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Knowledge Now: Update on Mild TBI

Levy CE. Knowledge Now: Update on Mild TBI. Paper presented at: American Academy of Physical Medicine and Rehabilitation Annual Assembly; 2012 Nov 15; Atlanta, GA.


Essentials of Assessment History The history should document the mechanism of injury, duration and severity of alteration of consciousness, presence of amnesia prior- or post-trauma, the nature, onset, and time-course of symptoms, (headache, dizziness, weakness, dysesthesias, vertigo, nausea, slurred speech, photophobia), response to treatment, prior head injuries, current and prior psychiatric diagnoses, educational attainment, occupational history, sleep history, and psychosocial risk factors, (i.e., substance use/abuse). Behavioral and cognitive changes should be noted. Physical examination a. The physical examination should include: neurologic: mental status, cranial nerve, and cerebellar testing; evaluation of tone, strength, sensation, muscle stretch reflexes, and postural stability/balance; vision: gross acuity, binocular function, and visual fields/attention testing; examination of the head, neck, and jaw including range of motion, and palpation for focal tenderness versus referred pain. b. The following may indicate an acute neurologic condition requiring urgent management: altered consciousness, progressively declining neurological status, pupillary asymmetry, seizures, repeated vomiting, diplopia, worsening headache, disorientation, unusual behavior, confusion, irritability, slurred speech, unsteadiness, weakness or numbness. Functional assessment Mobility and self-care dysfunction are not typical. Clinicians should be alert for disorders in thought, judgment, and mood, observe affect and behavior, and also note litigation and compensation issues that may influence behaviors and outcomes. Laboratory studies Although there is great interest in identifying diagnostic/prognostic biomarkers of mTBI, the promise of this approach has yet to be realized. Although laboratory testing is not necessary to confirm or manage symptoms associated with mTBI, it may be considered for evaluating non-TBI causes (i.e., metabolic disorders or infection) of symptoms. Imaging In the emergency department, a non-contrast head computed tomography (CT) may be indicated for mTBI presenting with certain neurological signs or symptoms suggesting a possible neurosurgical intervention. Abnormalities on standard structural CT or magnetic resonance imaging are not required for the diagnosis of mTBI. A clinical role for functional neuroimaging (positron emission tomography, single photon emission computed tomography, electroencephalography, magnetoencephalography) has yet to be determined. Neuroimaging is not indicated beyond the emergency phase (72 hours post-injury) unless deterioration occurs. Supplemental assessment tools Cognitive testing may be appropriate for supplemental examination of mTBI symptoms. Succinct cognitive batteries (e.g., Repeatable Battery for the Assessment of Neuropsychological Status [RBANS]; Immediate Post Concussion Assessment and Cognitive Testing [IMPACT]); assessing attention span, verbal memory/learning, working memory, and executive function are useful in determining if everyday cognition may be impaired. These tools provide objective quantification of mTBI-related cognitive sequellae, separate from the individual's self-report. Early predictions of outcomes Pre-injury: older age, female gender, low socioeconomic status, lower education, lower intellectual functioning, pre-existing mental health conditions (e.g., depression, anxiety, PTSD, substance use disorders); Peri-injury: lesser social support; Post-injury: litigation/compensation-seeking, co-morbid mental health conditions, chronic pain, lesser social support.

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