Discursive Essay on Central Neuropsychological Issues in Relation to Understanding of Mild Traumatic Brain Injury

There are many focal areas of neuropsychological disturbance associated with mild traumatic brain injury (mTBI). These include; impaired verbal retrieval, attentional deficits, and emotional distress. Equally other domains can be affected, for example, processing speed and memory, however, descriptions of mTBI most commonly include the first three. These issues may not present until a number of days after the insult. This may be due to the presence of other distracting injuries or because of cessation of normal duties due to visceral complaints of headaches and dizziness.

Verbal retrieval deficits may be unveiled through difficulty in recalling words readily, whether those be names, places, or objects. This dysnomia may produce misnamings or paraphasias with the substitution of similar semantically linked words, for example saying,” car,” instead of,” drive” (1) Such a presentation may be misconstrued as a memory failing, and yet it can be differentiated by utilizing cueing techniques. These can allow the patient to show their ability to know the word that they have difficulty recalling spontaneously. Hence, there is not infrequently a complaint of memory problems from this patient cohort which is actually attributable to an attentional and retrieval deficit rather than a memory problem per se. (2)

Slowed processing will present itself as an attentional deficit. This means that patients may be highly distractable, of poor concentration, and may have little ability to work in tandem at parallel tasks. There can be seen a tendency to underestimate time intervals and when there are severe attentional issues, the patient may experience disconcerting disorientation and even confusion.

During the first weeks following injury, in particular, activities that were previously automatic, such as mental calculations, reading, planning daily tasks, etc. require an intense focus. This loss of automaticity results from diffuse microscopic loci of damage throughout the whiter matter and upper brain stem. These increased requirements for concentrations, lead to a pervasive sense of fatigue. This symptom can be particularly disabling and is reinforced by the emotional dysregulation that is another feature of mTBI. In any illness, fatigue and tiredness will produce increased irritability levels and frustration, and this syndrome is no different. In fact, fatigue, mental inefficiency, and emotional dysregulation can be seen as a positive feedback loop, increasing the effect of the others. Education regarding these possible outcomes is essential in managing mTBI. Otherwise, the typical post-concussion syndrome can spiral into anxiety and depression. (3)

A comprehensive neuropsychological evaluation is a non-standardized entity. In a study looking at the current evaluation of patients with suspected mTBI, Blostein and Jones audited 35 trauma centers in the United States. They discovered that fewer than half had a standardized protocol for assessing patients. (6) This is likely a major contributing factor to the 50-90% of patients who go undiagnosed at presentation (7) These patients have a poorer prognosis due to the lack of follow-up or psychoeducation that can be afforded to them. An appropriate battery of testing would include the following areas; processing speed (Trail making test A), language (Boston Naming Test), visuospatial (Rey Complex Figure Test), executive functions (Trail Making Test B), memory (Story learning), attention (Continuous Performance Test of Attention). These tests will be compared to a premorbid estimate of functioning.

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Whilst the features of neuropsychological impairment in this syndrome are well typified, consensus regarding the expected course of the disease process is heterogeneous. Most individuals would be expected to recover normal neuropsychological function within 1 to 3 months. A systematic review of meta-analyses was carried out by Karr et al, which demonstrated a resolution of cognitive impairment at 90 days (8) However, some studies have suggested that subtle aspects of attention and working memory could be seen to be impaired even at 5 years post-injury (4). The minority of patients that report deleterious problems months after injury (a phenomenon known as a post-concussive syndrome) have polarised opinions among healthcare professionals. One side of this dichotomy attributes symptoms to neurological damage sustained from the injury itself. Others have theorized that chronic complaints of cognitive dysfunction have etiology in psychogenic factors such as pre-morbid personality or the acquisition of monetary gains that may be afforded to injured parties. (5) A number of studies have demonstrated a correlation between pre-morbid psychological vulnerabilities and the development of post-concussive symptoms (9) This would support the latter argument. This must be balanced by the evidence of studies, which shows that the severity of the injury is a strong predictor of future PCS development. (10)

There are relatively sparse volumes of literature on the utility of early neuropsychological interventions in preventing post-concussive syndrome. The best-supported practices are education on post-concussive symptoms, the likely course of illness, and reassurance that recovery is expected to be complete for the majority of patients. Advice regarding a period of rest before an incremental return to activities is another important piece of advice. These early psycho-educational interventions are supported by a number of systematic reviews (11) Such evidence would support the integration of educational sessions as part of the standard of care for those who have sustained mTBI. This is particularly true for populations that are at higher risk of PCS, for example, lower socio-economic groups, older persons, and those with pre-existing disabilities.

Treatment options for those with established PCS are largely extrapolated from existing modalities used for specific symptoms that are frequently reported in those with the syndrome. This is due to a lack of data regarding the minority of patients who have long-term problems following mTBI. The two main arms of treatment for these patients can be described as cognitive rehabilitation and psychotherapy. A systematic review of outcomes in a military population who undertook cognitive rehabilitation following mTBI has supported their efficacy in improving function. (12) Therapy in this domain can be applied to treat attention dysregulation which is a common feature of PCS, impacting concentration, functional memory, and task orientation. Examples of interventions with consensus backing include Time Pressure Management and Attention Process Training. The impact of this can be strengthened with education on strategies of compensation to manage attentional capacity.

Executive dysfunction can have a particularly far-reaching negative influence and can be challenging to ameliorate. Traditionally there will be a graded approach taking in a number of stages. Initially, there must be a development of awareness, which will allow for visualization of possible obstacles in relation to a task. This will facilitate the execution of tasks that must be followed by an evaluation of performance. One such therapeutic framework is the Cognitive Orientation to Occupational Performance.

Interventions for memory deficits can be internal or external. Visualization association techniques can allow the individual to tack on new information to that which is already familiar. Converting complex new information into more manageable blocks is useful as is utilizing acronyms. External techniques are myriad in the modern age and can include the use of alarms, calendars, and memory apps available on smartphones.

Cognitive rehabilitation should be integrated with psychological interventions addressing the emotional distress associated with PCS. Possible strategies include CBT, mindfulness sessions, or talk therapy. The greatest evidence exists for the utility of CBT in this domain.

References

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