This tool represents a standardized method of evaluating people after concussion in sport. This tool has been produced as part of the Summary and Agreement Statement of the Second International Symposium on Concussion in Sport, Prague 2004.
The Family Physician's Role in Caring for the Patient With Traumatic Brain Injury
By Frederic A. Rawlins III OMS III, Per Gunnar Brolinson DO, FACOFP, Dixie Tooke-Rawlins DO, FACOFP
ABSTRACT: The family physician has long cared for patients with acute minor traumatic brain injuries (MTBI) - from minor sports related injuries to falls in the elderly - as well as provided long-term care for patients with severe traumatic brain injury. For many years the complex sequelae that may relate to MTBI were not recognized. Today the family physician needs to be cognizant that MTBI is a complex process, associated with residual effects including confusion, disorientation, memory disorders, headaches, irritability, cognitive disorders, and social difficulties. The family physician must be prepared to care for the patient with MTBI with medical management and as the coordinator of the health care team. The family physician may also manage the long-term care of the patient with severe traumatic brain injury after discharge from neurosurgery and physiatry. As patients progress in the first five years following a head injury, it is imperative for the family physician to be knowledgeable in the comprehensive care of patients with traumatic brain injury. This article presents a review of the literature on traumatic brain injury, focused on the family physician’s role in patient care.
Introduction
Traumatic brain injury (TBI) is a significant cause of death, disability and financial burden in the United States. According to the CDC, TBI is responsible for 50,000 deaths and 235,000 hospitalizations per year.1 TBI accounts for 1.1 million visits to Emergency Departments annually.1 Mild traumatic brain injury (MTBI), sometimes also referred to as concussion, accounts for
75 percent of all traumatic brain injuries in the United States. MTBI costs the nation nearly $17 billion per year.2
In the emergency department, the family physician’s office, or on the field at a sporting event, it becomes the physician’s role to differentiate severe traumatic brain injury from MTBI, or no brain injury at all. Severe Traumatic Brain Injury is associated with extended periods of unconsciousness (greater than 30 minutes), prolonged post-traumatic amnesia (greater than 24 hours), or penetrating skull injury.2
Prevention: The Family Physician’s Role
There are many etiologies of TBI, although falls are the leading cause. Falls resulting in TBI primarily occur in the 0-4 and 75 and older age groups.3 Motor vehicle-traffic related causes result in the highest number of TBI- related hospitalizations. The rate of motor vehicle-traffic related TBIs are highest among the 15-19 year old age group.3
The CDC estimates approximately 300,000 sports and recreation related TBIs occur in the United States each year. Most of these are MTBI and are not treated in a hospital or emergency department. Blast wave injuries are also a leading cause of TBI today due to their prevalence in active duty military personnel.4 Blast wave MTBI is often missed until the residual effects are noted when the patient attempts to return to normal daily activity.
The family physician can be influential in counseling the families they care for in practices that promote prevention strategies. The most preventable causes of mild traumatic brain injury a family physician should address involve the use of bicycle helmets, seatbelts, and the prevention of falls in older populations. The family physician should incorporate education on the prevention of head injuries with the first and subsequent patient visits. The family physician can play an influential role in persuading a family to engage in preventive activities.
Sports Related MTBI
Mild TBI is becoming an increasing concern for the family physician treating sports related brain injuries.5 On an annual basis, of the estimated 300,000 sports related MTBI patients, 12 percent are hospitalized, 55 percent receive out-patient care, and an estimated 34 percent receive no medical care.2 Though there are many sport related causes of mild TBI, those best studied to date include football, hockey, and soccer. Recent studies have shown that the impacts realized by the participants of these three sports are much greater than once believed.
Football and hockey injuries were studied using a tri-axial accelerometer to measure intensity and frequency of impact. The number of impacts that occurred, resulting in measurable acceleration, occurred three times more often in football than in hockey. The average peak acceleration for football-related impacts was 29.2 ± 1.1 g versus an average peak acceleration of 35.0 ± 1.7 g for hockey impacts (p = 0.004). Frequency data were not collected from soccer because of player inability to wear the accelerometer. A reconstructed model measuring impact of players heading a kicked ball demonstrated average head acceleration force of 54.7 ± 4.1 g for soccer.6
A study of questionnaires sent out to university athletes in soccer and football found that 70.4 percent of the football players and 62.7 percent of the soccer players had experienced symptoms of a concussion during the previous year. Only 23.4 percent of concussed football players and 19.8 percent of concussed soccer players realized they had suffered a concussion or MTBI at the time of the injury. The responders reported more than one concussion was experienced by 84.6 percent of the concussed football players and 81.7 percent of the concussed soccer players. Examining symptom duration, 27.6 percent of all concussed football players and 18.8 percent of all concussed soccer players experienced symptoms for at least one day or longer.7
There are a few reasons concussions go unreported in athletics. The most common reasons for concussion not being reported include a player not thinking the injury was serious enough to warrant medical attention (66.4 percent of unreported injuries), motivation not to be withheld from competition (41.0 percent), and lack of awareness of probable concussion (36.1 percent).8
Many methods may be utilized to evaluate the risk of MTBI post-event and no single biomechanical measure is universal. Instead, a composite measure of linear acceleration, rotational acceleration, impact duration and location was found to be the most sensitive and specific in predicting mild traumatic brain injury (MTBI).9
There have been several published guidelines for the evaluation and management of sports-related MTBI. The most recent and, we believe, most clinically useful, come from the Second International Conference on Concussion in Sport, held in Prague in 2004.17 This paper contains a useful clinical evaluation guideline for sports-related concussions called the Sideline Concussion Assessment Tool (SCAT). The tool provides a wealth of relevant information for clinicians caring for the patient with post sports-related concussion. The components include assessment of memory, symptoms, cognitive assessment, neurological screening, and return to play assessment.
Military Service Related Brain Injuries
America’s armed forces in Iraq and Afghanistan are sustaining attacks almost daily from rocket-propelled grenades, improvised explosive devices, and land mines, resulting in blast injuries. While these explosions can result in severe traumatic brain injury and other life threatening injuries, they most often cause mild traumatic brain injury. Over 90 percent of combat-related TBI’s are closed head injuries. With MTBI, there may be no immediate outward sign of injury.4
Many combat injuries are caused by blasts. It has been estimated that over 50 percent of injuries sustained in combat are the result of explosive munitions including bombs, grenades, land mines, missiles and mortar/artillery shells.10 While blast injuries cause the vast majority of MTBI, gun shots, falls, and motor vehicle accidents are also important considerations. The incidence of TBI in the combat setting is estimated to be as high as 22 percent.4
Blast injuries are injuries that result from the complex pressure wave generated by an explosion. The explosion causes a rise in pressure over atmospheric pressure that creates a blast over pressurization wave. Primary blast injury occurs from an interaction between the over pressurization wave and the body. Differences in pressurization wave interaction from one organ system to another cause significant damage. Air-filled organs such as the ear, lung, and gastrointestinal tract and organs surrounded by fluid-filled cavities such as the brain and spinal cord are especially susceptible to primary blast injury. The over pressurization wave dissipates quickly; therefore the greatest risk of injury is directly related to proximity to the explosion.11,12
Nearly 15 percent of soldiers deployed have reported an injury involving loss of consciousness.13 More than 40 percent of those with injuries associated with loss of consciousness met the criteria for post traumatic stress disorder (PTSD). There are strong associations and crossovers of symptoms from MTBI not only with PTSD, but also with depression, physical health symptoms13, and chronic pain.14
Due to the frequency of TBI and its sequelae, the Defense and Veterans Brain Injury Center (DVBIC) stresses a prompt multi disciplinary approach to the care of military members who have experienced TBI. An extensive program has been formed whereby those veterans with a history of TBI may be referred to the DVBIC for a host of examinations, therapies, and rehabilitation programs.4
The family physician should be acutely aware of the frequency of MTBI and work with patients and families to engage veterans, athletes, and others with suspected TBI who are experiencing sequelae, to work with an experienced team to care for the patient (the DVBIC if a veteran). Too often the patient or their family does not recognize a change in emotions or personality that may be a result of a MTBI, and view emotional disability and lack of communication as behavioral problems. This may also be easily confused as PTSD in the returning veteran. The family physician should be suspicious of the possibility of MTBI in their patients who are experiencing these symptoms, make the diagnosis, and assist them with engaging in appropriate care.
Consequences of Traumatic Brain Injury
In a recent study it was estimated that 5.3 million Americans are estimated to have long-term or life-long effects from TBI. These effects include the need for assistance to perform routine activities of daily living (ADL).1 The difficulties experienced in patients with TBI include 1) thinking (memory and reasoning), 2) sensation (touch, taste, and smell), 3) language (communication, expression, and understanding), and 4) emotion (depression, anxiety, personality changes, aggression, acting out, and social inappropriateness). The difficulties in emotion, thinking, and communication interrupt the patient’s integration back into the family and community. Patients with these difficulties are often misinterpreted and experience difficulty gaining employment, making and maintaining relationships, and being a productive member of their family. Patients who do not cope well or who utilize drugs or alcohol may accentuate the emotional difficulties and are frequently arrested. It is important that the patient as well as their family understand the effects of alcohol or substance abuse on TBI.
In addition to the immediate effects seen, TBI can predispose an individual for epilepsy, Alzheimer’s disease, Parkinson’s disease, and other disorders of the CNS that become more prevalent with age.15 Repeated mild TBI’s occurring over a long period of time can result in cumulative neurological and cognitive deficits.
Repeated mild TBI’s occurring over a short period of time (hours, weeks, days) can be catastrophic or fatal.16 As a result of the potential for significant short and long term disability, early recognition and an aggressive multi-disciplinary treatment approach to the care of the TBI patient and their families are the most important role of the primary care physician.
The family physician can improve patient outcomes in those who have sustained MTBI by making an early diagnosis and implementing early treatment. Early MTBI symptoms may appear mild, but they can lead to significant, life-long impairment in an individual’s ability to function physically, cognitively, and psychologically. Although currently there are no standards for treatment and management of MTBI, appropriate diagnosis, treatment, referral, and education of the patient and family are critical for helping MTBI patients achieve optimal recovery. According to the CDC, in most cases of diagnosed MTBI, the patient recovers fully.2, 8, 9 Some research indicates that up to 15 percent of patients diagnosed with MTBI may have experienced persistent disabling problems.8, 9
As traumatic brain injury often results in a complex and broad range of impairments, a broad complex approach to medical management and rehabilitation is also required. Comprehensive care requires strong family support, a team of professionals, and a carefully balanced approach. The family physician is best equipped to assist the entire family in the coordination of care. A treatment approach is shown in the table below.
Minor traumatic brain injury may not require all the services listed above, however any one of the services may be required. MTBI residual symptoms include persistent headache, confusion, pain, cognitive and/or memory problems, fatigue, changes in sleep patterns, mood changes, and/or sensory problems such as changes in vision or hearing (post-concussion syndrome). According to the CDC, the family physician should consider MTBI as the occurrence of injury to the head arising from blunt trauma or acceleration or deceleration forces when one or more of the following conditions are attributable to the head injury:
In the case of MTBI, the family physician must assess the needs of the individual patient in providing the comprehensive care that is needed.
Assessing Concussion and Managing Return to Play
MTBIs may include both concussions and contusions. The term concussion is often used interchangeably with MTBI. However, the category of diagnosed concussions covers a clinical spectrum. Concussion may occur without loss of consciousness. Mild concussion may be present even if there is no external sign of trauma to the head. The Quality Standards Subcommittee of the American Academy of Neurology defines the spectrum of concussions recommended by the College of Neurology used in the management of the athlete in sports. This table is listed to the right.
Mr. Rawlins III is a third year osteopathic medical student at the Virginia College of Osteopathic Medicine (VCOM). Frederic has an interest in TBI and the relationship to the soldier as he is also an Air Force HPSP scholar and a student member of the Association of Military Osteopathic Physicians. Dr. Brolinson is the Associate Dean for Clinical Research at VCOM and the Chair of the Sports Medicine Department. Dr. Brolinson is board certified in Family Practice and in Sports Medicine. He is the Director of the Sports Medicine Fellowship at VCOM and the Head Team Physician for the Virginia Tech Hokies. Dr. Tooke-Rawlins was the founding Dean and has been the Dean and Executive Vice President of VCOM for the past seven years. Dr. Tooke-Rawlins is Board Certified in Family Practice since 2001 and is a Fellow in the ACOFP for the past decade.
The SCAT Card
This tool represents a standardized method of evaluating people after concussion in sport. This tool has been produced as part of the Summary and Agreement Statement of the Second International Symposium on Concussion in Sport, Prague 2004.
| Family Practice Management of Patients with Traumatic Brain Injury |
| Comprehensive Care |
| Medical management |
| Nutritional support |
| Ophthalmology disorders frequently occur, a neuro-opthalmologist should be consulted |
| Audiology and Speech Pathology evaluation and treatment if indicated |
| Physical Medicine and Rehabilitation for difficulties with ambulation/coordination/strength |
| Psychologic testing, counseling for patient and family if indicated |
| Psychiatry consult may also be indicated for medical management of depression or bipolar disorders which may follow a brain injury |
| Substance abuse prevention and intervention/treatment if indicated |
| Neurology evaluation if indicated for seizures or development of neurological disease |
| Cognitive impairments occur very often. Cognitive function may improve over several years |
| Initially occupational therapy is needed depending upon the severity of the impairment from the TBI |
| The patient should be referred for testing and additional non-medical community services to assist with returning to work and/or returning to a technical college or school. Veterans or vocational rehabilitation services are available for testing and assistance |
| Concussion Grades | Immediate Management | Return to Play |
| Grade 1 Concussion: Transient confusion, no loss of consciousness, and duration of mental status abnormalities on examination that resolve in less than 15 minutes. | Grade 1:
|
Grade 1 Concussion Multiple Grade 1 |
| Grade 2 Concussion: Transient confusion, no loss of consciousness, concussion symptoms or mental status abnormalities on examination that lasts more than 15 minutes. | Grade 2:
|
Grade 2 Concussion 1 week Multiple Grade 2 Concussions |
| Grade 3 Concussion: Any loss of consciousness, either brief (seconds) or prolonged (minutes). | Grade 3:
|
Grade 3 - Brief Loss of Consciousness (seconds) Grade 3 - Prolonged Loss of Consciousness (minutes) Multiple Grade 3 Concussions 1 month or longer, based on decision of evaluating physician |
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