The Silent Epidemic: Mild Traumatic Brain Injury, Part 2: "Managment of MTBI"￾

This Telly award winning documentary presentation includes information on medical complications, optimizing recovery, patient and family education, and more.

New Mexico’s Aging and Long-Term Services Department with funding from the State of NM and the US Health Resources and Service Administration. Used with permission.

Transcript of this video.

Mild Traumatic Brain Injury There's a lot of controversy in mild traumatic brain injury, but I think that most everybody would agree that early intervention is the solution. I think those of us that have had the experience of following individuals with these mild but significant injuries is that we see they get--that they improve if we manage those symptoms properly. The sooner you can get in with a person after a concussion and follow them along, the better it's going to be in terms of outcome. Many times the outcome is good, and there's even a few studies that point to this, that truly educating people about what is going on with them at this particular time and giving them symptomatic relief goes a long way in showing a good outcome. I think the problem is when it is ignored, when it's just thought it is insignificant, and not attended to, then we have more difficulties. Education of persons with mild traumatic brain injury and of their caregivers is extremely important, because early education may help provide a buffer against some of the stress that they may experience later when they have symptoms and can't explain the reason. People do better when they have information about what happened and that the prognosis is good, that gradual, spontaneous recovery is what is expected. And if they don't have that improvement, then they need to stay in touch with you. Otherwise you see people years later, and some of the psychosocial and financial and relationship damage has been done already, and that's very hard to go back and correct after--let's say--5 years or 10 years. It's important you provide the service early. The Silent Epidemic The Silent Epidemic: Management of MTBI Role of PCP: Team Captain and Advocate Early identification is one essential component of good outcome. Once a patient has been diagnosed with having sustained a mild traumatic brain injury, favorable outcomes further depend on support, education, and the teamwork of caregivers. Primary care providers, family practice docs, I believe, really need to be involved in the ongoing care of people with traumatic brain injuries, particularly in mild traumatic brain injuries. The primary care physician is in a unique position in the care of these individuals because in many cases, you have been seeing these people for years before. So, first, you'll know whether there is a change, and hopefully the individual will see you as soon as possible after the injury. But then you can also see whether the symptoms are improving as expected or whether the person is starting to do worse. If you have someone with a mild traumatic brain injury and they're coming to you with a host of problems--physical, cognitive, emotional--I believe that the best way is a truly interdisciplinary approach. You have a physician that almost serves as sort of the team captain, sort of oversees everything and brings the different professionals together. The primary care provider plays an important role in the overall treatment of these individuals because they may be seeing a number of medical specialists. And the difficulty is when you have a number of medical specialists, they're on a number of different medications, and every doctor thinks that their medication is the important one. So it's very vital to have somebody who has an overview of what's going on to decide whether the medications can be prescribed together, what medications are necessary and what are not, and how the patient is doing overall. Sometimes family or general practitioners can find themselves in the difficult situation of getting contrary opinions from their specialists, particularly in the case of mild traumatic brain injury. So, neurologists may evaluate and say, "No, there's no evidence of brain injury," because they're looking at it in terms of more severe brain injury that would present on a CT scan or show definite neurologic signs. A neuropsychologist may say, "No, there is evidence of brain injury," because they're recording emotional symptoms that they attribute to the brain injury. The converse can occur, too. I mean--there are some neuropsychologists who tend to minimize the occurrence of mild brain injury, at least the occurrence of persistent effects, and some neurologists who are very sensitive to these issues. In any case, I think when a general practitioner or a family practice doc finds themselves in this situation, they may need to be the ones, as they frequently are, to really advocate for the patient. It's really important, I think, that the primary care physician recognize how much help they may need from a case management perspective and that the main contact, sometimes the only contact, that they have into the system is the-- their primary care physician. When someone sustains a mild traumatic brain injury--you know--for purposes of insurance compensation, workers' comp claims, what have you, as medical care providers, we need to document the injury and write good reports. That sounds sort of basic. I can't tell you how difficult it is for patients and families who are dealing with this injury just in terms of clinical recovery, and then they're battling with insurance providers on having some coverage of their time away or their damages related to this injury. If there is poor documentation in the medical record, it becomes very challenging for them to make a case for themselves. People with brain injury may not be--and often are not--as able to advocate for themselves because of the cognitive and emotional impairments that they have, the fatigue. So again, they depend on their physicians to write a good report-- you know--to be willing to support them with the insurance provider that this is, in fact, necessary care. I think it's important, again, to let insurance companies or anybody know that if someone is having problems--emotional, behavioral, cognitive, whatever it is-- following a traumatic brain injury, that you relate those problems to the traumatic brain injury. Best Paradigm of Care Treatment Overview Mild traumatic brain injury is sort of an interesting injury, because some people really fly right through recovery with no symptoms. They will sustain an injury, perhaps stay in the hospital overnight, and be asymptomatic. No headaches, no cognitive changes, and they do really very well. Another subset of individuals appears to be symptomatic from the moment they are injured. They have headaches. They're having trouble with confusion, forgetfulness, some emotional lability, and those folks seem to be at a higher risk for symptoms that persist beyond what we would call--sort of--an expected amount of time. What we counsel people is that if you are not symptom-free within 3 or 4 weeks, we really need to see you back. In the short term following a mild traumatic brain injury, I think it's important to let folks know that--you know--in the vast majority of cases symptoms simply resolve, particularly if you've only had one traumatic brain injury. It's a little different if you've had repeated concussions, which is another discussion. But in the vast majority, folks will simply just need to know, "I'm likely to get better." They need to be offered support. But if the symptoms persist--you know--more than a month, more than a couple of months, then it's time to start taking action. Individuals with mild, uncomplicated TBI typically show no evidence of damage on standard CT/MR imaging, and their recovery will tend to proceed quickly. The course of care and outcome following a mild traumatic brain injury is often more prolonged for those who have sustained a mild complicated TBI, which is evidenced by positive neuroimaging. It is important to note that individuals in either group may experience persistent symptoms following their injuries. Pre-injury history, family dynamics, stress, depression, alcohol or substance abuse, and other co-morbid disorders may interact with the brain injury to prolong recovery time and the need for ongoing management. If they had evidence of damage on neuroimaging, you would want to tell them that they could generally expect that they may be feeling back to normal in 3 to 6 months, but they could have a little bit of a prolonged course of recovery because of the abnormal neurological findings, and so you would want to get those people some extra assistance, maybe some cognitive rehabilitation or some community re-entry help. Whereas the persons with uncomplicated mild traumatic brain injury, you may be able to give them an hour of education about mild traumatic brain injury and what to expect, and that may help them understand when they're having some symptoms like memory difficulties, headaches, difficulty sleeping, slowed speed of processing. They'll at least be able to understand what's happening to them and expect that it will recover. There should be the management of the symptoms. If they have headache, what can we do to reduce the headache? If they have sleep disturbance, what can we do to reduce the sleep disturbance? If they are fatigued, what can we do to reduce the fatigue? In other words, it should be taken seriously that these are true changes that have to be monitored and managed. Having an objective way of monitoring and managing symptoms over time with the physician is crucial. To be able to monitor systematically: Are those symptoms getting better? Are they getting worse? What's happening? Are they staying the same? That--the reason that information is so helpful is that I've seen patients where I've done that--who are not athletes--but we've shown that their symptoms get better, and then suddenly they start to get worse. And ask, "What happened during that period of time?" And what they tell me can be highly informative about the etiology. You know--what maybe happened is that they've had alcohol at a party, and they're less tolerant for alcohol after a brain injury, and the symptoms get worse. It may tell me--they may say, "Well, I hate to admit it, but I had a fight with my wife that night and I didn't sleep very well." And now that's more environmental that is contributing to the increase of symptomatology. And having the patients work with you in a way in which you are both on the same page of looking at what the symptoms are and what are the causes. This is very helpful for patients to get an understanding, because one of the things you want to do with mild traumatic brain injury patients is you want to reduce their anxiety. You want them to understand what has happened to them, and you want them to understand the natural course, and you want to give them tools or methods to reduce the symptoms. And if you reduce their anxiety, if they are knowledgeable, they often do very, very well. There should be some documentation of their neuropsychologic functions fairly early and repeated neuropsychological testing to see if, in fact, they are showing improvement with time. One of the biggest complaints I get from patients and even more so from their family members and sometimes coworkers is that folks are just irritable. Failure to control those emotions, control that irritability is a major problem that needs to be addressed, oftentimes through a combination of supportive psychotherapy services, behavior management, and oftentimes medication management as well. Most visual symptoms following mild TBI such as intermittent blur, diplopia, or visual field field defects tend to resolve within a few days of injury. If such symptoms persist, they may be resolvable with the use of lenses, prisms, or vision rehabilitation. Chronic symptoms that impact reading speed may require more intense cognitive remediation. Once the person is stabilized, then you want to look at what are their residual vision disturbances and symptoms. Look at how it's impacting their quality of life, and then refer to a neuro-optometrist who is familiar with dealing with acquired brain injury and traumatic brain injury, and they will be able to assess the individual and then refer or recommend accordingly if rehabilitation is indicated. Two organizations that have a lot of experience with traumatic brain injury and vision problems would include the College of Optometrists in Vision Development and the Neuro-Optometric Rehabilitation Association. Patients after a traumatic brain injury may have several cognitive problems. They could be memory, could be concentration, could be speed of processing, or it could be higher functioning such as organizing and planning. Cognitive remediation will--is a type of therapy where the individual works with practitioner to help develop strategies to help compensate for things that they used to do automatically, whether it was keeping track of appointments and remembering things or being able to do complex tasks where they used to go from A to E without even thinking, it now has to be broken down into the separate steps. There is some experimental data that would suggest if you do that, if an individual could actively engage themselves either in cognitive activity or exercise activity, that that actually will up-regulate brain-derived neurotrophic factors, or factors in the brain. A lot of the times insurance companies will choose not to cover some of the treatments we believe are important because they are "experimental" or not proven, but we have actually fairly good evidence that cognitive therapy is effective, and there have been a number of good, systematic reviews on this topic that shows, in fact, cognitive remediation does help people deal with their cognitive difficulties and emotional difficulties after traumatic brain injury. Oftentimes you have to go the extra mile and appeal the decisions and appeal the decisions above and beyond the appeals in that one particular insurance company. We owe it to our patients to give them the treatment that they need, but the cognitive therapy that we can offer is oftentimes the most difficult thing to get covered. Medical Complications Medical complications associated with mild traumatic brain injury are fairly common. The main complications of concern are increasing bleeds within the brain, whether it's an epidural hematoma that usually presents within minutes to hours or an expanding subdural hematoma which can--you know--be days or weeks. Increased intracranial pressure, spinal fluid leaks, things like this--hopefully these diagnoses are made in the acute period where medical attention and neurosurgical evaluation is available. Other diagnoses such as seizures and post-traumatic hydrocephalus are less common. Nonetheless, medical complications are an important and far-reaching component of mild traumatic brain injury. Most seizures occur within the first 7 days after a traumatic brain injury. If a seizure occurs, these are usually treated for a short period of time. Delayed post-traumatic seizures are those that occur after 7 days and usually should be seen by a neurologist so that appropriate therapy can be instituted with anti-epileptic medications. Thankfully, the effects of post-traumatic seizures are usually not severe and can be well-controlled with medication. Post-traumatic hydrocephalus is another diagnosis which we see with increasing frequency. This has to do with an impairment of the absorption of cerebrospinal fluid. A patient who has had a mild traumatic brain injury may present in a declining fashion several months or even years after a traumatic brain injury with hydrocephalus. Imaging here is critical, because a CAT scan of the head, for instance, can make the diagnosis of hydrocephalus when an original comparison study is available. We realize that these patients are very susceptible to having an impairment of cerebrospinal fluid metabolism to the point where they will benefit from the implantation of a shunt. Other medical complications from traumatic brain injury can include the inability to smell--anosmia--for instance, headaches, dystonia, tremor, sleep disturbances, vertigo--almost anything that can manifest from a neurological disease can be seen as an aftereffect of traumatic brain injury. Practitioners need to understand that these effects may be directly related or in a delayed fashion related to the diagnosis of traumatic brain injury. It's important to know when an imaging study may be helpful in the management of your patient, because many times imaging may show an abnormality, but that will not change treatment. I think you should seriously consider imaging when the person has either not improved or there has been a deterioration in their cognition or their emotions or their behavior, and you really want to rule out that there has been another brain lesion that may be accounting for this. When you order imaging, the imaging that should be ordered is an MRI, not a CT scan, because except for the acute setting, CT scan is not going to be sensitive enough to detect the abnormalities you are looking for. Any significant change in symptoms in the post-acute stage of recovery indicating neurological deterioration should lead to referral for immediate neuroimaging and be followed up with detailed neuropsychological evaluation. Medications Far and away the most common medical complication seen by the primary care physician after a traumatic brain injury is headache. Headaches can be diffuse, they can be intermittent, they can be constant, and treating these headaches is important in the recovery of the patient. First of all, nonsteroidal antiinflammatory medications such as Tylenol, naproxen, and ibuprofen are first-line agents in the treatment of mild traumatic brain injury. Secondary agents would include the usage of narcotics, but it is important to know that we would like to avoid the use of escalating doses of narcotics as these can have profound behavioral effects and can impair the recovery of patients with traumatic brain injury. Dizziness and vertigo are very common medical complications related to mild traumatic brain injury. Medications for the treatment of dizziness and vertigo include agents such as meclizine, or Antivert. A typical dosage is 12 to 25 milligrams b.i.d. to t.i.d. Precautions include bladder obstruction, asthma, and glaucoma. Compazine is also effective, 5 to 10 mg t.i.d. to q.i.d., being careful for bladder obstruction, asthma, and glaucoma. Phenergan is used widely as well, 12.5 to 25 milligrams p.o. q.i.d. with the effects of bladder obstruction and asthma. Scopolamine, or Transderm, patches, 1.5 milligram patches, are also effective. Once again, the complications of bladder or intestinal obstruction have been noted, but each and every one of these agents can be successfully used in the treatment and management of dizziness and vertigo following traumatic brain injury. The management of fatigue following traumatic brain injury can include pharmacological and non-pharmacological measures. Non-pharmacological measures should include balanced diet, sleep hygiene, regular exercise, and possibly psychotherapy. Pharmacological measures may include psychostimulants, dopamine agonists, amantadine, and modafinil. Sleep disorders following traumatic brain injury are very common. These can be treated most effectively with non-pharmacological measures such as keeping a regular sleep schedule; avoiding lengthy naps during the day; avoiding coffee, soda, and alcohol; avoiding bright lights and loud noises; and keeping a sleep log. Pharmacological measures for the treatment of sleep disturbances can include benzodiazapines, nonbenzodiazepines, modafinil, and melatonin. Medications for the treatment of mild traumatic brain injury-induced nausea can include Compazine, Phenergan, and Zofran. When you look at how common depression is after traumatic brain injury, the primary care physician should be very comfortable in prescribing an antidepressant, and one of the first-line SSRIs may be extremely helpful to--you know--help ameliorate the anxiety and depression, and they also are very helpful with post-traumatic stress disorder. There are two other medications or types of medications that may be helpful for cognitive problems. One are stimulants such as methylphenidate, which may help things such as speed of processing and fatigue. And the other are the acetylcholinesterase inhibitors such as Donepezil, which may help with other cognitive problems such as memory. One needs to be careful in prescribing any medication to a patient with mild traumatic brain injury that the effects may not be the same or may cause behavioral or other secondary effects which are not seen in the general population. Well, the rule of thumb is that you start low and go slow so that you start with a low dose and then you titrate slowly and that you're very careful in terms of the use of polypharmacy. You be careful about using medications that may alter mental status and increase or cause confusion in a person with a brain injury. Oftentimes, for instance, folks who have behavioral disturbances are just given a psychotic medication, an antipsychotic medication--probably the wrong thing to do in most cases because those medications can actually slow down your thinking, make things actually even a little worse, so we have to be careful what we're doing. Culturally Competent Management of TBI Offering culturally competent care may make the difference between life and death among certain populations such as American Indians and Alaska Natives who present for Western medical care. It is important that medical providers identify the ethnic or cultural background of their patient, identify the patient's community or tribe, and work with community health representatives, or CHRs, who understand the values of that community and are able to act as cultural liaisons or cultural brokers. It's so important that when we're treating somebody with a traumatic brain injury-- mild, moderate, or severe--that we remain sensitive to whatever cultural differences somebody may have in regard to either the diagnosis or even the manner in which we screen or understand their symptoms and the manner in which we treat them. I think that Western providers in Indian health service just need to be aware of the cultural aspects of their patient when they're American Indian or Alaskan Native. Many different cultures--the American Native population may have a certain belief in spirits and what have you, and I suppose that many physicians here, if someone would say, "Oh, the spirits have told me this, that, or the other thing," that perhaps there may be some psychosis involved and be very quick to prescribe medications when in fact that may not be the right approach. So we have to be sensitive to the unique population that we're treating. They might be viewed as someone who went to the brink of death and came back and now they have special powers or a certain path. Before providers do make their plan of care, including medications which might include antipsychotics and so forth, cognitive medications, they should consult with a cultural liaison or a cultural broker with the specific tribe to see if the behavior that's presented is actually normal for what could be viewed in the tribe. Discussion with community health representatives and other cultural liaisons will be important in coordinating Western medical care with that specified by traditional Native healers. This will encourage the greatest compatibility or compromise between the two approaches, where fasts, sweats, journeying, and long hours of prayer or dancing might impact physiological function, medications, and course of recovery. Avoiding Repeat Concussions Repeated traumatic brain injury is a major health concern. Far and away, the biggest risk for traumatic brain injury is in a patient who has suffered a prior traumatic brain injury. That is to say, those individuals who have had one injury are susceptible to having another one. Some of the common symptoms of traumatic brain injury which put a person at risk for acquiring additional injuries to the head include fatigue; headache; dizziness; vertigo; changes in reaction time, balance, or coordination; loss of attention; impaired judgment; impulsivity; and aggressiveness. Brain injury will heal to a certain point, and if that patient makes a complete recovery, a second injury may not, necessarily, portend a worse outcome. We do know, however, in watching patients, for instance, over long periods of time in professional football, in other sports, that if somebody has not recovered from a traumatic brain injury, has a second and a third insult, that they will never usually get back to their baseline. If we've not recovered from our first brain injury and then have a second injury, the effects are more than cumulative. They become greater to recover from. One of the concepts that has been, I think, meaningfully applied to neuropsychology and to the brain sciences is that there may be something called a brain reserve capacity. The brain has many redundant pathways, so to speak. It can take different injuries at different times, and because of the multiplicity of pathways the individual continues to function pretty well as they go along. However, with multiple traumas, we believe that the amount of redundancy that is available shrinks. So as primary care providers, as acute care providers, we need to let patients know that, "You're at an increased risk, and you need to be aware that you need to move more cautiously, you need to rest more, and don't engage in any even remotely risky activities until your symptoms are resolved." Return to Activity/Work A normal CAT scan and MRI scan only means that we cannot see injury that has occurred following a trauma. That does not in any way, shape, or form mean that a patient is able to go back to work or play or whatever the situation may be. The fact of the matter is that the strategy to determine whether or not a patient is able to return to work, return to play, or return to school has to be based on the individual effects that the traumatic brain injury has had on that patient. Professional athletes--they cannot take a risk of having another head trauma if they're still in the recovery process. There's no going back to work until they're symptom-free for a period of time. Sometimes people feel it should be at least a week, sometimes longer. If you are in a position where you can tolerate some inefficiencies in your cognitive functioning, then a graded going back to work is often prescribed. You know--let's go back to work for 4 hours 3 days a week. Then let's go to 4 hours 4 days a week. Let's see how you can tolerate it. Let's go back-- And so you do gradation. And so the return back to work requires an understanding, again, of what is the patient's present symptoms? What is their actual level of neuropsychological functioning? What does their job require? Okay? And is it safe to send them back? If people push themselves too hard to go back to work or go back to their activities, go back to athletic competition after that kind of injury and after those symptoms emerge, they will assure that those symptoms persist and just make things worse. It's important that the physician, the patient, oftentimes the therapist--which may include Psychology, occupational therapists, what have you--work together to say, "It's time to go back" or "It's time to go back with these modifications." And then its important to work with the employer to make sure that if there are modifications that need to be made that they are in place. Optimizing Recovery: Structuring Office Visits When you have a client coming in for a brain injury, you need to make sure you have enough time for them. Now, we're all time-pressed. We all understand that it's very, very difficult to do that. But people with brain injury are going to need some special accommodations. You're probably going to need to spend more time with them. You're going to need to think about what your schedule is like. You need to think about how prepared your front staff are to helping them. They may get lost. They may forget to bring things. They may need extra reminder calls. You need to find out how sensitive they are to noise, what kind of special needs they have in the waiting room. Are they going to be sensitive to light? I've had a number of people who cannot sit under fluorescent lights; it gives them headaches after brain injury. Those sorts of things need to be attended to when you're scheduling visits with people with brain injury. I would also put those folks into your higher-risk category and see them more frequently. You know--make them come into your office, if they're willing, of course. But schedule appointments so that they're coming back in to see you a little bit more often if you know they're a bit isolated. One of the challenges that primary care physicians and, for that matter, anybody is going to have when talking with someone with a brain injury is providing information at a level the person's going to understand. So the first thing you have to do is think about what jargon you're using and how sophisticated your language is and how long you're talking for, how long your sentences are, how fast you're talking because those things are going to make a big difference in the understanding level of the client, and you're going to have to adjust it based upon each person's individual cognitive functioning. So it's really important to understand how the person reasons, how they're able to attend, and how they're processing information. There was some research that was done a while ago that showed the average physician, not necessarily with a person with a brain injury, interrupts within 18 seconds of the start of a physician's visit. So the person comes in, you ask them, "How are you doing?" and within 18 seconds we start interrupting them. People with brain injury--you will lose them in terms of their cooperation and their commitment to doing what you're asking them to do if we do that. So you have to be really prepared to listen to their story. Research shows consistently that people leave physicians' offices very confused about what they're supposed to do regardless of whether they've had a brain injury or not. The follow-through on accurately taking medications, the follow-through on doing what they've been asked to do, is exquisitely poor even in the uninjured population. With people with brain injury, it's particularly so. I would really do a couple of things, and one is write down your instructions for the person. If they're having trouble remembering what you verbally told them during an office visit, write it down for them or have them write it down in their own words-- you know--what your basic recommendations are. I would also enlist the support of family and friends who are part of the persons' lives to assist with that, to be checking in with the person and making sure that they're following the guidelines to encourage recovery. Optimizing Recovery: Patient and Family Education I think it's very important when you're seeing someone who had a mild traumatic brain injury or a concussion injury not to give them the impression that nothing significant happened to them. Many times what happens is when someone has a mild traumatic brain injury no one explains to them what's going to happen, and so when they start to notice problems with thinking, problems with memory, or that they feel depressed or that they feel more tired they don't understand the reason for it, and that then causes stress, which prolongs their recovery and exacerbates all the difficulties that they may have. They're not crazy. They're not psychiatric. They're not--umm--all kinds of other things that people may lay on them. They've had a brain injury, and since people don't understand brain injury, they're going to wonder what's happening to them. And families are not going to understand it, and the boss and employer is not going to understand it, and they need some of that emotional support early. So the accurate diagnosis regarding the fact that they've had a mild brain injury early on is really crucial if you want to get treatment started, particularly during this early window where you can be effective. And we've found in our practice that once people understand what's going on, this goes a long way towards reducing some of those comorbid disorders. Just the fact that the physician can say, "Yes, I've seen this before; I know what this is," people feel such relief from that, so you want to do a lot of reassurance for people with brain injuries because they don't know what this is going to be like. It's important to use the term "brain injury" rather than "head trauma." Head trauma is misleading. It sounds like a scalp wound. And "brain damage" is pejorative and is going to scare the daylights out of everybody, so the term we tend to use is "brain injury." And we don't refer to the person as "brain injured" because that implies that the most important and only thing to know about them is their brain injury. The better term that people tend to use is "a person with a brain injury," meaning they're still a person. They're still a human being, and they have this thing that has happened, but it's not the only thing about them. And I often will tell them that, that this is one thing that we're going to have to factor in, like any other medical condition. I also will reassure them. They're gonna need--they're gonna be scared. I provide lots of reassurance that there can be therapy that can be done to help cognitive changes. I do tell folks that it's not as if your cognitive faculties are gone, never to return. They're just not as efficient for a while, particularly with people who were higher functioning at the onset of injury, prior to injury--very bright people. Their brain has always been extremely reliable for them. You know--they clip along; everything is very easy for them. A mild injury is very noticeable for those individuals and can be extremely frustrating. So I really like to especially tell people who use their brain all day, rely on their brain, very high-functioning, that these slight cognitive setbacks can be frustrating. But they are very common. Patients can be better on some days and worse on others. Overall, the most important aspect after making the diagnosis is reassuring the patient, letting the patient understand what--that he has suffered a traumatic brain injury and that he may be prone to having these cognitive, emotional, and behavioral changes, that they may come and go, and that that in and of itself is normal. Families are an important part of coping and dealing with someone with a brain injury. Families need education also. It's important for families to understand that there are not just cognitive changes but emotional changes, personality changes, sometimes motor-physical control from the brain to the body changes, and the family needs a lot of education about that. I think it's also important that we provide support to the families. Everybody wants to focus on the identified patient, the person with the brain injury, and forgets how devastating this may be for the family. Role changes may take place. A spouse may have to go to work, where the spouse didn't work before. Or they have to take on financial management for the family, where they didn't do that before. There may be more burden placed on a spouse for childrearing than there was before. There may be more burden placed on the family members for transportation if the person cannot drive. All of this tends to fall on the family. One of the things that happens with a chronic injury like a brain injury is the support system for the family starts dropping out because we all are used to helping out in the short run, and as time goes on, other people get on with their lives, so the burden falls on the spouse and the family to help cover the deficits of the person with the brain injury, and no one individual--a spouse, child, small family--can handle this alone. They need a team of people, and telling the family that they're going to need the team of people or giving them permission to say, "I can't keep this up. I need help." Brain injury is not a sprint. It's a marathon, so you have to pace yourself. The person has to pace themselves, and the family has to pace themselves. And as providers, we need to tell them this and help them do that. I would recommend having available pamphlets and handouts about brain injury, and I would refer everybody who you suspect has a brain injury to the Brain Injury Association because they will provide a lot of information and a lot of support. Medical providers will want to inform family members and even employers that they patient's behavioral, emotional, personality, or cognitive changes are not intentional, that physical and/or mental fatigue does not mean that the patient is lazy or malingering. They should be informed that the patient's condition is likely to improve over time, to be supportive and patient. They should also be instructed to seek immediate medical attention for the patient if a rapid decline is noted. Patients may also benefit from nonclinical interventions including techniques to manage stress such as Tai Chi, meditation, deep breathing, avoiding over-stimulation, adjusting pace, and not pushing through fatigue. Patients should be counseled to get more sleep and rest; avoid high-risk activities; use seat belts, helmets, and other safety measures; exercise; avoid alcohol, nicotine, and other chemicals; limit caffeine consumption; and eat a balanced and healthy diet. An important part, especially in the very early phases of recovering from a mild traumatic brain injury has to do with lifestyle and just taking good care of yourself, so, reducing stress, adequate sleep, good nutrition, regular exercise, aerobic exercise seems to be particularly beneficial, and again this doesn't have to be an aerobics class--a brisk walk around the block is better than nothing, and this the kind of thing we tell our patients. There are growth factors that are produced when a person exercises that are supposed to promote neurogenesis, meaning regeneration or growth of new neurons in the brain. So there are many reasons why a person should exercise, whether you have a brain injury or you don't. We're going by some evidence and clinical experience and what we think is logical and makes sense at the moment, but we need to realize that as we gain further evidence and do more sophisticated research, we'll find out more and hopefully be able to better treat our patients. Referral If a person with mild traumatic brain injury is not making the appropriate progress or the progress that you feel they should have made after a mild traumatic brain injury, it's important that you refer them to people who are experts in that area who can help them. For the primary care physician, it's much easier if you can put together a team of people who will assist you. You want a menu of experts who want to see people with brain injuries who will help you. And those people might include a physiatrist, a neurologist, a neuropsychologist, a speech pathologist, occupational therapist, vocational counselor. So for one set of symptoms you want--you might want a neuropsychologist and a speech pathologist and an occupational therapist. For a different set of symptoms where--let's say--returning to work is the issue, you might want the neuropsychologist and a vocational counselor involved. So you pick and choose. You have psychologists or neuropsychologists oftentimes to deal with the cognitive and the emotional problems. You may have occupational therapists to help deal with the fact that these folks are having difficulty with their activities of daily living, and it goes well beyond just washing and dressing themselves, but being able to balance their checkbook, shop, manage the household, things like that. Physical therapists that help with balance disturbances, maybe headaches and pain syndromes. Perhaps neuro-ophthalmologists or neuro-optometrists to help with some of the visual disturbances. Perhaps psychiatrists to help with some of the medication management. One of the jobs of the--sort of the team quarterback, oftentimes a physiatrist, a specialist in physical medicine and rehabilitation is to oversee all the activity, make sure everything jives together well and that the treatment is appropriate and that they're not getting inappropriate treatment. You want some kind of case manager involved. That could either be a case manager from the brain injury association of your particular state. It could be a county case manager. It could be a vocational counselor, but somebody who will help coordinate some of this for you. And you want to make sure that your team of experts are talking to each other so that if one of them generates a report it goes to all of them, or you have periodic phone conferences where they're all talking to each other. I think it's really important for the primary care physicians to understand what the resources are--things like the Brain Injury Association, things like county case managers, those sorts of folk who can really hook them into the system. In a sense, brain injury really never goes away. Even a mild brain injury that completely resolves is something that is going to be with that person for the rest of their lives. My experience has been that if you were there for someone with a brain injury, and they trust you and you bond with them and you commit to them, over the course of their lifetime if they're having troubles, they will come back to you. It is so hard for people with brain injury to find someone within the health care system that they believe in, who believes what's happened to them, who trusts them and who they will trust. They need that support. Make sure that you are getting treatment from a team of professionals that's well-organized, integrated, and have experience in dealing with folks with traumatic brain injury, because it's unlike anything else. Even though aspects of a TBI patient's care may be referred to other specialists, the primary care provider plays an important role in coordinating that care as the team captain. Some of the physical, emotional, or cognitive symptoms may present challenges in the patient's ability to access insurance coverage or negotiate workman's compensation claims, thereby requiring the primary care provider to take on an advocacy role for the patient. Mild TBI may result in medical complications, and symptoms will require mointoring and ongoing management until they resolve. This may involve the use of medications, the pursuit of cognitive remediation, and repeated neuropsychological testing. Primary care providers will need to guide the safe return to work and resumption of other normal activities. Structure office visits and be cognizant of cultural issues that may impact care and course of recovery. One of the most important factors in improving recovery outcome for patients with mild traumatic brain injury is education of the individual with the brain injury, their family members, and their employers. The most important factor of all may be setting positive expectations for recovery. Produced by Vista Media for Aging and Long Term Services Funded by Health Resources and Services Administration and New Mexico Aging and Long-Term Services Department Narrated by Carla Aragon Executive Producer: Linda Wodarczyk Gillet, PhD Produced and Directed By Wayne Johnson Written by Linda Wodarczyk Gillet, PhD and Wayne Johnson HRSA TBI Grant Project Coordinator: Linda Wodarczyk Gillet, PhD Project Supervision: Scott Pokorny, Auralie Tortorici, Doyle Smith, Marise McFadden Photography: Steve McCracken, Wayne Johnson Editing: Wayne Johnson, Steve McCracken
Posted on BrainLine March 29, 2010.