Rehabilitation Considerations Following Mild Traumatic Brain Injury

Journal of Rehabilitation,  Oct-Dec, 1998  by Robert J. Fabiano,  Julie Daugherty

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Traumatic brain injury encompasses a variety of conditions caused by an external mechanical force to the head resulting in damage to brain tissue. Mild traumatic brain injury refers to head trauma without loss of consciousness or with a loss of consciousness lasting less than 20 minutes (Gasquoine, 1997; Miller, 1996). Post-concussional syndrome is a term often used interchangeably with mild traumatic brain injury and refers to the array of cognitive, psychosocial, and behavioral manifestations associated with pathophysiological changes involved with traumatic brain injury.

Although the overall incidence of traumatic brain injury is difficult to determine, perhaps as many as 7-10 million new cases of traumatic brain injury are reported each year (Berker, 1996: Conboy, Barth, & Boll, 1986). Mild injuries constitute the largest portion of traumatic brain injuries (Krauss et al., 1984). Males represent 65-75% of those injured and 70% of injuries occur to persons under 30 years of age (Krauss & Nourjah, 1988; Vogenthaler, 1987).

Total costs for new cases of hospitalized traumatic brain injury in a given year in the United States have been estimated to exceed $8 billion over the course of the first four years following injury (Brooks, Lindstrom, McCray, & Whiteneck, 1995). While the majority of those who have incurred mild traumatic brain injuries will return to work, one-third will experience considerable difficulty, resulting in reduced productivity, frequent job changes, and lowered levels of responsibility that often culminate in considerable costs to businesses (Gamboa, 1994; McMahon & Flowers, 1987). According to the National Brain Injury Foundation, the economic costs associated with traumatic brain injury may be as high as $25 billion per year across the United States.

One way to begin to reduce these staggering costs is for rehabilitation professionals to improve their understanding of and ability to efficiently rehabilitate persons with traumatic brain injuries. Delayed diagnosis can result in a greater exacerbation of symptoms due to the development of psychological problems (Clements, 1997). The purpose of this article is to provide an overview of rehabilitation following mild traumatic brain injury. Emphasis is placed on the contributions of neuropsychological assessment to the rehabilitation process, the types of rehabilitation services that can be usefully employed for persons with mild traumatic brain injury, and the critical role of vocational rehabilitation.

Definition and Clinical Features

Mild traumatic brain injuries occur when the head is struck or moves abruptly and violently, resulting in an alteration in consciousness. A loss of consciousness is not imperative and it is well documented that severe complications can occur in the absence of coma (Jennett, 1976; Binder, 1986; Berker, 1996). Due to the fact that individuals are often not rendered unconscious, or if so, only briefly, and in the absence of other medical complications, the majority of these individuals are not hospitalized and are usually discharged from emergency rooms. Strauss and Savitsky (1934) coined the term "post-concussion syndrome" to represent the notion of cerebral concussion in the absence of a loss of consciousness. Their work recognized the complex interplay between brain injury, premorbid personality, the desire for compensation, and the great stress involved in dealing with a medical and legal system that treated many of these patients as less than honest (Miller, 1996).

Issues related to organicity, financial gain, and emotional overlay continue to provide the primary areas of differential diagnosis and controversy today. Causes of mild traumatic brain injury include falls, a blow to the head, or most commonly, the head striking a stationary object, such as in a motor vehicle accident. Additionally, mild traumatic brain injury may also occur after severe whiplash injury, even if the head is not struck and especially if the whiplash involves some rotation of the head in addition to linear movements (Sweeney, 1992).

Acute symptoms associated with concussions include: brief alterations in orientation; headaches; dizziness; vertigo; nausea: blurred vision; imbalance; and reductions in attention, concentration, and memory. Symptoms occurring later may include irritability, anxiety, and depression, and are often associated with, if not confounded by, considerable social and economic morbidity. What is now commonly understood and documented is that a significant number of these individuals will have continued symptoms well beyond the first several days from the time of the accident (Alves, Macciocchi, & Barth, 1993; Dikmen, Machamer, Winn, & Temkin, 1995). Reductions in cognitive functions including attention, concentration, memory, mental speed, and higher level problem solving are frequently reported (Gasquoine, 1997; McGrath, 1997). Attentional processes, often impaired following mild traumatic brain injuries, permeate all aspects of behavior, often resulting in functional limitations (Wood, 1987). Many of the cognitive signs of mild head injury are nonspecific and may fall into the categories of what have been referred to as disorders of executive functioning (Posthuma & Wild, 1988). These include the capacity for planning and organization, problem-solving skills, mental flexibility, abstract reasoning, initiation, motivation, and regulation of behavior. Alterations in mood, including irritability, anxiety, and depression, are frequent sequelae of mild traumatic brain injury. Symptoms of depression are often observed in survivors of mild traumatic brain injury who had no previous history. Advancing research suggests that depression may result from neurochemical changes following traumatic brain injuries in addition to psychological reactions (Jorge, Robinson, Aundt, Forrester, Geisler, & Starkstein, 1993; Dixon, Taft & Hayes, 1993). Finally, physiologic changes, including disruption in sleep, headaches, imbalance, and fatigue, contribute to the overall level of debilitation that can occur following concussions.