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Industry: Email Alert RSS FeedMild traumatic brain injury in persons with multiple trauma: the problem of delayed diagnosis
Journal of Rehabilitation, Jan-March, 1997 by Andrea D. Clements
This individual, though being treated by multiple physicians, having his case managed by a psychiatrist, and receiving worker's compensation benefits with all of the accompanying analyses, had an undetected brain injury for almost four years. Treatment had focused on surgical repair of orthopedic injuries, and management of pain. His treating psychiatrist, who monitored all of his medications, was primarily focusing on pain, post traumatic stress disorder (PISD), and depression to the exclusion of other related symptoms of MTBI including headaches, angry outbursts, and extreme forgetfulness to the point that he would repeatedly ask the same question throughout a day. When combined with the symptoms of lethargy and tearfulness which were presumed to be due to depression, one has the primary constellation of symptoms found in MTBI. Because this man did not strike his head during his fall, brain injury was not investigated, but a fall from a height of 25-30 feet would be the equivalent of coming to an abrupt stop while traveling approximately 22 miles per hour. It is known that nonimpact brain injury can result from acceleration and deceleration forces, and can result in more severe damage than a direct blow to the head (Bigler, 1987; Sweeney, 1992).
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In reviewing case materials, it was noted that this individual's intellectual functioning was well below average prior to injury, and this may have served to mask symptoms, such as the typical loss of intellectual functioning (Cullum et al., 1990). It is difficult to say if the course of recovery after the MTBI followed that predicted by previous studies due to a lack of repeat testing, but he still had substantial deficits after a 3 year 8 month recovery period.
Discussion
All of these men showed classical symptoms of MTBI, yet none was diagnosed before six months post injury. Two were diagnosed much later. One explanation for this is that orthopedic and tissue injuries are more visible, more easily diagnosed, and more easily treated. This encourages an emphasis on these types of injuries, resulting in less emphasis on cognitive and behavioral changes. None of these three individuals lost consciousness when they were injured. Had they, screening for TBI would most likely have been performed.
Another related explanation is that most physicians only come in contact with a traumatically injured person at or after the time of injury, and do not have knowledge of premorbid characteristics, which is essential in the diagnosis of MTBI. This author found that asking family members about changes in the person is a better preliminary screen for MTBI than questions asked of the patient. Examples would be to ask a spouse "Does your spouse cry more often than before the injury?" "Is your spouse more forgetful than before the injury?" or "Have your spouse's moods changed since the injury?" Typically if the spouse's response to these and similar questions is emphatic, the neuropsychological assessment will confirm the presence of MTBI. Follow up with a complete neuropsychological assessment is imperative to verify the presence of MTBI.
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