A seemingly benign event can lead to a long term problem. Though considered a “mild,” traumatic brain injury, a concussion may in fact have a significant impact, if not identified early and effectively managed. The Center for Disease Control estimates that out of 1.7 million traumatic brain injuries (TBIs) sustained each year in U.S., the vast majority (75%) are mild (CDC, 2010).

It is important to note that losing consciousness is not required for a diagnosis of concussion, and that abnormalities on brain CT/MRI scans are seen in only 5-10% of patients. In spite of this, microscopic changes (e.g. diffuse axonal injury), which tend to go undetected on imaging studies, can occur throughout the brain, and the patient may still experience problematic symptoms and functional impairments.

Concussion Symptoms and Consequences

A concussion is a trauma-induced disruption in brain function, characterized by a brief (less than 30 minute) loss of consciousness, relatively short (less than 24 hour) period of amnesia/memory loss, and/or a period of confusion/change in mental status. Common concussion symptoms include somatic complaints, such as headache, fatigue, sleep disturbance, nausea, vomiting, dizziness/vertigo, tinnitus, blurry vision and hypersensitivity/over-stimulation; cognitive complaints, including confusion/“brain fog,” slowed processing speed, decreased attention and concentration, memory deficits, and problems organizing one’s thoughts; and emotional symptoms, like depression, anxiety, irritability and reduced frustration tolerance.

It is easy to see how any of these symptoms could negatively affect the person’s ability to function within home, community, social and vocational settings, and return to a “normal” routine and quality of life. Furthermore, it has been said that while moderate to severe TBI outcomes are determined by “what the injury brings to the patient,” in a concussion or mild TBI, it is “what the patient brings to the injury.” Poorer outcomes have been found in those patients who are older, less educated, have a history of prior TBI or other co/pre-existing medical or psychiatric conditions, or are involved in litigation.

Two Different Concussion Patients

Researchers and clinicians have identified two distinct subgroups of patients with concussion. There are those “early recoverers” whose symptoms resolve relatively quickly, within the first few months post-injury, and who may not need formal intervention beyond rest, avoidance of overstimulation and a gradual return to activity. This represents the majority of patients, estimated at 75-90% of the mild brain injury population.

Much more challenging is the minority of patients who demonstrate persisting, sometimes disabling, symptoms that can last months to years post-injury. These patients with “persistent post-concussive syndrome” can be very challenging to accurately diagnose and effectively manage, and require a highly experienced team approach. Vestibular and oculomotor systems can be impacted and also be contributory, and persisting symptoms can be influenced and exacerbated by a variety of factors including premorbid personality and health, coping style, chronic pain, depression, PTSD. Iatrogenic factors, litigation stress, symptom exaggeration or malingering can also complicate an already challenging management scenario.

Successful Intervention Strategies

Formal early intervention is critical to achieving the best possible recovery outcome as patients who receive such supports report fewer post-concussive symptoms 3-6 months post-injury. A biopsychosocial care management approach is imperative to avoid harm, optimize recovery and facilitate a successful return to work. Only this methodology can address the complex interplay of variables that impact patients with concussion, particularly, those with persistent post-concussive syndrome.

A physical medicine and rehabilitation specialist with mild brain injury expertise can serve as the “quarterback” of the treatment team. Vestibular, neuro-optometric, pain management and/or neuropsychiatric specialists may need to be involved. Since the presence of normal CT, MRI or other scans do not necessarily indicate the absence of brain injury, specialized testing (e.g. functional MRI, neuropsychological assessment) may be necessary to provide objective evidence of impairment, and help identify treatment needs.

Intervention strategies may include provision of education and support regarding common symptoms, expected recovery course, and likelihood of a good outcome. Training in adaptive coping strategies (e.g., sleep hygiene, avoidance of drugs and alcohol) to support recovery and manage persistent somatic, cognitive and emotional challenges are important. Short term medication use may help with symptom management while the patient learns to incorporate longer-term coping strategies such psychological treatment and physical therapy. If necessary, an outpatient multidisciplinary brain injury rehabilitation program may provide the level of expertise and multidisciplinary approach needed to address persistent, disabling symptoms.

Identifying and engaging providers with the necessary expertise, developing trusting relationships with the injured worker and his or her family for engagement, and validating the patient’s experience without inadvertently fostering illness behavior are among the critical components and challenges facing those managing the care of injured workers with concussion or mild TBI.

About the Author

Dr. Deborah Benson is Senior Director of Clinical Services at Paradigm Outcomes. Over the course of her rehabilitation career, she has conducted basic and clinical research in neuroscience, taught psychology and cognitive rehabilitation, and served as Clinical Supervisor for graduate neuropsychology students. A New York State-licensed psychologist with a PhD in clinical neuropsychology from the City University of New York and board certification in rehabilitation psychology from the American Board of Professional Psychology, Deborah served on the board of the Brain Injury Association of New York State (BIANYS) and is currently on the association’s advisory council. She has coauthored multiple scholarly articles and books on brain injury rehabilitation and presented at numerous regional and national conferences.