SAN DIEGO – Never underestimate the importance of providing early education and positive reinforcement to patients who have sustained a traumatic brain injury.
"If you educate them, you’ll prevent a lot of emotional upset about what’s going to be happening over the next weeks or months," Dr. Michael A. Lobatz said at a meeting on primary care medicine sponsored by the Scripps Clinic. "When I see a patient with an acute concussive injury, I will tell them, ‘It’s going to get better; 85% of patients get better. The prognosis is good. Hang in there. We’re going to shut down some of your activity, but we’re going to wait for this to get better and you’re going to heal up.’ "
Dr. Michael A. Lobatz
He makes it a point to tell them that memory deficits are common after a TBI, and that such symptoms as dizziness, irritability, a decreased ability to process information and tasks, sleep disturbance, and impulsiveness may also occur. "If you do that, you will often avoid that shattered sense of self that people come away with when they’re left hanging, not understanding what’s actually going on with them," said Dr. Lobatz, a neurologist and the medical director at the Scripps Rehabilitation Center, Encinitas, Calif.
The Centers for Disease Control and Prevention estimates that each year, 1.7 million TBIs occur in the United States. Of these, about 1.4 million involve visits to the emergency department, 275,000 involve hospitalizations, and 52,000 result in death. Dr. Lobatz defined TBI as a bump, blow, or jolt to the head that disrupts the normal function of the brain. "This may range from mild to severe, with extended periods of loss of consciousness or prolonged periods of amnesia," he said. But most of the TBIs that occur are very mild, may resolve on their own, and might not even need medical attention.
There are at least 16 different grading systems for trying to measure severity of TBI, he said, the most recent being about 10 years old. "The good news is, the American Academy of Neurology is working on a new grading system that will probably published by November of this year," he said. "That will be very useful and most updated based on class I evidence."
According to current AAN guidelines, a grade 1 concussion is marked by spotty confusion, no loss of consciousness, and concussion symptoms that last less than 15 minutes; a grade 2 concussion is marked by spotty confusion, no loss of consciousness, and concussive symptoms or abnormalities that last longer than 15 minutes. By contrast, a grade 3 concussion is marked by any loss of consciousness whether brief (seconds) or prolonged (minutes).
The guidelines also include ratings for three different levels of posttraumatic amnesia. Mild injury is defined as a Glasgow Coma Scale (GCS) score of 13-15, with 15 being completely normal, plus a 0- to 20-minute loss of consciousness (LOC) and amnesia lasting less than 24 hours. A moderate injury is defined as LOC lasting 20 minutes to 6 hours with a GCS score of 9-12. A severe injury is defined as LOC lasting longer than 6 hours with a GCS score of 3-8. Dr. Lobatz noted that patients who have longer periods of anterograde amnesia "tend to have a more prolonged course to recovery or incomplete recovery. When you take your history, ask [patients] what they remember, not what they were told happened or what they think happened by their own logical deduction. When you preface your question like that, you’ll get more accurate information."
Sorting out preinjury vs. postinjury factors in TBI patients is no easy task. For example, preexisting factors "could be that they have some ADHD, poor school performance, or depression," he said. "Postinjury factors might include disruption of relationships, school, or work. You need an open mind when you see these patients, and you cannot do this [assessment] in 10 minutes."
The process is further complicated in the assessment of soldiers who present with a TBI and also have concomitant posttraumatic stress disorder. Distinguishing which symptoms stem from the TBI and which stem from the PTSD "is a little bit of the art of evaluating the soldier these days, trying to understand which one is more predominant," Dr. Lobatz said. "In our experience at Scripps in treating well over 100 of these soldiers, we find that it’s often mixed. They often have both problems going on. When the PTSD symptoms are overwhelming, that needs to be addressed first. When that’s cleared up, they can come back and get therapy for their concussive injury. Sometimes it’s the other way around and [both] can be addressed simultaneously with cognitive therapy."