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Is it Just a Bump on the Head?
Hints to recognize, evaluate and treat
Minor Traumatic Brain injury
by Karl D. Jones, M.D., P.A.
Dr. Jones is an attending physician
for Windmoor of Clearwater.
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INTRODUCTION
There has been gross neglect in the recognition, diagnosis and treatment associated with minor head trauma. During the course of evaluation these people usually appear to function normally until they attempt to resume their responsibilities at home, work, or school. The minor head injured person begins to complain of difficulty with concentration, memory, organization and handling of tasks that they had previously been able to perform efficiently. Spouses, family members, peers, co-workers begin to feel perplexed at the onset of behavioral and psychological changes that appear psychiatric in nature. Though there is no obvious neurological basis for the problem it is apparent that these persons experience significant cognitive, emotional and behavioral deficits that seriously interfere with their ability to lead full functional lives.
Yearly there are 3 million traumatic brain injuries. Psychosocial and psychological deficits are a source of disability to these patients and become a severe stress to themselves and their families.
THE NATURE OF MINOR HEAD INJURY
Minor Head Injury is considered to be:
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1.
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Trauma in which the head is struck or moves violently resulting in a transient alteration of consciousness.
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2.
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The trauma may be a blow, a fall, the head striking a stationary object or a severe whip lash even if the head is not struck.
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3.
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There may be brief loss of consciousness or no loss of consciousness.
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The most common form of minor traumatic brain injury is concussion.
CONSEQUENCES OF MINOR HEAD INJURY
There becomes obvious difficulty in vital areas of functioning such as:
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1.
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Work
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2.
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Family
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3.
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School
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4.
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Interpersonal Relationships
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5.
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Recreational Activities
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Unfortunately, the psychiatric impairments go unrecognized due to a lack of experience in evaluation and treatment by clinicians, therefore, many subtle but disabling symptoms go unnoticed. There has been no single source or evaluation tool which provides assessment and/or treatment of psychiatric syndromes associated with mild traumatic brain injury.
HELPFUL HINTS TO RECOGNIZE
MINOR TRAUMATIC BRAIN INJURY AND
ASSOCIATED SYNDROMES
ASSESSMENT
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Glascow Coma Scale
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Range 8 - 15
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Time of Unconsciousness
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0 - 60 seconds
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AREAS OF IMPAIRMENT
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1. General Intelligence
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- Mild
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2. Language
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- Mild
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3. Learning and Memory
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- Moderate
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4. Motor Skills
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- Significant
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5. Spatial Skills
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- Significant
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6. Complex Attention
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- Significant
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7. Integrative and Abstract Thinking
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- Moderate
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PSYCHIATRIC SYNDROMES ASSOCIATED WITH
TRAUMATIC BRAIN INJURY
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1.
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Depression
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2.
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Anxiety
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3.
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Psychosis
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4.
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Panic Anxiety
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5.
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Mania
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6.
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Dementia-like syndrome
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7.
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Phobias
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8.
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PTSD
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9.
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Personality changes and behavioral changes
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RISK FACTORS
Age:
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There is a higher degree of minor traumatic brain injuries between the age of 15 and 24. During middle age, there is a noted decline until the age of 60 where again the risk of minor traumatic brain injury increases due to increase risks attributed to aging such as visual changes, decline in muscle mass, sensory changes, illness, and the resultant changes in physical condition related to the aging process.
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Sex:
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There is a higher risk of minor traumatic brain injuries in the male population.
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Race:
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No determination or risk factors.
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Alcohol Use:
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Increases the risk of minor traumatic train injury significantly.
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Socioeconomic
Status:
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There is an increase risk of traumatic brain injury in the lowest income levels.
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RISK EXPOSURE
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1.
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Transportation*
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2.
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Falls*
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3.
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Sports
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* Minor Traumatic Brain injury is often overlooked in work related injuries.
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NEUROBEHAVIORAL SYMPTOMS
- in mild traumatic brain injury
COGNITIVE SYMPTOMS
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1.
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Changes in concentration
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2.
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Forgetfulness
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3.
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Difficulty assimilating information
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BEHAVIORAL CHANGES
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1.
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Anger
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2.
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Impulsivity
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3.
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Demonstrating change in behaviors
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Behaviors may become very obviously out of character for the person who has experienced a minor traumatic head injury, which may place them at risk during and after the recovery period.
EMOTIONAL CHANGES
OTHER COMPLAINTS WHICH OFTEN ARE
MISTAKEN FOR MALINGERING
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Headaches
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Fatigue
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Dizziness
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Changes in senses, hearing, vision
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Insomnia
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Restlessness
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Irritability
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LAY DESCRIPTIONS WHICH MAY BE PROVIDED TO
CLINICIANS AND MISSED IN MONOR TRAUMATIC
BRAIN INJURIES
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1.
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"I can't seem to get anything done anymore."
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2.
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"I go into a room and don't remember what I went for."
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3.
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"I get lost in traffic."
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4.
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"My work performance has declined."
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5.
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"I can't work with numbers as well as I did before."
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6.
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"I can't balance my checkbook."
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7.
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"I feel lost."
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8.
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"My family says my mood has changed."
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9.
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"I get angry with the people around me."
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10.
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"My life has not been the same since my accident."
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The are only a few examples of comments that might be provided during the course of taking a thorough history from the patient or may also be part of an explanation provided by a spouse or someone who has been familiar with the person who has experienced a mild traumatic brain injury.
DIAGNOSTIC TOOLS
Neuropsychiatric testing
Neuropsychiatric testing is probably the most non-evasive diagnostic tool to use for diagnosis of mild traumatic brain injury. Unfortunately this is usually not performed for a number of reasons. This testing is not utilized as intensely as it should, it is costly, and even certainly in the emergence of managed care, approval for this testing would be limited.
In the course of Neuropsychiatric testing premorbid factors should be considered and the end evaluation should be considered in the premorbid and post traumatic brain injury.
Areas that should be considered:
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Obtain school functioning/grade level/educational level.
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2.
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Estimate based on reading skills and vocabulary as these singly may be less affected by mild brain injury.
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3.
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Occupation, pre and post traumatic brain injury.
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X-rays
Radiologic imaging can certainly identify those injuries such as skull fractures. Further testing may include CT Scans or MRI's of the brain. Repeat scans may be necessary if initial scans are negative. Scans should be repeated if neurological symptoms persist or if signs of decompensation persist following a minor traumatic closed head injury. It is important to note that these radiological studies may remain negative throughout the whole process.
EEG
The benefit of an EEG especially in mild traumatic brain injury is very limited.
OK, So What is Executive Functioning?
Probably 9 out of 10 clinicians cannot tell you what Executive Functioning is, so no wonder we cannot put the pieces together. Persons at all levels practice executive functioning. Simply, being able to rise every day and have some idea as to where the end of the day is going to take you. This may be a good "lay" description. In more precise terms, executive functioning is:
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Goal Formulation
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2.
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Planning
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3.
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Carrying out goal directed plans
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4.
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Effective performance
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Executive functioning in itself may be a most obvious factor in diagnosing a minor traumatic brain injury when discovery of information is evaluated in a systematic, careful evaluation.
Evaluation of a patient's ability to sequence
Sequencing may be the most significantly affected behavior in a minor brain injury. The Wisconsin Card Sorting Test is a most useful measure here. Memorization test can help to alert the examiner to possible malingering or resultant consequence of a minor brain injury.
THE BEST TREATMENT
The best treatment for minor traumatic brain injuries is identification, with early treatment.
Education of the injured person and their family.
Support from family, friends, therapist, physicians.
Use and provision of ancillary services.
Therapy - Neuropsychological Rehab
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Identify limitations
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2.
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Develop alternative strategies
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3.
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Conditioning of new behaviors
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4.
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Implement environmental changes
(environmental engineering)
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5.
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Stress management
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6.
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A process of accommodation such that the person recognized, accepts and adjusts to a new set of limitations.
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7.
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Seek clinicians who are familiar with treatment and diagnosing of minor traumatic brain injury.
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Therapy - Neuropsychological Rehab
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1.
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Depression
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2.
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Anxiety
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3.
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Psychosis
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Holistic intervention should not be discounted such as:
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1.
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Vitamin therapies
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2.
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The use of antioxidants
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3.
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Herbal remedies
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4.
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Learning of relaxation techniques
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5.
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Use of medication
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6.
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Massage Therapies/Cranial Sacral massages
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As in any recommendation, these treatments should be explored with knowledgeable, competent clinicians who are familiar in these areas. This treatment choice should be left to the decision of the patient and/or family members/caregivers.
OUTCOMES
The outcomes of such an elusive event as minor traumatic brain injury can be:
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FUNCTIONAL OUTCOMES
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The person may experience a complete recovery.
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The cognitive impairment may persist but the injured person may succeed in recognizing and understanding the nature of the deficits.
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The injured person can live and work in a manner that is not seriously disrupted by the impairment.
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The injured person spontaneously compensates for the deficits by making common sense changes.
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2.
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DYSFUNCTIONAL OUTCOMES
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Nothing is wrong and if there is, nothing can be done about it.
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A message of failure leads to the reality of significant failure seen in overachievers and those whose self esteem is tied to observable achievement.
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Self blame, guilt, failure breeds depression.
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Not being able to meet expectations of others or to express the devastating nature of their internal turmoil and often leads to the feeling of "going crazy."
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Finally, as one can see the subtleness of the results of minor traumatic brain injury can lead to devastation of the injured persons life, especially in the significant areas of his daily living. The cost of this event is staggering financially, emotionally and socially. We have yet a lot of work to do to conquer this problem and alleviate the emotional pain and suffering for all those involved.
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