Mild Traumatic Brain Injury

Foluke A. Akinyemi

Shane McNamee

15: Mild Traumatic Brain Injury

PATIENT CARE

GOALS

Provide patient care that is compassionate, appropriate, and effective for the treatment of mild traumatic brain injury (MTBI) problems and the promotion of health.

OBJECTVES

1. Perform a pertinent history and physical of the MTBI adult patient.

2. Identify key impairments, functional, and activity limitations for adults with MTBI.

3. Identify the psychosocial and vocational implications of MTBI and strategies to address them.

4. Describe injuries commonly associated with MTBI.

5. Describe a sample rehabilitation treatment plan for adults with MTBI.

Key elements of the history should include at a minimum the history of present illness, past medical history, review of systems, medication review, psychosocial and vocational history, and allergies.

History of present illness should include the following:

1. Details of the injury event

2. Mechanism of injury

3. Duration and severity of alteration of consciousness

4. Length of amnesia, immediate symptoms

5. Symptom course and prior treatment

6. Other injuries (such as fractures and cervical trauma)

7. Patient’s symptoms and health concerns

8. Screening for premorbid conditions, potential cooccurring conditions, or other psychosocial risk factors such as substance use disorders that may exacerbate or maintain current symptom presentation

9. Assess danger to self or others

Past medical history should include any history of past brain injury; alcohol, tobacco, or illicit or prescription drug abuse; attention deficit hyperactivity disorder (ADHD), depression, anxiety, posttraumatic stress disorder (PTSD), chronic pain, and other psychosocial risk factors; acquired or congenital brain disease/abnormalities and past head or brain surgeries.

Social/vocational history: Preinjury academic and/or employment histories and marital/social support history are essential, particularly as they influence recovery following MTBI.

Review of systems: When obtaining the review of systems, the physiatrist should review the presence or absence of somatic symptoms commonly seen after MTBI and should ask about headache, vestibular system dysfunction, sleep disturbance, dizziness/coordination/balance problems, nausea, blurred vision, sensitivity to noise and sound, fatigue, and musculoskeletal pain.

The physiatrist should also screen for common cognitive problems such as impaired memory, concentration, attention, speed of processing, judgment, and executive control. If any of these are present, he or she should inquire about the impact of any of these symptoms on school or work performance.

The patient should be asked about symptoms such as depression, anxiety, agitation, irritability, impulsivity, and aggression and, if present, inquire about the impact of these difficulties on family/work relationships.

The patient should also be asked about the course and resolution (or lack thereof) of the symptoms since the time of injury. The frequency and severity of symptoms should be documented in order to set a baseline for monitoring subsequent treatment efficacy and for establishing co-occurring conditions.

It is also important to ask patients if and how their symptoms impact their daily functions, especially how they impact their basic activities of daily living (ADLs) and instrumental ADLs (IADLs). IADLs are activities and skills that allow patients to live independently such as managing finances, shopping, preparing meals, and performing basic housework.

Medications: Review of past and current medications and drug allergies should be performed. The physician should make note of past medications tried for the patient’s current symptoms, efficacy, and reason for stopping the medications, if applicable. Screen for current medications that may worsen neurologic recovery or cause sedation, cognitive slowing, or increased risk for suicidal ideations.

After each history taking, it is imperative that the physician validate the patient’s concerns and symptoms.

Physical examination should include the following:

A. Focused neurologic examination that includes the following:

1. Mental status examination (MSE)

2. Cranial nerve testing

3. Sensation

4. Extremity testing of tone

5. Muscle stretch reflexes

6. Motor strength testing

7. Postural stability (Romberg test; dynamic sitting and standing)

B. Focused vision examination including gross acuity, eye movement, binocular function, and visual fields/attention testing.

C. Focused musculoskeletal examination including range of motion, focal tenderness, and palpation of the head, neck, jaw, spine, and extremities.

D. Cognitive evaluation: There are several brief screening tools available, including the Mini Mental Status Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). MoCA has been validated in the setting of mild cognitive impairment associated with several clinical disorders. The test, test information, and administration instructions are accessible for clinicians at www.mocatest.org.

FUNCTIONAL IMPAIRMENTS AND ACTIVITY LIMITATIONS ASSOCIATED WITH MTBI

Impairments commonly seen in MTBI patients include impaired balance, coordination, vision, hearing, and sleep. Cognitive impairments such as memory, concentration, attention span, and speed of mental processing of information can be present. Behavioral and emotional impairments such as emotional liability and apathy can also be seen.

Patients with MTBI are typically independent in basic ADLs such as grooming, bathing, dressing, toileting, and mobility; however, a minority of patients may report that their symptoms negatively impact their abilities in IADLs, such as driving, home management, child care, financial management, and on-the-job or school performance.

KEY PSYCHOSOCIAL ASPECTS ASSOCIATED WITH MTBI AND ITS VOCATIONAL IMPLICATIONS

MTBI may create physical, social, marital, vocational, and avocational activity limitations and participation restrictions for the patient. For example, after MTBI, patients may be unable to return to work or school and have difficulty performing their role in their family or community. They may also have difficulties with relationships at home and/or work, such as problems relating to one’s spouse, children, and coworkers. They may also have comorbid depression, anxiety, and PTSD.

School and/or vocational needs must be addressed, and the decision on when and how to return to school or work is based on the severity of the cognitive, physical, and emotional impairments and the type of work previously engaged in.

Work performance and abilities may be negatively impacted from the cognitive, behavioral, and physical problems mentioned earlier. An individual may have problems securing or maintaining his job due to inability to meet his or her work demands. There may be difficulties with job performance—forgetting appointments, problems completing tasks, difficulties getting along with supervisors and coworkers. Subsequently, individuals may need to change occupations/jobs frequently and some eventually become unemployed.

Immediately following a TBI episode, symptomatic patients should have a period of rest to avoid sustaining another concussion and to facilitate a prompt recovery. After the short rest period, they should be encouraged to expediently return to normal activity (work, school, duty, leisure) and a gradual resumption of activity is recommended. A period of work restriction or accommodation such as provision of additional time to complete tasks and working in a quiet environment with additional supervision may be necessary to ensure successful reintegration. If symptoms reemerge after returning to previous normal activity levels, a monitored progressive return to normal activity as tolerated should be recommended (1).

Common injuries associated with MTBI include whiplash and musculoskeletal injuries, which may be seen in patients who have sustained TBI as a result of motor vehicle accident (MVA), falls, contact sport, subtle fractures, and substance abuse. In addition, cumulative effects of MTBI may include psychiatric disorders and loss of long-term memory.

Strategies to prevent MTBI and related injuries including education of the patient, family, and caregiver is the keystone to prevention (2). Clinicians should provide information to patients, families, and caregivers about risk behaviors and activities that increase potential for TBIs of all types. Other recommendations for preventing MTBIs include the following:

1. Consistent use of seat belt

2. Never drive under the influence of alcohol, drugs, or medications that can impair cognition or cause drowsiness

3. Consistent helmet use when engaging in at-risk activities such as biking, motorcycle, snowmobile, skiing, snowboarding, skating, contact sports, baseball or softball, and horse riding

4. Always buckle small children in cars

5. Regular vision check to decrease fall risk

6. Remove household tripping hazards

Patients with MTBI often complain of concurrent physical, cognitive, and behavioral symptoms. It is important to treat the symptoms that cause the patient the most distress first. Patients should be screened for comorbid mental health disorders. Headache is one of the most common symptoms associated with MTBI (3). Assessment and management of headaches in individuals with MTBI should be comparable with those for other causes of headache (4). (See Table 15.1 for recommendations for specific symptoms.)

In patients with persistent post-concussive symptoms, who are refractory to treatment, consideration should be given to other factors such as psychiatric issues, psychosocial support and also consider extrinsic factors such as patient involved in litigation and those seeking compensation for their injuries.

TABLE 15.1 Common Postconcussive Symptoms and Management Approach

SYMPTOMS	MANAGEMENT
Physical Problems
Headache	Prophylactic and abortive medications Education on stress and lifestyle management
Balance and vestibular dysfunction	Physical therapy, vestibular rehabilitation
Blurred vision/photosensitivity	Sunglasses for photosensitivity, vision therapy, referral to optometrist
Tinnitus and hearing impairment	Audiology referral for tinnitus and hearing impairment Education on hearing protection and environmental modifications
Musculoskeletal pain syndromes	Physical therapy, pain medication—avoid narcotics
Sleep disorder	Refer for sleep study if sleep apnea is suspected Educate on proper sleep hygiene to include avoidance of alcohol, caffeine products, or stimulants before sleep; establish a consistent sleep schedule, limit daytime naps, and avoid stimulating activities immediately before sleep Sleep medications—avoid benzodiazepines
Cognitive Problems
Impaired memory, concentration, attention, processing speed, executive control	Neuropsychology testing Cognitive remediation training Referral to speech pathology/occupational therapy for training on compensatory strategies Voice recorders, use of smart phones, and/Personal Digital Assistance (PDA) for memory aid. Global positioning devices (GPS) for direction and to avoid getting lost
Behavioral Problems
Depression Anxiety Irritability Poor impulse control Aggression PTSD	May require either psychotherapeutic or pharmacological treatment modalities, or both Medications include SSRIs Mental health referrals should be considered for management of depression, PTSD, and anxiety; referrals to substance abuse treatment specialists as needed

PHARMACOLOGICAL TREATMENT APPROACH TO MTBI

When considering medications to manage symptoms of MTBI, it is important to keep in mind that injured brains are sensitive to the side effects of medications. Choose medications with the least amount of negative effect on cognition, brain recovery, and minimal side effect profiles. Monitor patients closely during treatment and evaluate for potential toxicities and drug–drug interactions. Avoid medications that can lower the seizure threshold or result in drowsiness or slowed thinking. Avoid medications associated with increased risk of suicidal ideation. Examples of medications to avoid are benzodiazepines and anticholinergic and antidopaminergic agents.

SAMPLE REHABILITATION PROGRAM, MANAGEMENT, OR TREATMENT PLAN FOR MTBI

A 23-year-old man is involved in an MVA, in which he sustained mild grade 1 American Academy of Neurology (AAN) TBI. He presents to your office 3 months later with complaints of mild balance problems and dizziness, daily headaches lasting 4 hours, short-term memory impairments, light sensitivity, and mild impairment in hearing. He also reports difficulty falling and frequent awakening from sleep secondary to nightmares.

TREATMENT PLAN

Start by (a) validating the patient’s experience and symptoms, (b) educating the patient regarding the natural history of MTBI, and (c) reassuring the patient that most people with MTBI have resolution of their symptoms within a few weeks.

Symptom management for this patient includes the following:

1. Physical therapy for vestibular rehabilitation to address the dizziness and balance problems.

2. Speech therapy for compensatory strategies and memory aids.

3. Vision therapist for photosensitivity. Recommend sunglasses.

4. Audiology for hearing impairments.

5. Sleep management should include review and discussion of sleep hygiene. If sleep apnea is suspected, a referral for sleep study should be done first before prescribing sleep medications. In this case study, sleep apnea was ruled out; however, he stated that he did not like taking PO medications, so he was started on trazodone 50 mg QHS and also started on a trial of prazosin for nightmares.

6. If PTSD is suspected, referral for mental health treatment is indicated.

7. Headache management should start with attempts to characterize the type of headache—tension versus migraine versus combined. If the patient has migraine headaches, both prophylactic and abortive medications are indicated. Past and present medications were reviewed, and the patient was asked about efficacy and reasons for discontinuing medications. The patient was started on Sumatriptan for abortive therapy and topiramate for headache prophylaxis (Botox injection is another alternative).

9. Educate the patient on stress reduction and sleep management. Instruct him to avoid factors that trigger his migraines.

At the conclusion of the clinical visit, the patient was educated on how to avoid future TBI; a follow-up appointment is given and a written summary of important points and plans are provided to the patient.

Management of common symptoms in MTBI is given in Table 15.2.

MEDICAL KNOWLEDGE

GOAL

Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and sociobehavioral sciences pertaining to the field of TBI, as well as the application of this knowledge to guide holistic patient care.

TABLE 15.2 Management of Symptoms Common in MTBI

SYMPTOMS	KEY INFORMATION AND NONPHARMACOLOGY MANAGEMENT	PHARMACOLOGICAL MANAGEMENT
Headache	Treatment is based on type of headaches (migraine vs. tension vs. mixed) Treat contributory comorbid sleep, mental health disorders. Educate patient on avoiding triggers. Nonpharmacological treatment includes: Relaxation, biofeedback, visualization, extracranial pressure, and cold compresses. Regular exercise, maintaining regular sleep, and meal. Patients with episodic tension-type headache may also benefit from physical therapy to exercise neck muscles.	Abortive medications should be taken at onset of headache Nonnarcotic pain medication NSAIDs (e.g., ibuprofen and naproxen) Triptans (for migraines) NSAIDs such as aspirin, ibuprofen, or choline-magnesium-trisalicylate and acetaminophen are the first-line medications for treating tension headaches Combination medications (aspirin, acetaminophen, or both are often combined with caffeine or a sedative drug) in a single medication can be effective in treating episodic tension headache, but persistent usage can lead to rebound headaches Prophylactic medications are indicated for migraines occurring more than once a week or tension-type headache occurring more than 3 times a week. For headache that is disabling despite aggressive acute interventions; if the patient desires to reduce frequency of acute attacks; or when headaches compromise work attendance, societal integration, or daily life: divalproex, topiramate, and metoprolol are first-line headache prophylactic agents.
Musculoskeletal pain	May involve both pharmacological and nonpharmacological treatment such as physical therapy and modalities such as cold/heat, Transcutaneous electrical nerve stimulation (TENS)	Avoid use of narcotics as this can be detrimental to cognitive recovery
Insomnia/sleep dysfunction	Goal is to establish a regular, unbroken, nighttime sleep pattern and to improve perceptions of the quality of sleep Educate on sleep hygiene, establishing regular sleep routine, limiting caffeine and alcohol before bedtime Refer to sleep specialist to treat concurrent primary sleep disorder (e.g., sleep apnea, restless leg syndrome, or narcolepsy) if present Consider training patient in behavioral techniques, such as relaxation training or meditation; this may improve the quality of sleep	Nonbenzodiazepene sleep medications such as trazodone may be helpful in the short term Prazosin may be helpful in patients with nightmares
Cognitive impairments	Referral to speech and language pathology for compensatory memory strategies and memory aids may be indicated Screen for comorbid medical and psychiatric conditions such as PTSD that may be contributing to memory problems and determine if the psychiatric contribution is significant; this may need to be treated first before referring for speech and language therapy Patients with problems obtaining or maintaining employment may benefit from referral to vocational rehabilitation
Dizziness and disequilibrium disorders	May be secondary to inner ear disorders (peripheral vestibular disorders), central nervous system disorders, psychological disorders, and musculoskeletal disorders Perform a detailed medication review and ask about the temporal relationship of dizziness to the initiation or dosing of these medications; If possible, discontinue offending medication Management depends on etiology and may include pharmacological and nonpharmacological treatment; it may also include referral to physical therapy for vestibular rehabilitation and/or referral to Ear, Nose and Throat specialist; referral to neurology ophthalmology, vision rehabilitation	Medications should only be considered if symptoms are severe enough to significantly limit functional activities Trials should be limited to 2 weeks. First-line medication choice would be meclizine, followed by scopolamine and dimenhydrinate, depending upon symptom presentation
Comorbid depression/anxiety/PTSD	Assess suicidal/homicidal ideations Refer to mental health	First-line antidepressant is SSRIs such as citalopram and sertraline

OBJECTIVES

1. Discuss the following as they relate to MTBI: (a) epidemiology, (b) pathophysiology, (c) diagnostic test and criteria, (d) special patient population, (e) treatment approach, and (f) ethical issues.

EPIDEMIOLOGY

Traumatic brain injury (TBI) can be defined as brain dysfunction caused by external mechanical force to the brain. The external force may be due to contact, penetration, and/or acceleration/deceleration forces. It is an important public health problem in the United States, affecting approximately 1.7 million people annually and leading to a substantial number of cases of death and disability (5). TBI most commonly affects children between 0 and 4 years, adolescents 15 and 19 years, and adults over the age of 65. TBI is more common in males than in females in all affected age groups. In the civilian population, fall is the leading cause of TBI and motor vehicle/traffic injury is the second-leading cause of TBI, although it is the leading cause of TBI-related deaths. Approximately 80% of the total incidence of TBI is classified as MTBI (6). MTBIs cost the nation nearly $17 billion each year.

DIAGNOSTIC CRITERIA FOR MTBI

In this chapter, we will use the most commonly used criteria of MTBI as set forth by the Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine (ACRM) (7).

According to these criteria, a patient with MTBI is a person who has had a traumatically induced physiological disruption of brain function as manifested by at least one of the following:

1. Any period of loss of consciousness (LOC)

2. Any loss of memory for events immediately before or after the accident

3. Any alteration in mental state at the time of the accident

4. Focal neurological deficits that may or may not be transient

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