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Evaluation and Treatment of Mild Traumatic Brain Injury: The Role of Neuropsychology
Christopher Yeoh. Integrating Neuropsychological and Psychological Evaluations.
- Table of contents.
- Case study: A patient with PCS;
- Neuropsychological assessment in mild traumatic brain injury: A clinical overview?
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- 1. Introduction.
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Neuropsychological assessment in mild traumatic brain injury: A clinical overview
John Marshall. Contributing to these concerns is the finding that many discharge instructions failed to address the possibility that patients may develop persisting post-concussive symptoms [ 4 ]. Overall, these findings suggest a need to develop more clear guidelines regarding discharge instructions and psychoeducation for all patients diagnosed with a mTBI, regardless of whether or not they required hospitalization. Further, additional research is needed to provide more clarification as to when and for whom follow-up care is appropriate. As discussed above, there is a dearth of information provided to patients with mTBI discharged from the ED regarding symptom expectations.
During the acute and subacute phases of recovery from a mTBI, patients generally report symptoms that fall into one of three symptom clusters: somatic e. Commonly reported somatic symptoms include headache, sleep disruptions, dizziness, nausea, visual disturbance, photophobia, and phonophobia. Affective symptoms often reported by patients with mTBI include increased irritability, emotional lability, anxiety, and depression [ 17 , 18 ].
Fatigue is a frequent complaint after mTBI. Research regarding fatigue suggests that it is a multidimensional symptom, with many factors contributing to and exacerbating fatigue, including somatic symptoms, sleep disturbance, cognitive exertion, chronic situational stress, and mental health [ 19 , 20 , 21 , 22 ].
Similar to the cycle of symptom exacerbation observed in fatigue, many somatic, cognitive, and affective symptoms following mTBI interact with and exacerbate each other. Kay and colleagues [ 23 ] described a dysfunctional feedback loop that may result in the maintenance of numerous symptoms even after medical signs resolve. For example, when cognitive difficulties during the early phase of recovery co-occur with pain symptoms or emotional factors, a feedback loop may develop whereby the pain and emotional factors start to elicit secondary cognitive complaints.
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Over time, the interaction between these symptoms strengthens to the point that persisting pain and emotional factors will continue to elicit subjective cognitive complaints even after the primary cognitive complaints have resolved. Other researchers have identified the associations between mTBI symptoms as well. The outcomes of this patient group have generated much controversy, with the emergence of two polar opinions among professionals as to whether these persisting symptoms are the result of neurogenic factors e.
The controversy regarding this patient group has resulted in many researchers attempting to determine the etiology of their symptoms. Numerous studies have reported that patients with a premorbid psychopathology history are more likely to report post-concussion symptoms beyond one month post-injury [ 17 , 29 , 30 ]; however, the same researchers have shown that premorbid psychopathology no longer predicts post-concussion symptoms at the one year mark [ 29 ] and others have shown no association between premorbid psychopathology and post-concussion symptom reporting [ 31 ].
Premorbid personality traits, including perfectionism, grandiosity, individuals with unmet dependency needs, and borderline traits, have been identified as possible risk factors for development of PCS after mTBI [ 23 , 26 ]. Patients who present to the ED with moderate to severe somatic complaints e. Similarly, patients who are highly symptomatic at one month often continue to be highly symptomatic at one year [ 29 ].
Injury characteristics like mTBI severity and extra-cranial bodily injuries predict future PCS symptom development [ 14 , 29 ]. Biological factors that have been identified in prolonging mTBI recovery include genetics, older age, female sex, prior mTBI history, and poorer physical health, to name a few [ 14 , 29 , 30 , 32 , 33 ].
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Various psychosocial factors thought to contribute to poorer outcome post-injury include: disability or unemployment at time of injury, marital status, education level, occupational skill level, cognitive reserve, financial and recreation setbacks secondary to injury, involvement in litigation, substance abuse, and other life stressors [ 29 , 30 , 32 , 33 ].
Uomoto and Fann [ 34 ] found that symptomatic patients with mTBI history tended to overestimate their injury severity level and their residual cognitive impairment when compared with patients who had sustained a moderate or severe TBI. Furthermore, they found that patients who failed performance validity testing TOMM reported fewer premorbid symptoms and more debilitating post-concussion symptoms than patients with mTBI history who passed validity testing [ 35 ].
The literature presents different viewpoints on neurogenic versus psychogenic causes of PCS, and to date the reasons for symptom persistence after mTBI are not fully understood. However, many psychologists engage in patient-centered care, and therefore are able to evaluate, target, and treat the individual needs of each patient experiencing PCS, regardless of symptom etiology. In the sections that follow, the authors will provide a brief review of the evaluation and intervention methods available for patients with mTBI history within the field of neuropsychology, rehabilitation psychology, and cognitive rehabilitation.
The purpose of a neuropsychological evaluation is to assess the cognitive and functional deficits resulting from a neurological disorder or injury. As part of a comprehensive evaluation, the neuropsychologist conducts a thorough clinical interview that reviews the presenting condition and associated symptoms as well as premorbid patient characteristics and psychosocial history factors that may be contributing to the clinical presentation.
This detailed, holistic approach to evaluating the patient is especially helpful when it comes to working with patients recovering from a mTBI since, as discussed above in Section 5 , there are many confounding factors that are likely contributing to and exacerbating the symptomatic presentation. In addition, earlier evaluation ensures that the patient receives psychoeducation regarding mTBI and the expected recovery trajectory, the importance of which is discussed in more detail below in Section 7. The observed deficits can be relatively subtle and are influenced by numerous factors, including injury severity, time since injury, and the specific neuropsychological measures used [ 36 ].
With regard to the influence of time since injury, Karr and colleagues conducted a systematic review of meta-analyses and found that multiple studies report a return to cognitive baseline by 90 days post-injury [ 37 ]; however, some patients who have developed a more chronic PCS continue to show neuropsychological impairments on testing [ 25 , 33 ].
There is also great variability across neuropsychological tests with regard to their ability to capture cognitive deficits secondary to mTBI [ 37 ].
With regard to an evaluation of a patient with a mTBI, thorough assessment of attention, processing speed, executive functions, and memory is necessary to capture any current cognitive deficits. Mood measures should assess for symptoms of depression, anxiety, irritability, and emotional lability. Finally, inclusion of a self-report measure that captures symptoms that are common after a mTBI is recommended since the patient may have trouble relaying all of their symptoms during the clinical interview.
These measures also provide the patient with a method for ranking the severity of the symptoms at the time of the evaluation. When interpreting cognitive test performance, the neuropsychologist looks for patterns of deficits across the tests, since one test score indicative of impairment does not necessarily translate into diagnosis of a cognitive deficit.
Table 1 details a sample mTBI battery used by one of the authors C. Providers are encouraged to develop batteries based upon the individual needs of their patients as well as the referral question.
While several decades of research have established an increasingly clear picture of typical mTBI symptoms and the complexity of persisting PCS, research on effective interventions for this population has yielded mixed results, and therefore has not yet supported professional consensus on mTBI treatment. Despite the relative dearth of well-controlled prospective research studies in this population, the existing literature does provide preliminary support for a number of behavioral interventions for management and amelioration of symptoms following mTBI.
Given the complexity and variability of presenting problems after mTBI as detailed above, treatment must account for multiple factors including cognitive, emotional, and somatic symptoms. Neuropsychologists and rehabilitation psychologists are uniquely suited to manage care for these concerns holistically, given our expertise on psychological and cognitive functioning, as well as an established presence in Neurology and Rehabilitation departments.
The following section provides an overview of neuropsychological interventions for individuals who have sustained a mTBI.
Most individuals who sustain a mTBI spontaneously recover fully within the first few weeks or months, but a significant minority continue to experience persistent symptoms for months or years following injury [ 39 , 40 ]. A small but significant body of research has addressed the question of whether psychoeducational and supportive interventions in the acute phase after mTBI can prevent progression to persistent PCS. These interventions are based on the theory that persistent PCS is associated with attribution of symptoms to the mTBI and negative expectations about recovery [ 41 ].
Such interventions typically involve education on post-concussive symptoms, reassurance and education on the expectation for complete recovery, and guidance regarding rest and gradual resumption of typical activities. Psychoeducational early interventions have the strongest empirical support of any post-mTBI interventions, with several systematic reviews concluding they are well supported [ 42 , 43 , 44 ].
Traumatic brain injury
One recent systematic review with stringent methodological exclusion criteria [ 45 ] found that only two studies in the entire corpus of research on mTBI treatment met its standards; one supporting telephone-based early educational intervention [ 46 ], and one supporting recommendations for bed rest in the acute recovery phase [ 47 ]. Acute care for mTBI is typically provided by medical professionals, including ED staff and primary care physicians [ 48 , 49 ]. Individuals are often not referred for consultation with a neuropsychologist until their symptoms persist beyond the typical period of spontaneous recovery.
However, it is our opinion that the literature on early intervention after mTBI supports earlier consultation with psychology or neuropsychology, particularly for individuals at highest risk for developing persistent PCS. Psychological distress and psychosocial stressors are associated with greater likelihood of progression to persistent PCS [ 23 , 24 , 25 , 26 ], and neuropsychologists and rehabilitation psychologists are well equipped to provide early educational interventions that address the interplay of cognitive, emotional, and somatic symptoms.
In short, early consultation with Neuropsychology may be beneficial to more comprehensively address the needs of the subset of patients who are most at risk for persisting PCS. Current research supports early psychoeducational and supportive services after mTBI [ 42 , 43 , 44 ]; we would argue for broad application of such services, as these interventions are brief, relatively low cost, and may prevent progression to PCS, hence decreasing the individual burden of disability as well as the societal burden of more resource-intensive services.
A relatively smaller amount of research has examined interventions for the significant minority of individuals who continue to experience post-concussive symptoms for months or years. Awareness of PCS has increased in recent decades, due in part to high frequency of mTBI in the conflicts in Iraq and Afghanistan, as well as well-publicized cases involving athletes. The research literature on specific treatments for PCS is limited, and systematic reviews have consistently concluded that the existing literature is limited by methodological inconsistency [ 43 , 44 , 45 ]; however, clinicians can also refer to the much larger literature on treatment of specific symptoms common to PCS, such as cognitive rehabilitation for attention deficits, or cognitive behavioral therapy for symptoms of depression and anxiety.
Thorough discussion of specific interventions is beyond the scope of this review, but we strive to provide a brief overview of the types of treatments for PCS that may be provided by neuropsychologists and rehabilitation psychologists. The first step in treatment planning is a thorough neuropsychological assessment.
Related Neuropsychological Management of Mild Traumatic Brain Injury
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