Mild TBIs

Available evidence-based literature indicates people who had a mild traumatic brain injury (MTBI) may have long term effects from the traumatic brain injuries (TBI). Even seemingly inconsequential intracranial injuries, such as concussions, can have long-lasting effects that diminish functionality, cognition, social integration, and overall life satisfaction. A review of the literature has provided arguments for both sustained and short-lived impairments as a result of MTBI, and it is necessary to acknowledge the uncertainty that encompasses conflicting views of permanence and impermanence of symptoms. While it is possible that an individual who sustains a mild traumatic brain injury will experience long-lasting effects, it is also possible that another individual who sustains a similar MTBI will recover fully within one year of the injury. After all, the prognosis and lifelong outcome following MTBI varies widely among patients (Dagher, Richard-Denis, Lamoureux, de Guise, & Feyz, 2013). Common themes of this paper include typical symptoms, different types of MTBI, and risk factors that contribute to permanence of impairment.

Several studies that compared subjects with MTBI to those with more severe TBI have found that a higher level of disability and poorer life outcome is associated with subjects who sustained moderate to severe head injuries (Colantonio, Dawson, & McLellan, 1998). However, 5-7 years after injury, patients who sustained MTBI report significantly less post-concussion symptoms than control subjects (Åhman, Saveman, Styrke, Björnstig, & Stålnacke, 2013), proving that while many individuals who sustain TBI may continuously improve over time, many disabilities that result from TBI are permanent (Ruoff, 2001). Anywhere from 15% to 50% of individuals diagnosed with MTBI may struggle with persistent disabling problems for several years after initial injury, such as post-traumatic headache, sleep disturbance, disorders of balance, cognitive impairments, fatigue and mood or affective disorder for more than the normal recovery period of three months (Dagher et al., 2013; Ahman et al., 2013). Studies that screened for PTSD found that 20% of subjects had developed PTSD and 10% of subjects exhibited three or more post-traumatic stress-related symptoms 12 months after sustaining an injury (Ahman et al., 2013). Additionally, one in five participants with MTBI presented a below average IQ when assessed (Anderson, Brown, Newitt, & Hoile, 2011). Physical, mental, and cognitive limitations that result from mild head injuries also manifest themselves as emotions, such as anger and irritation. Further feelings of societal alienation and lack of understanding contributed to these frustrations and negative emotions (Ahman et al., 2013). The most frequent and persistent symptom reported after MTBI is fatigue, which has wide-ranging implications for daily functioning and quality of life. Fatigue not only affects daily functioning on a personal level, but can also be damaging to relationships with others, as patients sometimes feel that those they are close to often expect them to accomplish more than they are capable of managing (Ahman et al., 2013), which makes maintaining relationships challenging.

Mental health is one long-term outcome that should have more of a presence in the global discussion of TBI. While neurobehavioral consequences are less common than psychological problems, both deserve to be a part of the call to action for mental health awareness (Anderson et al., 2011). Other articles that found even when cognitive impairments resolved relatively quickly after the initial injury, individuals with MTBI reported more emotional distress than their non-injured counterparts (Kennedy, Krause, & Turkstra, 2008).

Even though young adults with mild traumatic brain injury are significantly more functional in areas such as returning to work, overall community integration, and home integration than their severely injured counterparts (Colantonio et al., 1998), there is no significant difference in symptom expression noted between patients with mild head injury and patients with more severe head injury. In fact, one study found that respondents with MTBI generally had more complaints of symptomatic difficulties associated with their injury than subjects who had a severe TBI (Colantonio et al., 1998). This discrepancy could be due to a larger capacity for self-monitoring and regulation and better memory to recall frequency of symptoms found in patients with mild TBI when compared to their more severely injured counterparts (Colantonio et al., 1998). Review of the literature revealed a recurring theme of lost sense of self and accompanying challenges, including feeling unsure of one’s true identity, emotional tendencies, and physical being, as well as facing the daunting task of reestablishing ways to connect with the world (Ahman et al., 2013), all of which could contribute to a lower reported life satisfaction among individuals with mild head injury.

As individuals embark on a process of recovery following their injury, it is important to consider the possibility of disability morphing over time as coping techniques are masterfully employed and perceptions are altered. Recent research has found that an externalized perception of control by others (also known as an external locus of control) has been associated with an increase in disability when subjects were assessed 5-7 years after the injury and 12-14 years after the injury. Studies have shown that lasting and sustainable improvements are often rooted in alteration of one’s perception of control. Doubts about self-worth and ability can stem from the loss of hope someone with an external locus of control often feels (McMillan, Teasdale, & Stewart, 2012). Shifting perceived power from external forces to internal forces could be beneficial for patients with MTBI, and one way to assist in this transition is counseling, which is acknowledged as a key intervention in the management of patients with MTBI (Dagher et al., 2013).

Many articles state that most individuals with mild traumatic brain injury will fully recover within 3-12 months after the injury (Dagher et al., 2013). Individuals with mild to moderate TBI generally report living “normal lives” with academic, occupational and economic ambitions, a satisfactory quality of life, and average cognitive ability and personality profiles (Anderson et al., 2011). This discrepancy in the literature could also be due to varying personal backgrounds of each subject. A survey of college football players found that the impact of one concussion was short-lived and generally didn’t last more than a few days, but a history of several head injuries was associated with long-term deficits and reduced functionality (Marschark, Richtsmeier, Richardson, Crovitz, & Henry, 2000). Certain risk factors have been identified as contributing to prolonged symptoms after injury, including prior head injuries, psychiatric problems, female sex, and litigation/compensation-seeking following the injury (Ahman et al., 2013), as well as post-injury low self-esteem (McMillan, et al., 2012), older age and longer length of stay (Dagher et al., 2013). It is also important to distinguish between complicated and uncomplicated injuries when discussing mild traumatic brain injuries. Complicated injuries are diagnosed by positive acute traumatic intracerebral findings on a CT scan, whereas uncomplicated MTBIs can be diagnosed with a normal CT scan. Patients with complicated MTBI have poorer outcomes than patients with uncomplicated MTBI (Dagher et al., 2013). While impermanence of symptoms and disability is certainly a possibility, there is no guarantee that a mild head injury will or will not result in permanent impairment.

The quality of life for individuals who have sustained MTBIs could be increased if more people were aware of and accepting of the “invisible” disability that often results from MTBI. Educating families and loved ones of individuals with TBI about barriers and challenges can encourage the creation realistic expectations that are tailored to the capabilities of the specific individual. Additionally, the topic of mental health is often neglected in the larger context of head injury research and intervention and deserves to be acknowledged, as increased knowledge of mental health could lead to better outcomes for individuals with TBI in both a short-term and long-term scope.

Åhman, S., Saveman, B., Styrke, J., Björnstig, U., & Stålnacke, B. (2013). Long-term follow-up of patients with mild traumatic brain injury: A mixed-methods study. Journal of Rehabilitation Medicine, 45(8), 758-764.

Anderson, V., Brown, S., Newitt, H., & Hoile, H. (2011). Long-term outcome from childhood traumatic brain injury: Intellectual ability, personality, and quality of life. Neuropsychology, 25(2), 176.

Colantonio, A., Dawson, D. R., & McLellan, B. A. (1998). Head injury in young adults: Long-term outcome. Archives of Physical Medicine and Rehabilitation, 79(5), 550-558.

Dagher, J. H., Richard-Denis, A., Lamoureux, J., de Guise, E., & Feyz, M. (2013). Acute global outcome in patients with mild uncomplicated and complicated traumatic brain injury. Brain Injury, 27(2), 189-199.

Kennedy, M. R. T., Krause, M. O., & Turkstra, L. S. (2008). An electronic survey about college experiences after traumatic brain injury. Neurorehabilitation, 23(6), 511-520 10p.

Marschark, M., Richtsmeier, L. M., Richardson, J. T., Crovitz, H. F., & Henry, J. (2000). Intellectual and emotional functioning in college students following mild traumatic brain injury in childhood and adolescence. The Journal of Head Trauma Rehabilitation, 15(6), 1227-1245.

McMillan, T. M., Teasdale, G. M., & Stewart, E. (2012). Disability in young people and adults after head injury: 12-14 year follow-up of a prospective cohort. Journal of Neurology, Neurosurgery, and Psychiatry, 83(11), 1086-1091. doi:10.1136/jnnp-2012-302746 [doi]

Ruoff, J. (2001). The student with a brain injury: Achieving goals for higher education. health and resource center, george washington university Retrieved from "http://www.brainline.org/content/2008/10/student-brain-injury-achieving-goals-higher-education_pageall.html