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

Evidence-Based Treatment for MBI

After the screening, assessment, and diagnosis for MBI are completed, decisions are made about treatment. Treatment for patients with mild-TBI focuses on symptom management, teaching compensatory strategies and environmental modifications, support during gradual resumption of work and social responsibilities, and psychoeducation with the patient and family. Recently, Cicerone and associates (2005) published an evidence-based review article focused on cognitive rehabilitation after stroke and TBI. They found evidence to support training in the use of external aids, such as a memory diary or voice organizer, and in assisting persons known to have moderate to severe memory impairment after TBI, even for patients who are many years postinjury. Compensatory strategies included using a portable pager to address specific problems of everyday function or a voice organizer to remediate for memory impairments (Hart, Hawkey, & Whyte, 2002; Wilson, Emslie, Quirk, & Evans, 1999, 2001; Wright et al., 2001). Typically, speech or occupational therapists focus on teaching people with MBI compensatory strategies for their cognitive dysfunction. The APN may be equipped to offer initial strategies to compensate for cognitive dysfunction and make appropriate referrals.

Comprehensive neuropsychological rehabilitation therapies involving combination therapies for persons with cognitive, emotional, interpersonal, and motivational deficits associated with TBI are focused on those with moderate to severe brain trauma. In Cicerone and associates' review (2005) of four studies focused on combination therapies, it was noted that although there is evidence that rehabilitation is beneficial for improving community integration and return to work for persons with moderate-to-severe injuries, this evidence is not available for those with milder injuries. Research concerning optimal treatment for those with MBI suggests that less expensive approaches may be effective and that the more comprehensive, multidisciplinary treatment should be targeted toward those with preinjury psychiatric problems (Ghaffar et al., 2006).

Cost-effective interventions (e.g., giving the patient an information booklet about symptoms and coping strategies, a telephone follow-up, or "as-needed services") were effective in alleviating chronic symptom development (Mittenberg, Tremont, Zielinski, Fichera, & Rayls, 1996; Paniak et al., 2000; Ponsford, 2005). Still, other healthcare professionals suggest that cognitive rehabilitation and emotional support are likely to improve the outcomes for persons with MBI (Paniak et al.; Tiersky et al., 2005). Clearly, additional intervention research is needed for those with MBI (Ponsford).

Two studies focused on symptom management for those with mild injury. Symptom management, although a focus of nursing intervention, has not been systematically studied.

Mittenberg and associates (1996) provided a 10page printed manual and a 1-hour treatment session about symptom management to a small group of patients with MBI and compared this group to a usual treatment control group. Both groups were recontacted 6 months later. The treatment group reported fewer and less severe symptoms. This study of 48 persons suggests that a brief, psychoeducational intervention may be effective in preventing prolonged symptoms after MBI. Cicerone and associates (1996) incorporated cognitive rehabilitation and symptom management strategies in a consecutive series of therapies for a group of persons referred because of MBI (Cicerone et al., 1996). They reported positive outcomes in cognitive function and symptom control for those identified as exhibiting "good clinical outcomes" compared to those with "poor clinical outcomes." Unfortunately, there was no control comparison group and the sample only included 20 persons with MBI. However, this study suggests that symptom management and helping persons develop skills in managing dizziness and visual or linguistic abilities can be beneficial. Clearly, more systematic study of symptom management after MBI is needed.

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