Rehabilitation Considerations Following Mild Traumatic Brain Injury.

Traumatic brain injury encompasses a variety of conditions caused by an external mechanical force to the head resulting in damage to brain tissue. Mild traumatic brain injury refers to head trauma without loss of consciousness or with a loss of consciousness lasting less than 20 minutes (Gasquoine, 1997; Miller, 1996). Post-concussional syndrome is a term often used interchangeably with mild traumatic brain injury and refers to the array of cognitive, psychosocial, and behavioral manifestations associated with pathophysiological changes involved with traumatic brain injury.

Although the overall incidence of traumatic brain injury is difficult to determine, perhaps as many as 7-10 million new cases of traumatic brain injury are reported each year (Berker, 1996: Conboy, Barth, & Boll, 1986). Mild injuries constitute the largest portion of traumatic brain injuries (Krauss et al., 1984). Males represent 65-75% of those injured and 70% of injuries occur to persons under 30 years of age (Krauss & Nourjah, 1988; Vogenthaler, 1987).

Total costs for new cases of hospitalized traumatic brain injury in a given year in the United States have been estimated to exceed $8 billion over the course of the first four years following injury (Brooks, Lindstrom, McCray, & Whiteneck, 1995). While the majority of those who have incurred mild traumatic brain injuries will return to work, one-third will experience considerable difficulty, resulting in reduced productivity, frequent job changes, and lowered levels of responsibility that often culminate in considerable costs to businesses (Gamboa, 1994; McMahon & Flowers, 1987). According to the National Brain Injury Foundation, the economic costs associated with traumatic brain injury may be as high as $25 billion per year across the United States.

One way to begin to reduce these staggering costs is for rehabilitation professionals to improve their understanding of and ability to efficiently rehabilitate persons with traumatic brain injuries. Delayed diagnosis can result in a greater exacerbation of symptoms due to the development of psychological problems (Clements, 1997). The purpose of this article is to provide an overview of rehabilitation following mild traumatic brain injury. Emphasis is placed on the contributions of neuropsychological assessment to the rehabilitation process, the types of rehabilitation services that can be usefully employed for persons with mild traumatic brain injury, and the critical role of vocational rehabilitation.

Definition and Clinical Features

Mild traumatic brain injuries occur when the head is struck or moves abruptly and violently, resulting in an alteration in consciousness. A loss of consciousness is not imperative and it is well documented that severe complications can occur in the absence of coma (Jennett, 1976; Binder, 1986; Berker, 1996). Due to the fact that individuals are often not rendered unconscious, or if so, only briefly, and in the absence of other medical complications, the majority of these individuals are not hospitalized and are usually discharged from emergency rooms. Strauss and Savitsky (1934) coined the term "post-concussion syndrome" to represent the notion of cerebral concussion in the absence of a loss of consciousness. Their work recognized the complex interplay between brain injury, premorbid personality, the desire for compensation, and the great stress involved in dealing with a medical and legal system that treated many of these patients as less than honest (Miller, 1996).

Issues related to organicity, financial gain, and emotional overlay continue to provide the primary areas of differential diagnosis and controversy today. Causes of mild traumatic brain injury include falls, a blow to the head, or most commonly, the head striking a stationary object, such as in a motor vehicle accident. Additionally, mild traumatic brain injury may also occur after severe whiplash injury, even if the head is not struck and especially if the whiplash involves some rotation of the head in addition to linear movements (Sweeney, 1992).

Acute symptoms associated with concussions include: brief alterations in orientation; headaches; dizziness; vertigo; nausea: blurred vision; imbalance; and reductions in attention, concentration, and memory. Symptoms occurring later may include irritability, anxiety, and depression, and are often associated with, if not confounded by, considerable social and economic morbidity. What is now commonly understood and documented is that a significant number of these individuals will have continued symptoms well beyond the first several days from the time of the accident (Alves, Macciocchi, & Barth, 1993; Dikmen, Machamer, Winn, & Temkin, 1995). Reductions in cognitive functions including attention, concentration, memory, mental speed, and higher level problem solving are frequently reported (Gasquoine, 1997; McGrath, 1997). Attentional processes, often impaired following mild traumatic brain injuries, permeate all aspects of behavior, often resulting in functional limitations (Wood, 1987). Many of the cognitive signs of mild head injury are nonspecific and may fall into the categories of what have been referred to as disorders of executive functioning (Posthuma & Wild, 1988). These include the capacity for planning and organization, problem-solving skills, mental flexibility, abstract reasoning, initiation, motivation, and regulation of behavior. Alterations in mood, including irritability, anxiety, and depression, are frequent sequelae of mild traumatic brain injury. Symptoms of depression are often observed in survivors of mild traumatic brain injury who had no previous history. Advancing research suggests that depression may result from neurochemical changes following traumatic brain injuries in addition to psychological reactions (Jorge, Robinson, Aundt, Forrester, Geisler, & Starkstein, 1993; Dixon, Taft & Hayes, 1993). Finally, physiologic changes, including disruption in sleep, headaches, imbalance, and fatigue, contribute to the overall level of debilitation that can occur following concussions.

Modern research has provided evidence from both animals and humans that axons, the extending structures of brain cells or neurons which allow communication between cells to occur, are diffusely injured throughout the brain in mild head injury (Dixon et al., 1993; Miller, 1996). While this microscopic shearing of axons is not identified with current diagnostic techniques such as CT or MRI, these morphological changes have been observed in autopsy studies and in simulation studies with animals. Furthermore, experimental studies have identified progressive axonal degeneration following mild traumatic Brain injuries, as well as pathological alterations in neurobiological elements, including neurotransmitters (Dixon et al., 1993). Neuropsychological test data has consistently documented changes on standardized measures of cognitive functioning after mild traumatic brain injury, even in the absence of neurodiagnostic findings. Thus, neuropsychological evaluation is often one of the most sensitive and objective means of detecting brain injury and lends the greatest information regarding rehabilitation needs and treatment directions.

Contributions of Neuropsychological Assessment to Diagnosis and Treatment

The primary goals of a neuropsychological assessment usually include: a history of the client's problems, including a review of past and current medical conditions; a description of the client's intellectual, cognitive, sensory, and psychomotor skills; a description of the client's emotional and behavioral status; and a description of family support systems and their value to the client. The information contained in the neuropsychological report is intended to facilitate and enhance rehabilitation treatment planning and goal setting. The main challenge to the neuropsychologist is to extract and integrate all of the above information to develop a coordinated treatment plan that incorporates the client's unique neuropsychological profile. Because persons with head injuries constitute a diverse group, the assessment process should be tailored to meet the unique needs of the client and answer the questions most important to the professionals who treat them (Bergquist et al., 1994). The assessment and descriptive report should address referral questions pertaining to the client's intellectual, cognitive, sensory, psychomotor, and emotional skills. Questions may be diagnostic in nature, asking for information concerning the nature of the client's symptoms and complaints in terms of their etiology and prognosis. Questions may also be descriptive, inquiring into the characteristics of the client's condition, such as asking how the client's problems are expressed (Lezak, 1983).

Traumatic brain injury can result in a wide variety of functional impairments. Therefore it is important to evaluate clients using diverse tests that are indicative of a wide variety of abilities and to communicate the results in a manner that is useful for other rehabilitation professionals (Kreutzer, Leininger, & Harris, 1990). Neuropsychological functions typically assessed include: general intellectual ability, verbal, perceptual, constructional, and executive functions; memory ability, orientation and attention, and motor performance; and personality, social, and emotional functioning. Data on intellectual functioning reflects a person's general fund of knowledge and capacity for new learning. This is an important function when considering re-training as part of a vocational rehabilitation program.

Verbal functioning, the ability to understand and use words effectively, is imperative for social functioning. A person's spontaneous speech, as well as his/her speech comprehension, naming, reading, and writing abilities will influence all aspects of job selection, training, and performance. Similarly, data on perceptual functioning, which encompasses vision, audition, and sensation, provide an understanding of a client's perception of her/his world. Personal safety and driving ability are two important functions that are highly dependent on perceptual abilities.

The ability to draw, copy, and complete two- and three-dimensional constructions may also be affected as a result of mild traumatic brain injury. Impaired constructional ability can make even the simplest of home repairs quite difficult and may greatly interfere with the work of persons who operate machinery or do assembly work.

Impaired memory ability interferes with the learning of new tasks and the retention of previously learned material. The ability to learn and recall visual, verbal, and tactile information allows one to organize the world and one's experiences in a predictable, purposeful manner. Thus, clients with any level of memory impairment may not only have difficulty recalling how to perform certain aspects of their job; they will have difficulty learning new job skills and dealing with any social and organizational changes at their place of employment.

Problems with orientation can include impaired time and distance estimation and impaired spatial, body, and topographical orientation. Functionally, this can contribute to problems maintaining a time schedule, driving, and following directions. Furthermore, a common sequela of mild traumatic brain injury, altered attention abilities, may make concentrating on even the simplest of tasks a major challenge. Difficulties with divided attention may prevent a person from being able to complete more than one job task at a time.

Conceptual and executive functioning abilities include mental flexibility, sequential planning and problem solving, abstract reasoning, and self-regulation. Clients with impairment in these areas can complete individual job tasks but may have great difficulty devising and following a sequence of job tasks to completion, especially if problems arise during the sequence that necessitate flexibility and creative problem solving.

Finally, mild traumatic brain injury may impair motor functions. This can result in decreased ability to coordinate eyes, hands, and feet, to manipulate objects, and to physically respond to visual and auditory stimuli.

In analyzing and interpreting neuropsychological test results, the neuropsychologist is asked to make three important judgments for each skill area assessed (Kreutzer, Leininger, & Harris, 1990). First, the client's performance within a given functional domain is determined by comparing her/his performance to that of the normal population. This comparison should be made to those of a similar sex, age, and level of education. Second, a determination is made about how the client's performance has been affected by the injury. Knowledge of common traumatic brain injury sequelae, reported symptoms, estimation of premorbid level of ability, and review of academic and vocational history should be used by the clinician to determine Which functional skills are impaired relative to pre-injury status. Lastly, the clinical neuropsychologist estimates whether a client's functioning in each skill area has declined, improved, or remained the same. This information is then analyzed by direct comparisons with prior test scores, self-and family report, subsequent injury or disease, recovery, medication, emotional and personality data.

In addition to resultant quantitative test data gathered as part of the neuropsychological assessment, direct observations of the patient's behavior during the course of the evaluation can provide invaluable qualitative data. Behavioral observations can be used to supplement quantitative data regarding the patient's emotional and personality functioning, approach to problem solving, frustration tolerance, interaction style, processing speed, as well as attention and concentration abilities. Additionally, it provides data on the client's attitude toward testing and her/his condition (Lezak, 1983). This information can be used by vocational rehabilitation professionals to structure training and work environments, and to provide feedback to the client.

Assessment of personality and emotional status is an important component of the neuropsychological evaluation for several reasons. In order to evaluate the patient's performance on the cognitive tests, the clinical neuropsychologist needs a basis for estimating the extent to which characterological predisposition, emotional state, and motivation affect the client's efficiency (Lezak, 1983). Documentation of social behavior patterns and emotional functioning that are symptomatic of particular brain disorders may play a large role in treatment planning and vocational rehabilitation efforts. For example, despite having the physical and cognitive skills to be able to perform his job as a sub-assembler at an automobile production plant, a 45 year old male client who has sustained a mild TBI as a result of a motor vehicle accident was unable to meet production quotas. Specifically, because of his increased level of irritability and decreased frustration tolerance, previously enjoyable "visits" from co-workers became irritating, difficult-to-manage interruptions that frequently ended in verbal altercations. Prior knowledge of these social and emotional functioning difficulties would have allowed this client's rehabilitation counselor to implement strategies designed to decrease the occurrence of interruptions and to assist the client in more effectively negotiating interpersonal interactions.

Certain tests of psychological and personality functioning can yield useful insights when interpreted cautiously by a clinician with knowledge of the common effects of brain injury. Information obtained from these tests should always be compared with the client's self-report, behavioral observations, and the report of family members. Additional emotional issues that should be addressed in the neuropsychological report because of the importance they play in vocational planning include the client's self-awareness of strengths and deficits, self-esteem and self-confidence, and extent of agreement between skill levels and personal goals.

In conclusion, the neuropsychological evaluation provides unique and critical information in the overall diagnosis, treatment, and outcome of persons with post-concussional disorders. The comprehensive assessment should address the client's strengths and weaknesses in functional areas, learning style, psychosocial adjustment and personality style, value system, and ethnic/cultural considerations. Furthermore, it should establish a communicative link with the rehabilitation counselor and other rehabilitation team members.

Rehabilitation Following Mild Traumatic Brain Injury

Despite the complexity in diagnostic issues related to post-concussional disorders, the fact is that with appropriate treatment the prognosis for individuals to approach gross levels of premorbid functioning remains favorable. This is corroborated by group studies which indicate that 65-90 percent of those who have suffered mild traumatic brain injuries are able to return to competitive employment (Denny-Brown, 1942, 1945; Fraser, Dikmen, McLean, Miller, & Temkin, 1988; Van Zomeren & Vanden Berg, 1985; Sander, Kreutzer, Rosenthal, Delmonico, & Young, 1996). This contrasts significantly with unemployment figures approaching 70 percent for those who have suffered severe traumatic brain injuries (Fabiano & Crewe, 1995). Furthermore, rehabilitation efforts need not be excessive or drawn out, such that overall costs are relatively "mild" in contrast to severe injuries if provided in an appropriate manner. This recommended approach is in light of intense scrutiny related to the efficacy and cost effectiveness of rehabilitation for those who have suffered traumatic brain injuries (Hall & Wright, 1995). The question of efficacy becomes even more obscured as the vast majority of literature on rehabilitation effectiveness has been obtained on individuals with severe traumatic brain injuries.

A number of studies have indicated the benefits of rehabilitation for those who have incurred traumatic brain injuries. Prigatano et al. (1984) found modest levels of improvement in employment and neuropsychological functioning with subjects who suffered severe traumatic brain injuries and had completed a comprehensive rehabilitation program compared to a control group. Aronow (1987) found that a treatment group of traumatic brain injury survivors achieved a better cost outcome than those who did not complete rehabilitation. Cope and Hall (1982) found that traumatic brain injury patients who received rehabilitation following a longer interval from onset required a longer period of rehabilitation services. These findings were replicated by Hall and Wright (1995) in a separate study of individuals who received early or late admission for rehabilitation. Ruff and Baser (1990) reported findings of significant improvement in memory and attention following completion of a neuropsychological treatment program.

Rehabilitation following mild traumatic brain injury places greater emphasis on the treatment of cognitive, psychosocial, and behavioral issues. Specific cognitive remediative activities in attention, concentration, memory, language comprehension, and higher level problem solving provide an appropriate component of rehabilitation (Sohlberg & Mateer, 1989). Instruction and training in compensatory strategies provides the foundation for a portion of rehabilitation efforts. A significant component of mild traumatic brain injuries is the overall reduction in spontaneous mental efficiency (Sohlberg & Mateer, 1989; Lezak, 1995). This places greater emphasis on the adherence to a more structured approach to daily living. This includes the development of and compliance with daily routines, greater reliance on external information storage systems (such as daily planners and calendars), the use of note taking and audio cassettes to record lengthy information exchanges (such as lectures or meetings), building in structured times for rest, delineating tasks to specific components (thereby reducing complexity), implementing environmental modifications to reduce distractions, and other strategies which place greater emphasis on external assistance, thereby reducing overall cognitive demands to manage large amounts of competing information.

Finally, addressing the psychosocial issues related to alterations in cognitive functions and affective changes is paramount to the rehabilitation process. Many individuals have been undiagnosed or misdiagnosed prior to coming to the attention of appropriate health care specialists. The process of healing begins by providing education regarding mild traumatic brain injury symptomatology. This provides a basis on which these individuals can then accurately attribute their symptoms. Over time, by providing support for psychosocial needs while simultaneously beginning to empower the individual to manage the condition in an adaptive manner, the majority of these individuals are gradually able to regain confidence in their mental abilities, albeit with the assistance of the compensatory strategies that they have learned in therapeutic sessions. Psychological interventions can be augmented with specific pharmacological agents to treat disorders of depression, anxiety, fatigue, and other symptoms. The ability to assist the clients in regaining their confidence can be facilitated by offering a favorable prognosis to return to many of their premorbid activities (Kay, 1991). The result is a gradual return to many premorbid activities, school, and employment. Certain activities may be more difficult and persons with traumatic brain injuries will often have to work harder and in a more organized and systematized manner.

Vocational Rehabilitation

Vocational rehabilitation services are a critical component in the rehabilitation process. While the majority of individuals with mild traumatic brain injuries are able to return to competitive employment, one-third or more will demonstrate reduced productivity resulting in frequent job changes. By working closely with the interdisciplinary team, many compensatory strategies can be implemented within the job site by the vocational rehabilitation counselor as reasonable accommodations under the provisions of the Americans with Disabilities Act (Sachs & Redd, 1993). Employer education can be a crucial component to the process. By providing appropriate accommodations, reinforcing compensatory strategies, and increasing employer education, many of the problems encountered in the workplace can be reduced. In developing a vocational rehabilitation plan, the rehabilitation professional, at minimum, needs to assess the patient's premorbid employment and occupational history, post-injury neurocognitive status, and psychosocial adjustment to the effects of the mild traumatic brain injury. Developing a premorbid employment history should include a review of educational attainment, any vocational training, the types of occupations held, and further details regarding an individual's employment history. This includes the number and duration of jobs held, specific occupations, and specific job demands and tasks associated with particular occupations.

Consultation with rehabilitation professionals including a physician, neuropsychologist, physical therapist, occupational therapist, and speech and language therapist can provide valuable assistance in identifying strengths and weaknesses related to specific occupational demands, as well as developing compensatory strategies. These can be enacted as reasonable accommodations at the work site. These professionals can assist in educating employers about the specific characteristics related to mild traumatic brain injuries, as well as providing consultation within the work environment to implement specific compensatory strategies.

Accommodations

Mild traumatic brain injuries are neurologic disabilities. The disability symptoms are frequently cognitive. Specific accommodations involve various systems and strategies designed to reduce, organize, and retrieve information. Structuring routines, providing tasks and deadlines in writing, developing organizational structures, such as filing systems and daily schedule books, all assist in reducing the effects of an individual's neurological disability and are reasonable accommodations. Using audio cassette players or microcassettes to record meetings or other information can assist in the retention of information necessary to perform a job.

Monitoring an individual's performance, providing corrective actions, and maintaining contact with the employer can assist in the successful retention of employment. The goals are to achieve an appropriate balance between the physical and cognitive demands of a job and the ability of the individual to effectively meet these demands, often with the assistance of accommodations and environmental modifications.

Conclusion

Despite the controversy regarding the diagnosis of post-concussional disorders for over a century, the unfortunate fact is that the disorder exists and occurs at epidemic proportions. The more favorable news is that with accurate diagnosis, including a comprehensive neuropsychological evaluation and appropriate treatment by an interdisciplinary rehabilitation team that specializes in the treatment of mild traumatic brain injuries, the vast majority of individuals are able to restore their lives, stabilize their families, and return to many premorbid activities, including employment.

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Robert J. Fabiano

Julie Daugherty

Michigan State University