MIAMI BEACH – Mild traumatic brain injury can be controversial in both clinical and legal contexts. A conflict arises when patients report disability but neurologic exams appear normal.
“There can be a mismatch between mild injury, a normal exam, and multiple symptoms that lead to an evaluation for legal or insurance reasons. A comprehensive neuropsychiatric evaluation is needed and provides critical data,” Dr. Jacob C. Holzer said at the annual meeting of the American Academy of Psychiatry and the Law.
“Maybe the patient had an evaluation right before or right after the injury. The outcome needs to make sense and match with functioning in the real world,” said Dr. Holzer of the division of psychiatry and medicine at Massachusetts General Hospital, Boston.
In acute traumatic brain injury (TBI), there can be loss of consciousness, confusion, and amnesia. Frontal and anterior temporal regions are most vulnerable to injury. Chronic TBI generally features psychiatric and neurologic symptoms, seizures, and concussion syndrome.
With mild TBI, however, consciousness may or may not be disrupted. Most cases of mild injury resolve within weeks to months, although some endure. Patients with mild injury tend to score in the 13–15 range on the Glasgow Coma Scale. “The prognosis tends to be pretty good when you look at specific goals, such as motor functioning. The enduring picture is that cognitive deficits tend to be long lasting,” Dr. Holzer said.
Symptoms of acute mild TBI cluster in cognitive, somatic, and psychiatric areas. Cognitive effects include impairments in memory, attention, concentration, and speed of information processing. Somatic symptoms can include headache, dizziness, nausea, fatigue, and poor sleep quality. Psychiatric effects include depression, which is very common, and anxiety.
“Imaging studies and neurodiagnostic tests may or may not help” with diagnosis and management of a patient with mild TBI, Dr. Holzer noted. He suggested using structural or functional imaging as one component of a comprehensive evaluation.
For a long time, the literature comprised primarily animal studies, but newer imaging studies in humans are supplanting these previous findings. “It's really interesting looking at athletes who have injuries–studies have found statistically significant differences between groups,” he said. Electrophysiologic studies demonstrate consistent changes among athletes, and neuropsychiatric assessment can demonstrate differences in simple and complex attention areas.
“That is not to say everything is positive,” Dr. Holzer said. Some negative studies indicate that there are no significant differences between athletes and nonathletes.
“This is a hot area in the news, looking at high school sports, including adolescents who get repeated concussions,” said Dr. Holzer, who indicated that he had no relevant financial relationship pertaining to the context of his presentation.
Technology may lend insight. Researchers developed a group of sensors that go inside a football helmet and alert a coach on the sidelines when forces are great enough to cause a concussion (Head Impact Telemetry System, Simbex LLC). The sensors are used by several high school and college football teams such as Virginia Tech, Blacksburg, the University of North Carolina at Chapel Hill, and Dartmouth, Hanover, N.H.