Initial Evaluation and Treatment of Traumatic Brain Injury
YOUR NEUROCOGNITIVE REHABILITATION TEAM:
Conventional neurocognitive rehabilitation
often involves many disciplines. Each discipline has a specific
background and strategies to offer in the recovery process. Below is
a list of some of the more common
disciplines. The practitioners you see will be determined by the particulars
of your injury.
- Neurologist: Neurologists are medical doctors who specialize in conditions of the centralnervous system (brain and spinal cord). They will often act as coordinators of rehabilitation services. They are an integral part of the diagnostic process, as they are the ones that order imaging and other tests that are essential in your diagnosis. Additionally, your neurologist will prescribe any medication you may require.
- Neuropsychologist: Neuropsychologists specialize in measuring brain and behavior relationships through the use of empirically validated instruments. They assist in diagnosing the areas of the brain that have been affected by injury or disease and in offering strategies for treatment.
- Occupational therapist: Occupational therapists
focus on the functional aspects of
neurocognitive remediation. Treatment focuses on safety, driving, social
skills, and the
management of everyday responsibilities. Their training is similar to that of physical therapists, with a primary focus on the upper body functioning. - Physical
therapist: Physical therapists are trained
in techniques to decrease pain and
increase strength and mobility. They often treat neck, back, and limb
pain and other
whiplash injuries. Specific techniques include the use of electrodes, ultrasound, ice packs, hot packs, and exercise. - Speech and language therapist: Speech therapists work to resolve communication, swallowing, and hearing impairments. Approaches to neurocommunications include interventions to treat language deficits.
- Vocational therapists: The primary focus of vocational therapists is in developing the skills that are necessary for the return to work. Therapy focuses not only on developing the skills necessary to return to work, but also on exploring alternative occupational options. Pet therapy is another technique commonly used by vocational therapists.
A thorough neurological evaluation should involve a comprehensive history, including a family history of neurological disorders so that genetic influences can be considered. It should also include an examination of current medications, a review of current symptoms, a comprehensive medical workup, and a comprehensive neurological workup. The medical and neurological workup might include:
Neuropsychological testing:
- X-rays
- Neurological imaging, such as computerized axial tomography scans (CAT), magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT), and positron emission tomography (PET)
- Electroencephalogram (EEG) to look at the electrical activity of the brain
- Electromyogram (EMG) to measure activities of muscles
- Blood workup (some of the more common areas of evaluation include thyroid functioning, vitamin levels such as B12, electrolytes, glucose level, liver function test, and heavy metals screening, to name a few)
- A lumbar puncture to check for infections within the central nervous system
- A cranial nerve examination
- A motor system examination
- A mental status examination
- A sensory examination
Diagnostic Techniques:
There are many diagnostic methods that may help your physician and other health-care professionals further diagnose and treat your injury. The use of these options will also help to determine the type and seriousness of the injury. The following review is intended to familiarize you with some of the more common techniques used with neurological disorders and injuries.
X-Rays:
Skull X-rays are almost always done immediately after the injury to evaluate damage to the skull. The initial detection of fractures of the skull will allow the medical team to focus on the areas of the brain that may be the most damaged or prone to secondary damage. Although X-rays have limited ability to capture the damage to the brain, they can identify areas of intracranial pressure (pressure in the skull) and the presence of foreign bodies within the brain.
CAT or CT (Computerized Axial Tomography):
The level of sophistication in imaging that we currently have began with the CAT or CT in the early 1970s. The technology of the CAT allows the diagnostician to view specific brain regions and the blood supply within the brain in order to distinguish damaged brain areas. In cases of severe injury, a CAT will usually be ordered upon admission and repeated regularly to gauge the progression of recovery and to monitor the development of any secondary injuries.
MRI (Magnetic Resonance Imaging):
The MRI is a technology that was developed within the past two decades. Three-dimensional images of the brain are produced through the use of a strong magnetic field. Images are much more detailed than those found with CAT, making the MRI able to detect more subtle brain insults. The newest technology involving MRI is the functional MRI. This technique allows the mapping of the brain’s activity by means of detecting changes in the brain’s metabolism and oxygen uptake.
SPECT (Single Photon Emission Computerized Tomography) or PET:
(Positron Emission Tomography) SPECT and PET are imaging techniques used to detect cerebral blood flow and brain metabolism. As different areas of the brain are used during the imaging process, the changes in the brain’s activity are imaged in a color representation of activity. The use of this technology is limited in that it is expensive and requires the injection of radioactive glucose or radiotracers.
Lumbar Puncture:
A lumbar puncture is the method used to obtain cerebral spinal fluid for further study. The fluid is drawn directly from the lower spine with the use of a thin needle. The study of the spinal fluid can assist in the diagnostic procedure by revealing any infections and by measuring the intracranial pressure.
Angiogram:
Angiograms are used to detect any abnormalities in the vascular integrity of the CNS. A dye is injected into a blood vessel and X-rays are taken after the injection. This allows the examiner to view the vascular system of the brain in real time and to detect any injury or defects.
Electrophysiological Studies (EEG):
EEG studies provide information on the electrical functioning of the brain. Small electrodes are placed on the scalp and electrical activity is recorded in a graphic format. The procedure is most often used in the differential diagnosis of seizure activity.
Excerpts from the Mild Traumatic Brain Injury Workbook, Mason, D.J.; New Harbinger Publications