Repetitive Head Injury Syndrome David Cifu, MD, eMedicine.com (page 4 of 8) Page 4 of 8

Treatment

Acute Phase

Rehabilitation Program
Physical Therapy
The goal of all therapy is to maximize the patient's strength and functional independence.

Athletes who have had severe head injuries may require rehabilitation for a prolonged period. In most patients, mild brain injuries do not require extensive rehabilitation, but they do require focal medical and rehabilitation care based on the individual's clinical evaluation and diagnostic test results.

Physical therapy is helpful in patients with increased tone, motor deficits, or mobility problems after a brain injury. Range-of-motion exercises are helpful in managing spasticity and preventing contractures.

Occupational Therapy
Occupational therapy is helpful in patients with brain injuries who may have motor and/or cognitive processing deficits and who may need to improve their ability to perform activities of daily living. The use of assistive devices can also be addressed.

Speech Therapy
Speech therapy is often useful in detecting subtle changes in the patient's thought processes and speech patterns. A speech therapist can help a patient with brain injury overcome barriers related to these changes.

Recreational Therapy
Recreational therapy is helpful in achieving community reintegration of the patient. Neuropsychologic measures may be good indicators of residual injury, and repeated testing may reveal when the athlete reaches a plateau.

Medical Issues/Complications

Medical issues in patients with brain injuries include the following:

• Homeostatic abnormalities: Loss of autonomic control of blood pressure or respiration and cardiac abnormalities may occur.
• Endocrine abnormalities: The syndrome of inappropriate antidiuretic hormone (SIADH) and diabetes insipidus are common problems.
• Behavioral issues: The patient may become uninhibited, impulsive, or agitated. Aggressive treatment with behavioral programs, counseling, and short-term medication usage is most effective. Medication usage (mood stabilizers, atypical antipsychotics) should be instituted carefully and with full knowledge of the indicators of clinical success, duration of treatment, and potential adverse effects.
• Deep venous thrombosis: Cifu et al showed that approximately 20% of patients admitted to a brain-injury rehabilitation unit had deep venous thrombosis.²⁸
• Pulmonary embolus: This is a rare condition, but if it is suspected, emergent treatment is indicated.
• Complications of severe brain injury: Brainstem herniation, rebleeding, and death may occur.

Minor issues in patients with brain injuries include the following:

• Dizziness: Most commonly, this is due to limitations in neck movement (pain) and peripheral trauma to the vestibular/labyrinthine system. Rarely, it is due to injury to the brainstem (central) balance coordinating structures. Dizziness is treated with medications and therapy.
• Insomnia: This is commonly related to issues of pain, dizziness, behavioral problems, nightmares/flashbacks, altered physical activity levels, or idiopathic reasons. Insomnia is best treated with a rapid return to activity, treatment of secondary issues, and short-term nonaddictive sleep aides.
• Behavioral issues: Behavior may vary from excessive (see above) or depressed. Normalizing sleep-wake cycles, controlling pain, reactivating physical skills, and reassurance help most individuals. Individualized psychotherapy is also highly effective.
• Photophobia/hyperacusis: These conditions are rarely significant long-term issues. They should be treated aggressively initially with dark glasses/white-noise generators and then a rapid weaning program. Sustained difficulties may suggest an undetected injury or secondary psychologic issues.

Surgical Intervention

Evacuation is required for epidural hematomas, significant subdural hematomas, and large intracerebral hematomas that cause mass effect. Ventriculostomy may be required for significant edema and/or possible herniation.

Recovery Phase

Rehabilitation Program

Physical Therapy
In the case of a severe head injury, many of the aforementioned therapies can be continued in an outpatient setting, but most of the rehabilitation process is focused on reintegrating patients with brain injuries into their home environment and community.

Maintenance Phase

Rehabilitation Program

Physical Therapy
Patients with TBI may require educational or neuropsychologic support for an extended period, depending on the severity of the head injury.

Occupational Therapy
See Acute Phase, Rehabilitation Program, Occupational Therapy.

Speech Therapy
See Acute Phase, Rehabilitation Program, Speech Therapy.

Recreational Therapy
See Acute Phase, Rehabilitation Program, Recreational Therapy.

Medication

Care should be used when instituting therapy with medications that potentially have sedating effects, because sedation may complicate the monitoring of a patient with a brain injury. Some medications that can have significant sedating effects on such patients include H2 blockers (eg, ranitidine, famotidine), diphenhydramine, narcotic pain relievers, nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, antipsychotics, and seizure medications.

Some medications may improve the patient's focus and alertness. A few of these medications are discussed below. In addition to the agents that may enhance thinking skills, aggressive management of specific symptoms is also warranted, including insomnia (trazodone), headaches (butalbital, aspirin, and caffeine [Fiorinal]; isometheptene mucate, dichloralphenazone, and acetaminophen [Midrin]; acetaminophen; NSAIDs; local agents), dizziness (meclizine, buspirone, vestibular programs, liberatory technique), and depression (cognitive behavioral therapy, selective serotonin reuptake inhibitors [SSRIs]).

From eMedicine.com. Reprinted with permission. www.emedicine.com/sports/TOPIC113.HTM.

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