Assisting Patients with Traumatic Brain Injury: A Brief Guide for Primary Care Physicians Margaret A. Struchen, Ph.D. 1,2 Lynne C. Davis, Ph.D. 1,2 Stephen R. McCauley, Ph.D. 1 1 Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 2 Brain Injury Research Center, TIRR Memorial Hermann, Houston, TX
A TBI occurs when an outside mechanical force is applied to the head and affects brain functioning.
The physical force can consist of a blow to the head (such as from an assault, a fall, or when an individual strikes his/her head during a motor vehicle accident) or a rapid acceleration-deceleration event (like a motor vehicle accident).
It is possible for the brain to become injured even if the head has not directly struck or been struck by another object.
The brain can become injured whether or not the skull is fractured.
Intracranial hypertension : most common cause of death from TBI from those surviving initial injury due to brainstem herniation compromising vital functions. 4 Compression effects and/or ischemic injury secondary to intracranial hypertension can cause further impairment for those who survive.
Brain shift : Pressure effects from bleeds, edema can cause mass effect or brain shift leading to additional damage to brain tissue.
Biochemical processes : that occur as part of the body’s response to injury can cause additional cell death and therefore, poorer functional outcome.
Brain swelling : can occur due to increased cerebral blood volume or cerebral edema. Swelling may be localized adjacent to contusions, diffuse within a cerebral hemisphere, or diffuse throughout both hemispheres.
Cerebral ischemia : can occur even without increased intracranial pressure and may relate to vascular disruption and vasospasm.
Most acute hospital care is focused on limiting or eliminating secondary injury to the brain by:
Level of severity can be related to many variables, including the amount of force involved and the speed at which the head or object was moving at the time of injury.
Injury severity classification labels refer to the initial injury, not to the eventual outcome (i.e., a person with a severe injury may have a good outcome, a person with a mild injury may have a poor outcome).
Typically, initial injuries with greater severity are associated with poorer outcomes.
Injury severity classification assist with initial triaging.
After TBI, common for persons to be confused or disoriented for a period of time after injury. The ability to remember information during this time is affected. In general, the longer the period of post-traumatic confusion, the more severe the injury.
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If so, accompanied by loss of consciousness (LOC), confusion, or memory disturbance?
Obtain details of any hospital treatment, neuroimaging studies, brain-injury related surgeries, and rehabilitation services.
If patient has had head injury but no LOC, confusion, or memory problems, it is unlikely that a TBI has occurred. If head injury is accompanied by these problems, it is likely that a TBI has occurred. Query to determine severity of injury.
Although secondary gain (e.g., participation in litigation or receiving insurance or other compensation after injury) is often a concern, studies have found that a large percentage of those with persisting PCS symptoms have no such incentive – so do not automatically assume that secondary gain is the root cause of your patient’s symptoms. 3-4
Chronic symptom presentation in patients with an initial uncomplicated mild TBI is likely multifactorial (physical, psychological and environmental).
Careful identification of factors and referral to those experienced in these issues (e.g., physiatrists, neuropsychologists, and the like) will be important to the management of these patients.
Assessment of suicidality in patients with TBI is important as regular part of your evaluation of mood in these patients. Persons with TBI and depression are at greater risk for suicide relative to those with depression and no history of TBI. 23-25
Strongest predictors of suicide attempts in patients with TBI are:
Increased feelings of hostility/aggression 23
Substance use 25
Patients who are post-TBI with co-morbid diagnoses of mood disorder and substance abuse were at 21 times higher odds of suicide attempts than persons without TBI. 26
Diagnosis of PTSD in patients with TBI is controversial since concern over whether patients with no memory of circumstances around the traumatic event could develop features and meet criteria for PTSD (frequent re-experiencing of event unlikely to occur).
Discussion of these is beyond scope of this podcast, but convincing evidence that PTSD can develop in patient with TBI severe enough to result in period of amnesia surrounding traumatic event.
During acute recovery from severe TBI, patients may experience agitated behavior and as much as 33% may exhibit aggression and/or agitation at 6 months post-injury. 36
A high percentage of patients with severe TBI (anywhere from 31-71%) report increased irritability, aggression, or agitated behavior over the long term. Also occurs in those with mild and moderate TBI, however. 37
Pre-injury history of poor social functioning, substance abuse, and presence of major depression significantly correlated with aggressive behavior in persons with TBI. 38
Problems with sexual functioning and/or intimacy issues are not uncommon among persons with TBI.
Although typically not addressed during medical appointments, including a standard question or questions about sexual functioning may be important (especially if other factors such as prescription medications or depression may impact sexual functioning).
Although alcohol and substance use/abuse often declines in the near-term following TBI, longer-term follow-up studies suggest that use (of alcohol in particular) increases to pre-injury levels over time.
Approximately 15-25% of persons with TBI who were abstinent or light drinkers prior to injury may become heavy drinkers after injury. 55
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Your patient with TBI may benefit from referral to specialized healthcare providers and/or TBI-related resources. Here are some resources that you may find helpful in working with your patient with TBI:
Physiatrist: physician specializing in rehabilitation of neurological conditions like TBI, stroke, and spinal cord injury. Such physicians also treat musculoskeletal injuries, pain syndromes, and sports injuries. Other physician specialists who may be helpful for your patient with TBI include: behavioral neurologists, neurorehabilitation specialists, and neuropsychiatrists/
Neuropsychologists: clinical psychologists with advanced training in brain-behavior relationships. They specialize in the assessment of cognitive functioning and may provide specification of your patient’s cognitive strengths and weaknesses, along with recommendations for interventions and referrals.
Speech language pathologists: specialize in assessment, diagnosis, and treatment of language and cognitive communication disorders. They also evaluate and treat swallowing problems.
Occupational therapists: work with patients to maximize performance of activities of daily living (e.g., dressing, grooming, bathing, feeding, etc.)
Physical therapists: work with patients to improve their ability to move and function within their environment and to restore fitness and health.
Your patient with TBI and his or her family may also benefit from referral to state and nationally-run resources that may provide information and assistance. Examples include:
Brain Injury Association of America: leading organization servicing and advocating for persons with TBI and their families. A network of 40 state affiliates and hundreds of local chapters provide information, education, and support.
North American Brain Injury Society: organization composed of professionals involved in care of those with brain injury. Provides educational programs and scientific updates to all those interested.
Vocational Services: Each state agency provides funding to assist patients in searching for employment, obtaining job training, and providing support for services to facilitate return to work.