Evaluation and Treatment of Mild Traumatic Brain Injury: The Role of Neuropsychology.

brain sciences Review Evaluation and Treatment of Mild Traumatic Brain Injury: The Role of Neuropsychology Carolyn Prince 1, * and Maya E. Bruhns 2 1 2 * JFK Johnson Rehabilitation Institute, Center for Brain Injuries, Edison, NJ 08820, USA Alta Bates Summit Medical Center, Oakland, CA 94609, USA; Correspondence: ; Tel.: +1-732-906-2640 (ext. 42242) Received: 1 July 2017; Accepted: 9 August 2017; Published: 17 August 2017 Abstract: Awareness of mild traumatic brain injury (mTBI) and persisting post-concussive syndrome (PCS) has increased substantially in the past few decades, with a corresponding increase in research on diagnosis, management, and treatment of patients with mTBI. The purpose of this article is to provide a narrative review of the current literature on behavioral assessment and management of patients presenting with mTBI/PCS, and to detail the potential role of neuropsychologists and rehabilitation psychologists in interdisciplinary care for this population during the acute, subacute, and chronic phases of recovery. Keywords: mTBI; concussion; PCS; neuropsychology; cognitive rehabilitation 1. Introduction In 2013, an estimated 2.5 million traumatic brain injury-related emergency department (ED) visits occurred in the United States [1]. Although estimates across analyses vary, it is generally thought that 75%–90% of these injuries would be classified as mild [2,3]. These percentages likely underestimate the total number of mild traumatic brain injuries (mTBI) since patients do not always present to the ED following a mTBI, with some patients following up with general practitioners and others not seeking any medical care [2,4]. As a result, a high percentage of mTBIs in the United States and worldwide may go underdiagnosed or unidentified. The purpose of this article is to detail the role of neuropsychologists and rehabilitation psychologists in the interdisciplinary care of patients with a history of mTBI. Our review focuses primarily on civilian adults who have sustained a mTBI, since the additional factors associated with assessment and treatment of children, adolescents, veterans, and/or athletes is beyond our intended scope. Despite this population focus, much of the information covered is likely generalizable across the mTBI population at large. In this review, we aim to provide education on neuropsychological evaluation and treatment of this often underdiagnosed and underserved population. 2. Defining Mild Traumatic Brain Injury Adding to the complication of the likely underdiagnosis of mTBI is the lack of an interdisciplinary consensus regarding what constitutes a mTBI [4–6]. The American Congress of Rehabilitation Medicine (ACRM) was the first to establish diagnostic criteria of mTBI as involving “a traumatically induced physiological disruption of brain function, as manifested by at least one of the following: i) any period of loss of consciousness; ii) any loss of memory for events immediately before or after the accident; iii) any alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused); and iv) focal neurological deficit(s) that may or may not be transient; but where the severity of the injury does not exceed the following: loss of consciousness of approximately 30 min or less; after 30 min an initial Glasgow Coma Scale (GCS) of 13–15; and posttraumatic amnesia (PTA) not greater Brain Sci. 2017, 7, 105; doi:10.3390/brainsci7080105 www.mdpi.com/journal/brainsci Brain Sci. 2017, 7, 105 2 of 14 than 24 h” [7] (p. 86). In their report to Congress, the US Centers for Disease Control and Prevention (CDC) posited a comparable, though less specific conceptual definition of mTBI as “any period of observed or self-reported: transient confusion, disorientation, or impaired consciousness; dysfunction of memory around the time of injury; loss of consciousness lasting less than 30 min” as well as “observed signs of neurological or neuropsychological dysfunction” [2] (p. 2). More recently, the Word Health Organization (WHO) task force on Mild Traumatic Brain Injury put forth a definition based on a review of the literature that varied from the ACRM diagnosis by simplifying the classification of altered mental status to “confusion or disorientation” and changing the “focal neurological deficit(s)” criteria of the ACRM definition to: “Other transient neurological abnormalities, such as focal signs, seizure, and intracranial lesion, which are not requiring surgery.” In addition, the WHO definition allows for the GCS score of 13–15 to be assessed after the typical 30-min timeframe, which accounts for a possible delay in assessment by a qualified healthcare provider [8] (p. 115). The lack of consensus in terminology complicates matters further, with the research literature using terms like concussion, mild head trauma, and mild head injury interchangeably. For clarity, this review will use the term mTBI exclusively. 3. Acute Identification and Evaluation of Mild Traumatic Brain Injury In addition to the lack of a standard definition of mTBI, there is much variability in acute medical management of this common condition. In their evaluation of 41 guidelines related to mTBI, Peloso and colleagues [9] only categorized three as being evidence-based and reported that “in the absence of clear evidence, experts frequently disagree” [9] (p. 111). Blostein and Jones [10] surveyed 35 level I trauma centers in the United States regarding their evaluation and discharge of patients with suspected mTBI. They found that less than half of the centers had a standardized protocol in place for evaluating all patients with suspected mTBI. Foks and colleagues [11] found a similar lack of consistency in mTBI evaluation and management when they surveyed 71 neurotrauma centers in Europe and Israel. Powell and colleagues [12] found that over half of the 197 patients identified as having a mTBI by study personnel were not documented with that diagnosis by medical personnel in the ED. Within the Veteran population, Pogoda and colleagues [13] showed that clinical judgment differed from ACRM-based criteria for mTBI history in 24% of the cases seen for a comprehensive TBI evaluation, with the majority of these disagreements indicating that clinician judgment on mTBI diagnosis was inconsistent with ACRM-based criteria (Clinician N/ACRM Y). This outcome of Clinician N/ACRM Y reportedly occurred more often when veterans reported higher affective symptoms accompanied by lower reported cognitive and physical symptoms. The lack of consistent guidelines regarding acute ED evaluation and management of patients suspected as having sustained a mTBI likely contributes to the estimates that “50%–90% of patients with mTBI often go unidentified or undiagnosed in the hospital ED” [14] (p. 272). Patients who go undiagnosed may be at a higher risk for a “complicated recovery” [12] (p. 1554) because they are not provided with psychoeducation regarding (...truncated)