TRAUMATIC BRAIN INJURY 1998

Diagnosis of Mild TBI | Prognosis for Coma | Rehabilitation

SUMMARY Criteria for establishing the existence of mild TBI remain problematic. There is no objective gold standard.

Determining whether mild head trauma has resulted in mild TBI is a medicolegal conundrum of epidemic proportions. Annually between 1% and 2% of the North American population suffer head trauma¹, and the majority of head injuries are minor.

PRACTICE POINT

Pitfalls in the Diagnosis of Mild TBI 1. Objective clinical findings sparse 2. Symptoms
	a. nonspecific b. common in the non head-injured
3. Neuropsychological abnormalities
	a. rarely diagnostic b. common in normals

No diagnostic method is close to exact science. Tests that are too specific will fail to diagnose some cases of mild TBI, whereas tests that are too sensitive will diagnose TBI that does not exist².

Attending physicians and independent medical experts reviewing for the claimant lawyer will inevitably err by sometimes incorrectly diagnosing TBI, whereas defence independent medical experts will inevitably miss some cases.

A major source of diagnostic difficulty is that the majority of symptoms of mild TBI are both incapable of being validated objectively, and common in those who have chronic pain from non-head injury³, and even in the uninjured population¹.

Abnormalities on neuropsychological testing in one or more of the standard battery of tests are sufficiently common in the noninjured population that considerable caution is required in interpreting such test results in isolation².

Where a typical profile of "frontal lobe" tests (a misnomer) is present, the diagnosis is usually corroborated by other medical evidence.

Prognosis for Coma | Diagnosis of Mild TBI | Rehabilitation

SUMMARY Evoked Potentials within the first week are the best predictors of the outcome of TBI coma.

Canadian researchers showed⁴ that, in contrast with coma from oxygen-deprivation, neurological examination is a poor prognosticator for TBI coma and electrophysiological testing is much more useful.

PRACTICE POINT

Prognostic Tests for TBI Coma: 1. First week Evoked Potentials
	a. Brainstem b. SomatoSensory
*2. ElectroEncephaloGraphy (EEG)?*
3. NOT neurological assessment

In particular, brain stem auditory evoked potentials (BAEP) and somatosensory evoked potentials (SEP) within the first week are the most useful tests, whereas the additional contribution from ElectroEncephaloGraphy (EEG) is unclear.

Litigators can reasonably expect attending physicians to provide a meaningful estimate of outcome from an early stage of TBI coma.

Rehabilitation | Prognosis for Coma | Diagnosis of Mild TBI

SUMMARY There is little empirical evidence that formal rehabilitation programmes have a material impact on Traumatic Brain Injury.

A team of researchers undertook⁵ systematic review of over 3000 medical research papers to answer key questions about the efficacy of rehabilitation for TBI.

PRACTICE POINT

Benefit from Rehabilitation Programmes:

1. Early multidisciplinary - no proof
2. Intensity, specific types - no proof
3. Cognitive - modest benefit
4. Supported employment - perhaps
5. Care-coordination - conflicting evidence

1. Should interdisciplinary rehabilitation begin during the acute hospitalization for traumatic brain injury?

There was no evidence for or against early rehabilitation in patients with mild to moderate injury. A single case series study supported an association in severe TBI between acute provision of rehabilitation on the one hand and decreased length of hospitalisation and some short-term non-cognitive outcomes on the other.

2. Does the intensity of inpatient interdisciplinary rehabilitation affect long-term outcomes?

No quality studies existed to answer this question. Neither amount of time nor selection of particular treatments could be shown to have a beneficial long-term effect.

3. Does the application of cognitive rehabilitation enhance outcomes for people who sustain TBI?

There was limited quality research that computer-aided cognitive rehabilitation (CACR) improved immediate recall on neuropsychological testing, but the clinical relevance remains uncertain. A single moderate quality study found that Compensatory Cognitive Rehabilitation (CCR) reduced anxiety, and improved self-concept and interpersonal relationships.

4. Does the application of supported employment enhance outcomes for people with TBI?

Supported employment might improve vocational outcome, according to a couple of moderate quality research papers.

5. Does the provision of long-term care coordination enhance the general functional status of people with TBI?

Significant functional improvement might result from case-manager approaches, though the results of research were conflicting.