Mild Traumatic Brain Injury: An Update for Advanced Practice Nurses

Esther Bay, PhD APRN BC CCRN; Samuel A. McLean, MD MPH

Disclosures

J Neurosci Nurs. 2007;39(1):43-51. 

In This Article

Symptom Experience After Mild Traumatic Brain Injury

Posttraumatic complaints after MBI are not well understood. This ambiguity centers on issues associated with delays in seeking treatment, health-care professionals' lack of knowledge about the detection and diagnosis of MBI (CDC, 2003), symptom overlap with other diagnoses or conditions (Borg et al., 2004), heightened endorsement of symptoms in order to benefit from litigation claims (Binder & Rohling, 1996), an underlying mood disorder (Rapoport, McCullagh, Streiner, & Feinstein, 2003), or the lack of sensitive diagnostic tools or biochemical markers that correlate with symptom reports (Borg et al.).

Delay in seeking treatment may be important in MBI recovery. These delays are associated with the injured person discounting symptoms, incorrectly interpreting symptoms, guilt over the circumstances involved in the injury, and denial that anything serious occurred (Mooney, Speed, & Sheppard, 2005). Reasons for the delay in seeking treatment have been underinvestigated.

Developmental issues may partially explain delay in seeking treatment after MBI. Persons 18-25 years old and those over 75 years old are most at risk for TBI (CDC, 1999). Younger people may delay seeking treatment because of their lack of familiarity with illness and the healthcare system, misinterpretation about the significance of symptoms, inadequate medical insurance, or the actual circumstances involving their accident and associated brain injury. In a study of 343 people with head injuries, 16% refused emergency transport. Those refusing transport were younger, male, victims of assault, and less likely to have lost consciousness (Shah et al., 2004). The injury may have been connected to risk-taking activities such as speeding, drunk driving, or participating in sports. By contrast, those over 75 years may attribute fatigue, dizziness, or change in memory to the aging process or delay treatment because of inadequate medical insurance or fear of reprisal associated with a crash or fall. Collectively, little is known about decisions to seek treatment after TBI (Shah et al.).

The CDC acknowledges an overall lack of understanding about the detection and diagnosis of MBI among healthcare professionals (CDC, 2003). The CDC provides "toolkits" to assist coaches, health professionals, and family members in helping people with brain injury (CDC, 2005). These toolkits contain information about MBI and provide guidelines for prevention, diagnosis, and treatment.

In addition, there are multiple reasons that healthcare professionals experience difficulty in MBI detection. There is overlap of symptoms with other diagnoses or conditions, such as substance abuse, pain, or depression (Dikmen & Levin, 1993). Malingerers may feign symptoms in order to benefit from litigation claims (Binder & Rohling, 1996; Suhr & Gunstad, 2002). Finally, the lack of biochemical markers or sensitive diagnostic tools for MBI complicates this process (Borg et al., 2004).

Patients who experience MBI display a variety of symptoms. These symptoms usually subside within the first year (Dikmen, Macramé, & Timken, 2001).

In a sample of 107 patients admitted to an ED for initial treatment, the most prevalent symptoms reported were forgetfulness, drowsiness, headache, dizziness, trouble concentrating, and lightheadedness. After 6 months, most complaints had diminished with some people still reporting headache, dizziness, and drowsiness. The initial presence of headache, dizziness, and drowsiness in the ED was associated with increased symptoms at the 6-month evaluation (de Kruijk et al., 2002).

The sensitivity and specificity of symptoms of MBI have been reported and predominately are clustered in the cognitive domain (Gordon, Haddad, Brown, Hibbard, & Sliwinski, 2000). Specific symptoms were also found to predict the likelihood of a complicated MBI. In a systematic review, Borg and associates (2004) noted that when a depressed skull fracture was present along with nausea, vomiting, and headache, the presence of intracranial lesions was likely even in patients with GCS scores of 15. For the APN, questions specifically focused on the cognitive domain are critical, as is determining the presence of headache, nausea, or vomiting.

Between 20% and 80% of people with mild injury will continue to experience symptoms 6 months after the injury (de Kruijk et al., 2002). This phenomenon is termed postconcussion syndrome (PCS). PCS, as defined by the American Psychiatric Association, is associated with quantifiable deficits in memory or attention and the onset or worsening of any three of the following symptoms: tiring easily, disordered sleep, headaches, vertigo/dizziness, irritability, anxiety/depression/affective lability, changes in personality, or apathy (McCauley et al., 2001). Persons at risk for PCS include older females with psychosocial stress, social difficulties, and prolonged posttraumatic amnesia (McCauley et al.). Between 10% and 15% of persons with mild injuries will be symptomatic for a year or longer (Chamelian & Feinstein, 2004; Paniak, Toller-Lobe, Reynolds, Melnyk, & Nagy, 2000). Sustained postinjury symptoms may result in reduced return-to-work potential for those with MBI (Ruffolo et al., 1999). For the APN, correlating memory or attention deficits with presenting and long-lasting symptoms can be a challenge. Focused interviewing questions and dismissal of competing diagnoses are critical to proper diagnosis and evidence-based treatment.

In the following example, a 49-year-old female sought medical care for persistent headaches, dizziness, and irritability at work and at home. She had been involved in a motor vehicle crash within the past 3 months, but she did not seek medical treatment at the time because she was very busy at work as a legal assistant. Following the accident, her car required extensive repairs. The APN inquired about the accident by asking if the woman was disoriented at the time of the accident and if anyone had noticed any seizure-type activities or if she had complained of headache or other neurological symptoms. The injured woman reported that she had kept asking the same questions repeatedly and had experienced a significant headache for the first few days. These headaches recently reoccurred. Since the accident, she reported working longer hours in an effort to keep up with the paperwork. She seemed to read more slowly, disliked interruptions, and became quite irritated when office staff members were loud or boisterous. She reported waves of dizziness when she turned her head too suddenly, but did not experience balance difficulties. This case typifies delays in seeking treatment, compensatory strategies initiated by the injured person in a case of MBI, and symptomatology consistent with PCS.

Two of the prominent symptoms of this individual (i.e., dizziness and headache) are common MBI symptoms. Chamelian and Feinstein (2004) reported that dizziness in those with mild-to-moderate TBI was an independent predictor of failure to return to work when assessed in persons who were 6 months from their injury date. They concluded that dizziness was not entirely associated with anxiety or other psychological variables (Chamelian & Feinstein). Headache after MBI is associated with poor outcome (de Kruijk et al., 2002). Other experts claim that headache may be associated with injuries to the musculoskeletal system, inflammation of the sinus tracts, or a combination of biopsychosocial issues (Martelli, Zasler, Bender, & Nicholson, 2004). Headaches after TBI have acute or delayed onset and are associated with more emotional distress, although study of this relationship over time is lacking (Walker, Seel, Curtiss, & Wardent, 2005).

Another competing diagnosis is malingering. In Binder and Rohling's (1996) meta-analytic review concerning the effects of money on recovery after TBI, there was evidence that—especially in cases of MBI—healthcare professionals should consider the effects of financial incentives, such as disability or litigation claims, on reported symptoms. Suhr, Tranel, Wefel, and Barrash (1997) further reported that memory performance after TBI can result from factors other than the injury. Medication use, psychological distress, malingering, and litigation status were implicated in other explanations for postinjury symptoms (Suhr et al., 1997). Sensitive and specific memory tests have the potential to discriminate malingerers from those with actual MBI. Thus, there are competing diagnoses for common symptoms of brain injury, requiring APNs to perform thorough intake histories about psychological distress, litigation status, and the onset of symptoms in association with aggravating and alleviating factors. Referrals for neuropsychological testing may be warranted to support a definitive diagnosis of MBI.

In addition to cognitive and somatic symptoms associated with MBI, many patients report psychological difficulties. Anxiety, depression, and posttraumatic stress disorder (PTSD) are prevalent after TBI, are not associated with the severity of injury, and yet, are associated with worse outcome (Moldover et al., 2004; Rapoport et al., 2003). Patients with irritability, mood lability, insomnia, or cognitive changes such as forgetfulness or organizational difficulties, should also be assessed for depression, PTSD, or anxiety disorders. In fact, Wang, Chan, and Deng (2006) reported that postconcussive symptoms were similarly present in both an MBI and healthy college sample when depression was used as a covariate. Currently, investigations are being conducted to determine to what degree these psychiatric disorders result from biochemical or neuroanatomical changes (Bryant, 2001; Hibbard et al., 2004; Jorge et al., 2004; Levin et al., 2001).

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