Betty Clooney Center: Serving Persons with Traumatic Brain Injury with TBISince 1983

Undetected Mild Brain Injury Can Wreck Lives

November 21, 2000 - By Claudia Stahl

A car accident has occurred. A shaken driver emerges, thankful that his seatbelt saved him from an unwelcome encounter with the windshield. His slight whiplash seems trivial compared to a crumpled rear bumper. But the car’s damage is obvious, and will be quickly repaired. The driver’s damage, however, might be far more evasive. If he sustained a minor (or mild) brain injury, the repair process could take years-if it is detected.

Mild brain injury can occur if the brain suddenly shifts in the skull. Impact to the head or forceful shaking may be enough to cause stretches or tears in nerve fibers on the brain that affect any number of performance skills. The damage evades CT scans and MRI, but not the tests of daily living.

“This is a disorder that reflects itself in life,” said Elaine Woo, MD, program director of the brain injury program at Spaulding Rehabilitation Hospital in Boston. “Patients with mild brain injury say, “I can’t pay attention; I’m easily overwhelmed; I can’t organize or finish tasks.” All of the things we call our executive skills are affected, and these are (controlled) in the front of the brain.”

The physical forgiveness of mild brain injury is perhaps a tragic irony. In most cases, patients walk into the emergency room, are treated for back pain, neck pain, or other obvious physical problems, and released. “They seem fine until they return to work and realize they do not have the same planning skills. Or until they realize their home management abilities are lost-bills go unpaid, meals get simpler because they cannot keep track of preparing more than one food at a time. They avoid parties or going out to restaurants because the background noise is too distracting,” said Pauline Fiorello, OTR/L, senior therapist at Spaulding.

Mild/minor brain injury is slowly becoming recognized as a distinct diagnosis. In 1986, Thomas Kay, PhD, coordinator of the Head Trauma Research Project at the New York University Medical Center, published a paper, Minor Head Injury: An Introduction for Professionals, for the National Head Injury Foundation. In it he explained that diffuse minor brain injury does not affect domains of cognition such as language and perception, but commonly affects the “overall speed, efficiency, execution and integration of mental processes,” noted Dr. Kay. “People with mild brain injury may not be able to quickly process tasks or handle too many responsibilities at one time. Shifting attention among tasks can be equally problematic, resulting in a decreased ability to problem solve.”

An injury specific to an area of the brain is known as a local mild brain injury. These are often caused when the frontal and temporal lobes of the brain come in contact with the skull and are bruised. The deficits are similar to those which occur in diffuse mild brain injury, but can be more specialized.

In any case, the combination of problems experienced by people with mild head injury can lead to difficulties with abstract thinking and judgment, Dr. Kay explained. Theses are the complications which escape standardized methods of detection.

There are somatic problems resulting from the injury. Dr. Woo said theses may include headache; nausea; dizziness; fatigue; impaired sense of smell, taste and hearing; ringing in the ears and/or double vision. Psychological symptoms such as mood swings, loss of normal inhibitions, depression and irritability are also directly relatable to such an injury.

Fiorello said in too many instances individuals with theses injuries are told time and again there is nothing wrong with them-that they will get better. But without intervention, they might not get better. The end result can be devastating-social isolation, and depression.

“It’s not atypical for patients to come in and say they had been to psychiatrists and neurologists who were not even aware of mild brain injury,” said Fiorello.

Dr. Woo described the condition as “a disorder of coping.” Normal adaptation mechanisms, such as closing a door to a noisy hallway, are no longer natural solutions.

Dr. Woo said 100-200 patients with mild head injury are admitted to Spaulding each year. Most have been referred by physicians, bosses or family members who have noticed their deficits. Some are referred by lawyers who need medical documentation that there is something wrong with their clients.

“The person looks normal and can hold a normal conversation,” said Fiorello. Dr. Wood pointed out that more 50 percent of mild head injuries are sustained in car accidents, so legal actions surrounding the injury are common.

The goal of therapy with mild brain injury patients is not to assist them in regaining the skills they’ve lost, but rather to recognize and adapt to the deficits. Visual cues and structures are often the key to a more successful lifestyle.

Prior to injury, a person with mild brain injury may have been able to keep mental track of everything. Therefore the first step that a therapist may need to take is to convince the individual that visual and auditory aids such as wall calendars, electronic organizers and watches with alarms, will help them to remain organized and manage their time.

Patients with mild brain injury also may need assistance with driving. “Many people report they get lost, that they cannot drive in traffic…..or that they cannot drive and listen to the radio. We do pre-driving evaluations here.’ said Fiorello.

The most effective method of rehabilitation for patients with mild brain injury is to provide them with structure, Fiorello believes. She educates them about how to control their environment, rather than be controlled by it.