Mild traumatic brain injury

Mild Traumatic Brain Injury: A Silent Epidemic in Our Practices

Author: Page Walker Buck

In recent years, mild traumatic brain injury (mTBI), also known as concussion, has emerged as a major public health concern. Of the 1.5 million Americans whose TBIs are documented by medical staff each year, estimates suggest that 85 percent are considered “mild” (Bazarian et al., 2005). Although these kinds of injuries were once considered a virtual “rite of passage”—particularly in sports—we now know that they have potentially lifelong cognitive, physical, emotional, and social consequences. Despite this slowly increasing awareness, countless mTBIs go undiagnosed every year as a result of a confluence of underawareness, underreporting, underdiagnosis, and misdiagnosis. The endemic prevalence of undiagnosed mTBI presents a significant and worrisome public health challenge, especially given the clear links between head injury and mental illness, substance abuse, and criminality (Helgeson, 2010).

For social workers, this silent epidemic has practice implications that we cannot afford to ignore. There is mounting evidence that individuals in our practices may also be struggling with a history of TBI. One study found that approximately 70 percent of individuals with co-occurring substance abuse and mental health issues had a history—although not necessarily a diagnosis—of TBI (Corrigan & Deutschle, 2008). In another study, an astounding 87 percent of a county jail population reported a history of head injury (Slaughter, Fann, & Ehde, 2003). Combined with findings that suicide rates are higher among TBI survivors (Silver, Kramer, Greenwald, & Weissman, 2001), and potentially highest among the mild injury group (Teasdale & Engberg, 2001), this evidence suggests the need for new standards in competent practice.

Revised practice guideline on mild traumatic head/brain injury: mainly for secondary care

Authors: Opstelten W, Goudswaard AN.

Recommendations for referral of patients with mild traumatic head or brain injury to hospital-based emergency departments aim to minimize the risk of missing severe intracerebral injuries. As these recommendations were derived from secondary care data, application of the recommendations in general practice is likely to reduce the positive predictive value for severe intracerebral injury and may, therefore, result in more unnecessary referrals. Instead, in primary care an advice to wake up the patient several times during the first 24 hours after trauma may help to notice in time the development of severe intracranial pathology.

Influence of poor effort on neuropsychological test performance in U.S. military personnel following mild traumatic brain injury

Authors: Lange RT, Pancholi S, Bhagwat A, Anderson-Barnes V, French LM.

The purpose of this study was to examine the influence of poor effort on neuropsychological test performance in military personnel following mild traumatic brain injury (MTBI). Participants were 143 U.S. service members who sustained a TBI, divided into three groups based on injury severity and performance on the Word Memory Test and four embedded markers of poor effort: MTBI-pass (n = 87), MTBI-fail (n = 21), and STBI-pass (n = 35; where STBI denotes severe TBI). Patients were evaluated at the Walter Reed Army Medical Center on average 3.9 months (SD = 3.4) post injury. The majority of the sample was Caucasian (84.6%), was male (93.0%), and had 12+ years of education (96.5%). Measures included the Personality Assessment Inventory (PAI) and 13 common neurocognitive measures. Patients in the MTBI-fail group performed worse on the majority of neurocognitive measures, followed by the Severe TBI-Pass group and the MTBI-pass group. Using a criterion of three or more low scores <10th percentile, the MTBI-fail group had the greatest rate of impairment (76.2%), followed by the Severe TBI-Pass group (34.3%) and MTBI-pass group (16.1%). On the PAI, the MTBI-fail group had higher scores on the majority of clinical scales (p < .05). There were a greater number of elevated scales (e.g., 5 or more elevated mild or higher) in the MTBI-fail group (71.4%) than in the MTBI-pass group (32.2%) and Severe TBI-Pass group (17.1%). Effort testing is an important component of postacute neuropsychological evaluations following combat-related MTBI. Those who fail effort testing are likely to be misdiagnosed as having severe cognitive impairment, and their symptom reporting is likely to be inaccurate.

Mathematical simulation of mild brain injury in children heading soccer balls

Authors: Ponce E, Pérez J, Ponce D, Andresen M.

Background: Heading professional soccer balls can generate mild traumatic brain injury in children. The long-term consequences could include difficulty in solving problems and deficits in memory and language. Aim: To assess the impact of a professional adult soccer ball on a child´s head, using the finite element method and dynamic effects to predict brain damage. Material and Methods: The minimum conditions of an adult game were considered: the ball speed was 6 m/s and the diffuse blow was 345 and 369 Newtons (N), on the forehead and top of the head, respectively. A head was modeled in order to know the stresses, strains and displacements generated by the impacts. The extent of the alteration was determined by comparing the strength of brain tissue, with predictions of computed stresses. The geometric characteristics of the head were transferred from medical images. The input data of the materials of a child´s head was obtained from the literature. Results: In the case of heading with the forehead, mathematical simulation showed frontal lobe alterations, with brain stresses between 0.064 and 0.059 N/mm2. When the heading was with the upper head zone, the brain alterations were in the parietal lobe, with stresses between 0.089 and 0.067 N/mm². In the cerebral spinal fluid the pressure was 3.61 to 3.24 N/mm2. Conclusions: The mathematical simulations reveal evidence of brain alterations caused by a child heading adult soccer balls. The model presented is an economical and quick tool that can help predict brain damage. It demonstrates the ability of the cerebral spinal fluid (CSF) to absorb shock loads.

Histopathological and Behavioral Effects of Immediate and Delayed Hemorrhagic Shock after Mild Traumatic Brain Injury in Rats

Authors: Cruz-Navarro J, Pillai S, Cherian L, Garcia R, Grill RJ, Robertson C.

The purpose of this study was to investigate increased susceptibility of the brain after controlled mild cortical impact injury to secondary ischemic insult. The effects of duration and timing of the secondary insult after the initial cortical injury were studied. Rats underwent a 3 m/sec, 2.5 mm deformation cortical impact injury followed by hypotension (mean pressure 40 mmHg) induced by withdrawing blood from a femoral vein. Duration of hypotension was varied from 40 to 60 minutes. The timing of 60 minutes of hypotension was varied from immediately post-injury to 7 days after the injury. Outcome was assessed by behavioral tasks and histological examination at 2 weeks post-injury. Other animals underwent measurement of acute physiology including mean blood pressure, intracranial pressure, and laser Doppler perfusion. Increasing durations of hypotension resulted in marked expansion of the contusion, from 6.5?1.8 mm? with sham hypotension to 27.1?3.9 mm? with 60 minutes of hypotension. This worsening of the contusion was found only when then hypotension occurred immediately or 1 hr after injury. CA3 neuron loss followed a similar pattern but the injury group differences were not significant. Motor tasks and performance on Morris water maze task were significantly worse following 50 and 60 minutes of hypotension. Studies of the acute cerebral hemodynamics demonstrated that CBF was significantly more impaired during hypotension in the animals that underwent the mild TBI compared to sham TBI. The perfusion deficit was worst at the impact site, but also significant in peri-contusional brain. With 50 and 60 minutes of hypotension, CBF did not recover following resuscitation at the impact site, and recovered only transiently in peri-contusional brain. These results demonstrate that mild TBI, like more severe levels of TBI, can impair the brain's ability to maintain CBF during a period of hypotension, and result in a worse outcome.

Headache management in concussion and mild traumatic brain injury

Authors: Lucas S.

Headache is one of the most common symptoms after traumatic brain injury (TBI), and posttraumatic headache (PTH) may be part of a constellation of symptoms that is seen in the postconcussive syndrome. PTH has no defining clinical features; currently it is classified as a secondary headache based on its close temporal relationship to the injury. A growing number of studies are characterizing PTH by using primary headache classifications. Moderate to severe PTH that is often disabling may be classified as migraine or probable migraine and is found in substantial numbers of individuals. Recent data from civilian adult, pediatric, and military populations all find that PTH may be more of a chronic problem than previously thought, with a prevalence of close to half of the injured population. In addition, if PTH definitions are strictly adhered to, then many cases of PTH may be missed, thus underestimating the scope of the problem. New headaches may be reported well after the 7 days required for diagnosis of PTH by the guidelines of the International Classification of Headache Disorders, 2nd edition. A history of headache before a head injury occurs and female gender are possible risk factors for headache after TBI. Treatment of PTH may be acute or preventive, and recommendations are made for the use of migraine-specific acute therapy when indicated. Preventive therapy may be considered when PTH is frequent, disabling, or refractory to acute therapies. Comorbid conditions should be considered when choosing an appropriate preventive therapy. The symptom of headache as a "return to play" or "return to duty" barrier must be viewed in the context of other symptoms of mild TBI.

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