Mild Traumatic Brain Injury (mtbi): An Occupational Dilemma William H. Cann, MD MPH Occupational Medicine Trainee Occupational Medicine Trainee University of Washington
Disclosures None This presentation reflects only the opinions of thepresenter presenter. It does not reflect the views of the University of Washington or the Department of the Air Force
Objectives Define mtbi and describe its epidemiology List Signs and Symptoms of mtbi Recognize tools to help hl diagnose mtbi Consider Management Strategy Resources Discuss Return to Work (RTW) challenges and opportunities
TBI: Historically classified by the Glasgow Coma Scale (GCS) score Mild: 13 15 Moderate: 9 12 Severe: <= 8 Generally: Mild: 80% Moderate: 10% Severe: 10%
mtbi A patient with mild traumatic brain injury is a person who has had a traumaticallyinducedphysiological induced disruption ofbrainfunction function, as manifested by at least one of the following: Any period of loss of consciousness; Any loss of memory for events immediately before of after the accident; Any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented, or confused);and 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 minutes or less; After 30 minutes, an initial Glasgow Coma Scale (GCS) of 13 15; and Posttraumatic amnesia (PTA) not greater than 24 hours The American Congress of Rehabilitation Medicine (ACRM), 1993.
Concussion Brain injury defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathological and biomechanical constructs that may be utilized in defining the nature of a concussive head injury include: Concussion may be caused by either a direct blow to the head, face, neck or elsewhere on the body with an impulsive i force transmitted dto the head. Concussion typically results in the rapid onset of short lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours. Concussion may result in neuropathological l changes, but tthe acute clinical i l symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged
Statistics on TBI 2014 CDC report estimated that, in 2010, TBI accounted for 2.5 million emergency department visits, hospitalizations and deaths in the US. 75 90% of thesecases are thought to bemtbi 87% treated and released 11% hospitalized and discharged 2% died 2000 CDC estimate of $12B direct/indirect costs 2006 WA L&I study cited d928 cases of TBI between 1994 2001 with lifetime claim cost of $159M from the WA State Fund
Leading Causes of mtbi Non Occupational Injuries Falls (40%) Motor vehicle trauma (15%) Unintentionally struck by/against events (15%) Assaults (10%) Unknown (20%) Occupational Injuries Falls (40 60%) Motor vehicle trauma (20%) Blunt Force (20%)
mtbi Signs and Symptoms Physical: headache, e, nausea, vomiting, blurred/double vision, balance problems, dizziness, postural instability, light/noise sensitivity, tinnitus Behavioral: drowsiness, fatigue/lethargy, irritability, it depression, anxiety, it sleeping more than usual or difficulty falling asleep Cognitive: feeling slowed down or in a fog or dazed, difficulty concentrating and/or remembering
The Decision to Image Addressed in the 2008 American College of Emergency Physicians Clinical Policy Statement, specifically for mtbi A noncontrast head CT is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia only if one or more of the following is present: headache, vomiting, age greater than 60 years, drug or alcohol intoxication, deficits in short term memory, physical evidence of trauma above the clavicle, l posttraumatic ti seizure, GCS score less than 15, focal neurologic deficit, or coagulopathy. Level A Rec. In mild TBI patients t without t significant ifi extracranial linjuries i and a serum S 100B level less than 0.1 g/l measured within 4 hours of injury, consideration can be given to not performing a CT CT. Level C Rec
Diagnosing mtbi Challenging g symptoms are common with PTSD, Depression, Headache Syndromes, etc. Reasonable mechanism of injury Acute Concussion Evaluation (ACE) Form Injury Characteristics Symptom Checklist Risk Factors for Protracted Recovery Red Flags Follow up Action Plan Montreal Cognitive Assessment
mtbi Natural Course Majority of mtbi patients will completely recover within 3 months of the initial injury Estimates of persistent symptoms and disability after mtbi vary between 5 and 20% Mostcommon persistent symptoms are headaches, dizziness, fatigue, insomnia and visual disturbances Classify headache per ICHD II guidelines and treat appropriately
Post Concussion Syndrome (ICD 10) History of head trauma with loss of consciousness preceding symptom onset by a maximum of 4 weeks Symptoms in 3 or more of the following categories: Headache, dizziness, malaise, fatigue, noise intolerance Irritability, depression, anxiety, emotional lability Subjective concentration, memory, or intellectual difficulties with neuropsychological evidence of marked impairment Insomnia Reduced alcohol tolerance Preoccupation with above symptoms and fear of brain damage with hypochondriacal concern and adoption of sick role
Management Office monitoring is appropriate if symptom severity is decreasing and fully resolve in 3 5 days Referral to a mtbi specialist is appropriate if symptom reduction is not evident 3 5 days after the injury** Consult Clinical Practice Guidelines Ontario Neurotrauma Foundation (ONF) Guidelines State of Colorado Department of Labor and Employment Consensus statement on concussion inn Sport: 4 th International Conference on Concussion in Sport held in Zurich, November 2012. VA/DoD Clinical Practice Guidelines Focus on treating symptoms & patient/family education
VA/DoD Clinical Practice Guidelines VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI Immediately following any concussion/mtbi, individuals who present with post injury symptoms should have a period of rest to avoid sustaining another concussion and to facilitate a prompt recovery. Individuals id with ihconcussion/mtbi should ldbe encouraged to expediently return to normal activity (work, school, duty, leisure) at their maximal capacity. There has been no research evidence that early return to work after concussion/mtbi with or without symptoms is detrimental.
Where to Refer PM&R Neurology Psychiatry ENT Ophthalmology/Neuro Ophthalmology Rehabilitation Specialists Occupational, Cognitive, Vestibular, Speech Brain Injury Rehabilitation Program
Neuropsychological Testing Generally considered at the 3 month mark as most individuals are recovered by then Consider early referral for injured workers Early Neuropsych consultation/intervention Screening Neuropsych evaluation Comprehensive Neuropsych evaluation Normal values extend down to the 16 th percentile Majority of healthy individuals will demonstrate at least one performance score down to the 16 th percentile
Return to Work Rest is key Relative Rest Return to normal work as soon as possible Gradual resumption of duties is recommended If symptoms re emerge after returning to full duty, then monitored progressive return to full llduty is recommended dd Schedule Consideration Shortened work day Allow for breaks when symptoms increase Reduced task assignment and responsibilities Safety Considerations No driving dii (for at least t24 hours) No heavy lifting/no working with machinery No heights due to risk of dizziness/balance problems
Resources for Challenging Cases Consider a referral to Neurology Vocational Services Unit Employment Planning Services Comprehensive Vocational Evaluations Community Employment Services Job Development Job Supports Jobsite Training
Patient Resources
References American Congress of Rehabilitation Medicine (ACRM). Definition of mild traumatic brain injury. J Head Trauma Rehabil 1993;8(3):86 87. Chang, V. et al, Mild Traumatic Brain Injury in the Occupational Setting. PM&R 2011;3:S387 S395. Centers for Disease Control and Prevention. (2014). Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation. National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention. Atlanta, GA. Jagoda, A. et al. Clinical Policy: Neuroimaging and Decision making in Adult Mild Traumatic Brain Injury in the Acute Setting. Ann Emerg Med. 2008;52:714 748. McNamee, S. et al. Minimizng the effect of TBI related physical sequelae on vocational return. J Rehab Research & Develop 2009;46(6):8893 908. McCrory P, Meeuwisse WH, Aubry M, et al. Br J Sports Med 2013;47:250 258. 258 State of Colorado, Department of Labor and Employment Division of Workers Compensation. Traumatic Brain Injury Medical Treatment Guidelines. Effective: January 14, 2013. Accessed online 21 September 2015 at: http://www.healthpsych.com/tools/tbi.pdf VA/DoD Clinical Practice Guideline for Management of Concussion/mTBI. Publiished April 2009. Accessed online 01 August 2015 at: http://www.healthquality.va.gov/guidelines/rehab/mtbi/concussion_mtbi_full_1_0.pdf Wrona, R. The use of state workers compensation administrative data to identify injury scenarios and quantify costs of work related traumatic brain injuries. i J Sft Safety Research h2006;37:75 81. 75