Concussion and Traumatic Brain Injury Services
There is great variability in traumatic brain injuries, but most patients come to our clinic in one of three situations. Our programs are organized around these general differences.
- Some patients come, usually with a referral from an Emergency Room or their primary care physician (PCP) because of symptoms in the period soon after a mild injury or concussion. We may be the first specialty care.
- Others come, usually with a referral from their PCP (primary care physician), many weeks or months after what was initially diagnosed as a mild injury, but symptoms have persisted. There has often been prior specialty evaluation and care. These are the patients whom we often defer seeing and recommend alternative plans of care.
- And some will have had a severe injury, weeks or months before having had a long hospitalization, often including rehabilitation, but now requiring advice about the next — outpatient period of rehabilitation
There are some problems that emerge after concussion that Keep in mind that we are not prepared to treat. Patients who remain disabled months or even years after an apparently mild injury often require an intensity and duration of treatment that we cannot provide. This particular problem is discussed in the section on programs. For some patients, recovery is stalled because of intractable headaches. This problem is better addressed in a specialized headache program even if the origin of headaches was a concussion.
Soon After Mild Injury or Concussion
The Clinic provides timely access to an outpatient evaluation for individuals who have had or who suspect they have had a mild traumatic brain injury or concussion. Early evaluation has multiple benefits:
- Early diagnosis and treatment of symptoms of concussion such as headache, dizziness or sleep problems may accelerate recovery and prevent disability.
- Cognitive assessment focused on the critical and common complaints after concussion can identify appropriate treatment and accommodation.
- Providing education and reassurance to patients and their family members about the expected time for and course of recovery allows creation of appropriate — but temporary — accommodations at home, school or work until recovery is complete. Our Traumatic Brain Injury team approaches the evaluation and treatment of mild traumatic brain injury or concussion according to the following principles:
- Recovery from an uncomplicated mild traumatic brain injury or concussion is usually complete over days to a few weeks.
- Extended clinic-based cognitive (brain function) rehabilitation is not needed.
- The team’s role is to identify and treat symptoms, educate and reassure patients and their family members, and make recommendations about how to adjust during recovery.
- During follow-up visits the Traumatic Brain Injury Clinic will determine the specific components of the injury that have not recovered or that might be delaying overall recovery. Once identified we can offer:
- Treatments for the physical symptoms you are experiencing, such as headache, balance problems, neck pain and sleep problems.
- A brief program to educate you and give suggestions and recommendations about how to compensate.
- A program of directed psychological care — revolving around Cognitive Behavioral Therapy methodologies to help you manage other symptoms. Since January, 2010 (as of September, 2014) 50 patients have been treated with our mixed approach including symptom management education including sleep and exercise, Cognitive Behavioral Therapy, progressive relaxation, and work or school accommodations.
- Medications for anxiety or depression if necessary or requested.
- Referrals to helpful programs nearer to your home, if that is preferred.
Weeks or Months Following Injury or Concussion
Some individuals who have had a concussion continue to experience disruptive symptoms weeks or months following the injury. This is sometimes called the post-concussive syndrome (PCS). The symptoms of PCS can be quite variable from one patient to another but headaches, balance problems or dizziness, concentration difficulties, forgetfulness, and emotional symptoms are all quite common.
Our team is potentially available to provide consultation to educate and lend support to patients with this condition based on the following principles:
- A diagnosis of PCS by itself does not inform treatment and may obscure important differences between patients.
- Symptoms that persist for more than a few weeks after a concussion are not usually directly due to brain trauma but a careful assessment is necessary to determine cause.
- Other factors related to the accident or trauma — but not brain injury — may become the cause of disability as time passes and the major obstacle to resolution of symptoms:
- persistent headaches
- sleep disruptions
- emotional issues
- lack of energy
Each of these problems can be treated. Once identified, the TBI/Concussion team will develop and implement a comprehensive treatment plan. These types of consultations often include resources to the specialties outside of our clinic including sleep medicine, pain management, clinical psychology and psychiatry. Of note, the approach used in our clinic is designed to treat symptoms shortly after a concussive injury and not those with protracted/prolonged symptoms — often the result of intractable pain (usually headache) and significant emotional disruption (such as a complex stress reaction, depression, worry).
The Traumatic Brain Injury team is uniquely qualified to evaluate individuals who have experienced severe head trauma. Generally, such patients have already received inpatient hospital care and may have even completed a course of inpatient rehabilitative care. The Beth Israel Deaconess team is here to provide comprehensive evaluation of an individual’s neurological cognitive status on an outpatient basis and to develop a multidisciplinary, individualized treatment to help the individual continue his/her recovery.
The Traumatic Brain Injury team approaches the evaluation and treatment of severe traumatic brain injury according to the following principles:
- Improvement, and perhaps even recovery, should be expected except for the most extreme injuries.
- Some residual disability often does persist after a severe injury.
- Because severe injuries are often very complex, an intensive re-assessment, perhaps including a new MRI or CT of the brain, may be required to identify the exact nature of the injury.
- Education about appropriate accommodations for home, school and work activities during recovery is critical for individuals who are recovering from severe brain injury.
- Managing a longer and possibly incomplete recovery may require the team to refer an individual to other, very specialized services.
- Support from other people who have experienced similar injuries and their family members, as well as programs experienced in helping people with severe head injury, are valuable resources for individuals who are dealing with long-term issues of disability, retirement and leisure when return to work or school is not possible.
- Many of the programs that assist severe TBI patients are listed in the Resources section. Links to resources.
Almost by definition, severe injuries may cause much more complex disability. In addition to more cognitive problems, they may have more problems with control of movement, balance, speech and emotions. By the time that patients come to this program they will have already seen many physicians and other health care professionals.
Our goals for severely injured patients now back in the community are:
- A fresh assessment of current status and prognosis for continued recovery
- Determination of need for basic neuromedical care: Seizures? Spasticity? Pain
- Determination of options for integrating on-going medical care, further rehabilitation plans, return to work or school and all of the issues facing people who have been out of their normal lives for weeks or longer.
Community-based treatment is recommended when an individual is in the later stages of recovery from severe brain injury, yet programs can be difficult to find. Some patients will simply never return to their former level of functioning and the treatment plan needs to recognize that constraint. In these cases, referrals to resources such as Mass Rehab, SHIP services for assistance applying for private disability, local and state government disability, and Social Security Disability benefits should be included in the plan.