Final words on mTBI & iatrogenic morbidity

The purpose of any article is to both inform and to stir debate, and Drs Steven Anderson and Shao Hua Lu [BCMJ 2008;50(1):11] have taken issue with some of the comments made in my article published in your journal in November 2007 [BCMJ 2007;49(9):495], where I did express concern about the definition of mild traumatic brain injury (mTBI) as proposed by the American Congress of Rehabilitation Medicine (ACRM) in 1993. 

As I noted in my initial report, the committee of the ACRM which made this definition consisted of seven psychologists, five physiatrists, one registered nurse, and one registered clinical counselor. There were no neurologists, no neurosurgeons, and no psychiatrists on the committee. 

Criteria offered to make the diagnosis of mTBI consisted of at least one of the following:

• Any loss of consciousness.

• Any loss of memory for events im­me­diately before or after the accident.

• Any alteration in mental state at the time of the accident; e.g., feeling dazed, disoriented or confused.

• Focal neurological deficits that may or may not be transient.

As can be seen, and I emphasized this aspect in my article, the criteria re­quired to make the diagnosis of mTBI were very lax and made no provision for other possible causes such as transient anxiety, disbelief, or even distraction at the time of the incident. Indeed, there continues to be some controversy, even among physiatrists themselves, regarding the role of this medical specialty in the care of people with alleged traumatic brain injury.

In 1999, at the Third World Congress on Traumatic Brain Injury in Que­bec City, Zasler (Physiatry)[1] noted that “in general, physiatrists are the best suited physicians to direct brain injury rehabilitation programs,” but “one of the biggest problems in this field is that of the continued disparity in nomenclature used by physiatrists as well as by other medical specialists.” 

The author also noted that physiatrists should remain aware of the potential for secondary gain, malingering, chronic pain and pre- and postinjury psychiatric disorders to affect subjective symptoms or the recovery course (or both). Indeed, while the mTBI Committee of the Head Injury Special Interest Group of the ACRM propose the definition of mTBI, the World Health Organization notes no consensus with regard to the definition of mTBI.

While my colleagues state that prior to the ACRM definition of mTBI being published in 1993 that postconcussive symptoms were poorly defined and patients were given a number of labels which they noted, this is not correct and I would refer to a number of references in the literature with, among others, Jennett.[2] 

An editorial in the British Journal of Psychiatry[3] also described symptoms of the postconcussion syndrome which have been followed for many years prior to the ACRM proposed definition of mTBI. Specifically, there should be loss of consciousness under 20 minutes, posttraumatic amnesia of under 1 hour, and a Glasgow Coma Scale score between 13 and 15.

At no stage did I deny that physiatrists are important in following and treating patients during brain rehabilitation programs with persons who have suffered major head injuries. My colleagues have, however, either misread or misinterpreted the article where the danger of iatrogenic morbidity was emphasized. Specifically, there is the danger of producing symptoms of anxiety and depression de novo in making the diagnosis of mTBI based on lax criteria already mentioned. If any of our patients’ symptoms are iatrogenic, we have done them a disservice.

This aspect was once again em­phasized in my article and hopefully my colleagues would take heed that physicians should be most cautious in labeling any patient with a traumatic brain injury, especially as the proposed criteria in making such diagnosis are so lax and ill-defined.

—H. Davis, MD
Vancouver

This letter concludes the debate.—ED