraocular muscles or from indirect injury, such as exposure keratopathy, due to incomplete lid closure and inadequate eye lubrication after a traumatic facial palsy.


Postconcussion Syndrome


The postconcussion syndrome is a complex of somatic, affective, and cognitive symptoms that is well described in the medical literature, which may complicate the recovery after a TBI, which may be a presenting feature of TBI, and which may result from brain injury or from trauma involving other head/neck structures. The most common symptoms are headache and dizziness followed by impaired sleep, neck pain, hearing loss, and emotional and/or cognitive problems. The neuropsychological problems may pose an important challenge in the rehabilitation of dual diagnosis patients.


Headache


Headache is usually peripheral in origin rather than due to central nervous system causes and may also result from the effect of various medications. In dual diagnosis patients with cervical spine injury, radiculopathy involving the second and/or third nerve root may cause headaches. In patients with posttraumatic dizziness, headache may be due to inner ear injuries, such as benign positional vertigo or a perilymphatic fistula. Possible central causes of posttraumatic headache include pneumocephalus, CSF fistulas, and chronic extra-axial fluid collections, such as a subdural hematoma or hygroma. Neuroimaging studies and/or neurologic consultation should be considered when headaches interfere with rehabilitation progress.


Dizziness


Dizziness is usually peripheral in origin rather than due to central nervous system causes and may also result from the effect of various medications. The most common posttraumatic cause is benign positional vertigo due to inner ear injury. In dual diagnosis patients with cervical spine injury, dizziness may be related to the cervical spine trauma.


Hearing loss


Hearing loss may be due to neural or conductive injury. Conductive causes include tympanic membrane rupture, ossicle disruption, or a middle ear hematoma. Hearing loss related to neural injury of cranial nerve 8 often occurs in association with temporal bone skull fractures and/or vestibular injury.


Sleep impairment


Sleep impairment is common in TBI and SCI patients and may be multifactorial in etiology. Chronic pain, anxiety, and/or depression may be causes. Impaired sleep may interfere with rehabilitation progress.


Neck pain


Neck pain is especially common when the mechanism of trauma involved a motor vehicle accident in which there was hyperflexion and hyperextension of the neck. In addition to cervical SCI, other associated pathologic findings may include torn muscles or ligaments, vertebral column fractures, radiculopathy, and occasionally a Horner syndrome from cervical sympathetic pathway involvement.


Neuropsychological symptoms


Neuropsychological symptoms, including emotional and/or cognitive impairments, in a dual diagnosis patient may sometimes be the presenting feature of a TBI. Emotional symptoms may include irritability, lability, anxiety, and depression. Cognitive symptoms may include difficulties with concentration, attention, memory, word finding/speech, perception, information processing, and executive functions.


Neuropsychological symptoms in dual diagnosis patients may result from brain injury and/or may be related to nonorganic factors. Patients with unilateral or multifocal brain lesions on neuroimaging studies are more likely to have neuropsychological symptoms as a result of brain trauma. Emotional symptoms unrelated to brain injury may stem from the subjective experience of somatic problems, such as pain, cognitive difficulties, or adjustment issues related to the trauma. Cognitive symptoms unrelated to brain injury may occur from distracted concentration/attention due to anxiety, depression, or somatic problems, including pain.


Seizures


The risk of posttraumatic epilepsy increases with worsening brain injury severity, intracerebral hematoma, cortical contusions, depressed skull fractures, and/or seizures that occur after the first week after trauma, in which case anticonvulsant medication prophylaxis is warranted. A preexisting poorly controlled seizure disorder or a previously undiagnosed seizure disorder may sometimes be the source of a seizure that contributed to the trauma that resulted in dual diagnosis TBI/SCI.


Complications in Dual Diagnosis with Moderate–Severe TBI


Complications in moderate–severe TBI in dual diagnosis patients may be life threatening or quality-of-life threatening and may manifest during the acute care hospitalization or instead may sometimes be initially diagnosed during rehabilitation. Potential complications of moderate–severe TBI may include physical, cognitive/behavioral, metabolic, and posttraumatic complications ( Box 2 ). Rehabilitation challenges posed by some of these physical, cognitive, and emotional problems are also discussed in the following section.


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Apr 17, 2017 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Dual Diagnosis

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