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Mild traumatic brain injury in persons with multiple trauma: the problem of delayed diagnosis

Journal of Rehabilitation, Jan-March, 1997 by Andrea D. Clements

With all that is currently known about symptoms that indicate mild traumatic brain injury (MTBI), it is unfortunate that many individuals go undiagnosed for long periods of time after sustaining such an injury. As noted by Zasler (1993), MTBI is poorly understood and often under diagnosed or misdiagnosed by health care professionals. The stereotypical constellation of symptoms produced by MTBI includes memory difficulties, problems with attention and concentration, lethargy, sleep disturbance, irritability, depression, headaches (Alves, Macciocchi, & Barth, 1993; Bigler, 1990; Cullum, Kuck, & Ruff, 1990; Gennarelli, 1986; Kwentus, Hart, Peck, & Kornstein, 1985), speed of processing information (Kay, Newman, Cavallo, Ezrachi, & Resnick, 1992), and sometimes seizures (Brown, Fann, & Grant, 1994; Verduyn, 1992). Each of these could be attributed to other causes, and in the face of multiple traumatic injuries, may be overlooked as symptoms which, when combined, are indicative of MTBI.

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Memory, attention deficits, and speed of processing information have been identified as some of the longer lasting and more pervasive neuropsychological symptoms seen in head injured adults (Kay et al., 1994; Telzrow, 1990), though psychomotor slowing and seizures present further functional problems such as danger of additional injuries and the inability to drive (Brown et al., 1994; Cullum et al., 1990; Verduyn, 1992). The presence of emotional, behavioral, and personality change after head injury has been recognized since at least 1942. Although there is some question as to whether these symptoms are based in physiology or are a product of psychological reaction to the injury, they are often much more seriously handicapping than residual cognitive and physical disabilities (Cullum et al., 1990; Lezak & O'Brien, 1990). Yet even in individuals who show many or all of these symptoms, a diagnosis may not be made until several months, or even several years after the initial injury.

When MTBI is suspected, "(a)ll too often, global indices such as intelligence test scores are used to presumably (yet inadequately) gauge the severity of [an individual's] deficits..." (Cullum et al., 1990, p. 134). Although seventeen studies of intellectual recovery consistently found a decrease in overall intellectual test performance in the early stages of recovery, most individuals showed improvement after two to three years, with many returning to near premorbid levels on global IQ. If intelligence is found to be at or near the premorbid level, uninformed professionals might rule out MTBI. Deficits can also be masked if the person was intellectually high functioning premorbidly (Cullum et al., 1990). Deficits in higher cognitive functions can occur in the face of relatively normal performance on other more basic tasks (Cullum et al., 1990), explaining the improvement in intelligence tests scores without a comparable improvement in function. Wood (1987) showed that attention, which is often impaired by MTBI, is more important than intelligence (measured by IQ) during the learning of a simple discrimination task, and suggests that attention permeates all aspects of behavior. This helps to clarify why functional deficits continue in the face of intellectual recovery. Deficits in attention are particularly serious because there is little evidence for success of attention training procedures (Bigler, 1990).

The purpose in studying the following three cases was to describe the process of arriving at the diagnosis of MTBI in persons with multiple traumatic injuries, and the constellation of symptoms present in each case. The difficulty of and delay in establishing the presence of MTBI in persons with multiple traumatic injuries is apparent from these cases.

Method

Subjects

All three individuals involved in this study were married white males. One was in his early thirties and the other two in their mid-forties. One was injured in an industrial accident, and the other two in motor vehicle accidents. One was diagnosed with MTBI six months post injury, one was diagnosed 1 year 8 months post injury, and the individual injured in the industrial accident was not diagnosed for almost four years. All were involved in litigation, and none had been gainfully employed since injury.

Instrumentation

A standard interview form was loosely followed in a clinical interview with each man and his wife, and follow up questioning was guided by the responses received. Exhaustive medical and psychological records were reviewed for each, and physicians were consulted by telephone, mail, or both.

Procedure

Medical and psychological records were reviewed for each person studied, and each was interviewed at least twice, at least one time with his wife present. Information was compiled over a six month to two year period in each case, and then retrieved from existing records for this study.

Results

Case 1

This 47 year old male subject, was injured in a motor vehicle accident in which he sustained multiple orthopedic injuries. Two months later he underwent treatment for previously undetected internal injuries. He did not undergo assessment for traumatic brain injury until six months post injury. This assessment was precipitated by symptoms including headaches, depression, forgetfulness, confusion, and emotional lability, and may have been delayed due to his other medical treatments. The assessment resulted in a diagnosis of MTBI, and cognitive retraining was begun. As noted by Telzrow (1990) little change in attention or concentration has been noted though this man was 2 years 9 months post injury at the time of this study.

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Mild traumatic brain injury in persons with multiple trauma: the problem of delayed diagnosis

Journal of Rehabilitation, Jan-March, 1997 by Andrea D. Clements

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