TBI and iatrogenic morbidity

In his November 2007 BC Medical Journal article,[1] Dr H. Davis ex­pressed concerns regarding using the definition of mild traumatic brain injury (mTBI) proposed by the American Congress of Rehabilitation Medicine (ACRMD) in 1993.[2] 
 Prior to the ACRMD definition of mTBI being published in 1993, post-concussive symptoms were poorly de­fined and patients were given a number of labels such as minor head injury, post-concussive syndrome, traumatic head syndrome, post-brain injury syndrome, and posttraumatic syndrome. 

Over time the ACRMD criteria for mTBI has become the gold standard. It is now used in research throughout the world.[3] The definition of mTBI is consistent with current scientific findings. Patients can develop physical, cognitive, and emotional difficulties despite having no loss of consciousness or lengthy period of posttraumatic amnesia (PTA). 

The ACRMD definition of mTBI also in­cludes examples of the physical, cognitive, and behavioral changes that occur following mTBI. However, the authors clearly point out that physical symptoms (e.g., dizziness, nausea) could also be caused by peripheral nerve injury or other causes, cognitive deficits (e.g., reduced memory and attention) could be accounted for by psychological disorders or other causes, and behavioral changes (e.g., emotional lability and irritability) could be due to psychological reaction to physical symptoms or other causes.

Dr Davis indicated that there is controversy regarding the role of physiatrists (physical medicine specialists) in the care of patients with traumatic brain injury. However, physiatrists are the specialists who most closely follow and treat patients during their brain rehabilitation programs, such as the programs run at the GF Strong Rehabilitation Centre. Physiatrists tend to take a holistic ap­proach to treating their patients and they have training both in under­standing neurological problems and treating associated musculoskeletal injuries.  

Dr Davis states the obvious when he writes that neuropsychological findings can be due to many factors other than mTBI (e.g., depression, pain, fatigue). This would normally be called a “differential diagnosis.” He also states the obvious in indicating that clinicians can cause iatrogenic morbidity if depression or other disorders are not treated in patients who have also been diagnosed with mTBI. Symptoms of fatigue, insomnia, and cognitive impairment are nonspecific and can present in both mTBI and other psychiatric conditions. A clear history is necessary. 

It is important to correctly diagnosis and treat patients who have mTBI because a small percentage of them (10% to 15%) will have ongoing difficulties, and patients who have had mTBI are at increased risk of developing permanent deficits if they are exposed to subsequent brain injuries. Literature has shown, for example, that there is an increased likelihood of long-term neurological damage and learning disability among athletes who have had multiple concussions. As consultation-liaison psychiatrists we educate patients about their in­juries, including mTBI, and provide support and guidance during their recuperation.

References

1. Davis H. Traumatic brain injury and iatrogenic morbidity. BC Med J 2007;49:495-497.
2. Kay K, Harrington D, Adams R, et al. Definition of mild traumatic brain injury. J Head Trauma Rehabil 1993;8;86-87.
3. Sterr A, Herron KA, Hayward C, et al. Are mild head injuries as mild as we think? Neurobehavioural concomitants of chro­nic post-concussion syndrome. BMC Neurology 2006;6:1-10.