Medical
- Review pain medications to avoid medications which can cause dependence
or rebound headache.
- Avoid over the counter medications that contain caffeine such as
Excedrin, Anacin.
- Gradually reduce caffeine intake, in particular, for individuals with
irritability or sleep disruption.
- Consider short-term (90-120 days) utilization of stimulant therapy. This
is particularly useful in cases where speed of processing is demonstrated to
be delayed or slowed. Ritalin can be particularly effective, initiating
therapy at 10 mg. at 8:00 a.m. for 3-4 days, progressing to 10 mg. at 8:00
a.m. and 10 mg. at noon, progressing to 20 mg. at 8:00 a.m. and 10 mg. at
noon, progressing to 20 mg. at 8:00 a.m. and 20 mg. at noon for a period of
approximately 90 days. The medication should be tapered in a schedule
similar to initiating therapy.
- Anti-anxietals should be systematically weaned. Anti-depressant
therapies can be considered. Preferential response seems related to
serotonergic medications. Consider changing dosage to before bed should
undue daytime sedation occur with serotonergic medications.
- Pharmacological assistance to re-establish sleep patterns can be used on
a short-term basis. Medications such as Restoril and Ambien can be used and
should be tapered prior to discontinuation. Total days used should be less
than two weeks. A program should be initiated for sleep education and return
to normal sleep cycle and pattern. Naps should be avoided. Regular bedtime
and rise-time should be utilized. The individual should be counseled to
remain in bed with the lights off if they awaken during the night. An
individual awakened by dream activity may be advised to utilize a low sodium
diet and ample hydration prior to bed time. Individuals whose sleep is
disrupted for urination can be counseled to restrict fluids two hours prior
to bed time, emptying the bladder prior to retiring. Use an alarm clock to
ensure a consistent and routine rise time should be encouraged. Exercise in
the early portion of the day should be undertaken to increase physical
conditioning. Exercise in the evening hours should be avoided.
- Complaints of parathesias or radiculopathy should be evaluated via
sophisticated imaging of the cervical region of appropriate thoracic/lumbar
region.
- Headache management should be conducted following careful
differentiation of potential etiologies with appropriate consults for
headaches arising from sinusitis, temporomandibular joint dysfunction, or
cervical strain/sprain. Additionally, the contribution of vestibular
hypersensitivity to increased tension in the cervical musculature should be
considered. Long-standing cervical strain/sprain is often associated with
temporomandibular joint dysfunction and headache as a symptom triad.
Consideration should be given to augmenting the above treatments with
relaxation, visual imagery, or hypnotherapy.
- Medications for dizziness, such as Antivert, should be avoided wherever
possible. Instead, physical therapy for treatment of vestibular
hypersensitivity should be undertaken with medication provided which is
comfort-oriented, such as Raglan for nausea. In extreme cases, utilization
of medications such as Antivert may be necessary and should be used on a
tapering basis in conjunction with treatment for vestibular
hypersensitivity.
- Careful neuro-ophthalmologic evaluation should be undertaken for
complaints of
visual blurring, double
vision,
difficulty reading, etc. Diplopia should be measured with documentation of
the divergence in prism diopters, nystagmus should be characterized,
oculomotor pursuits should be characterized, visual fields and visual acuity
should be characterized. Referral should be made to occupational therapy or
visual therapy for addressing oculomotor deficits which result in deficits
in saccades, pursuits, or diplopia. Patching should be avoided. Use of prism
lenses, on a graduated basis, can be helpful. Strabismus repair surgeries
should be avoided until at least one year post injury and until no further
progression is seen in resolution of ocular divergence. Should strabismus
repair be undertaken, this is best accomplished with adjustable sutures. The
need to undertake these surgeries is rare in post-concussion syndrome.
- Referral should be made to physical therapy to increase flexibility,
improve strength, improve cardiorespiratory endurance, improve muscular
endurance, improve range of motion, decrease pain, and treat vestibular
hypersensitivity. Physical therapy should carefully evaluate sleep positions
in cases involving back pain. A routine exercise program to improve physical
conditioning should be undertaken. If sleep problems exist, every effort
should be made to undertake the exercise routine at times other than the
evening hours.
- The treating physician's goal should be to gradually progress to no
long-term medications, with possible exception of antidepressant or
mood-altering medications (Lithium) in individuals with a pre-injury chronic
condition or anticonvulsants in individuals with a seizure disorder. This
does not preclude long-term use of chronic medications such as
antihypertensives, etc., when used for those conditions. Any hypertensive
used for behavioral dyscontrol should be weaned.
Cognition
- The individual should be referred to treatment designed to improve
ability to maintain focus of attention, ability to shift focus of attention,
ability to maintain vigilance, perceptual feature identification,
categorization, cognitive rigidity, cognitive flexibility, and speed of
processing.
- Attempts should be undertaken to understand the relative etiological
contribution to decreased cognitive function of neurological damage versus
psychological/emotional disturbances such as anxiety and depression.
Family
- Education should be provided to the family regarding all deficits and
their relationship to the concussive injury. The family should be educated
regarding the importance of all interventions and the relationship of the
interventions to each other. Family must understand the role of medications
and substances, both beneficial and detrimental. Family systems should be
evaluated and counseling provided for families as well as injured
individuals for purposes of this educational process and adjustment to
abrupt changes in routines and lifestyles.
Psychosocial
- Psychiatric/psychological diagnoses should be made carefully, ruling out
the influence of medications, sleep disturbance, complex partial seizure
disorders, and pre-injury personality characteristics. Counseling efforts
should be routine for purposes of education and adjustment to changes in
routine, lifestyle, vocation, family, etc. Counseling should address issues
of sexual performance from an educational perspective. Reduction in male
libido is often related to emotional issues while difficulties such as
inability to maintain erection are often related to attentional deficits
and/or depression.
- The therapist should ensure a gradual return to a normal pre-injury
lifestyle and routine prior to discontinuation of treatment.
- It may be necessary to undertake systematic desensitization approaches,
relaxation approaches, hypnotherapies, rational emotive therapy, or
biofeedback, in isolation or in tandem.
- Education should be given regarding the cumulative nature of mild
traumatic brain injury and counsel should be given to avoid engaging in
activities which will potentially result in additional injuries.
Vocational
- Return to vocational involvement is most often possible; however, must
be undertaken only following resolution of problems in all other areas.
Return to work should be graduated from part time to full time and should be
supervised by a competent vocational rehabilitation counselor who will
observe job performance regularly, meet with the injured worker regularly,
and meet with the employer regularly. Utilization of a job coach to assist
with initial placement should be considered. The contact should be three
times per week, at a minimum. Job modifications and/or work place
modifications may be advisable for those individuals having suffered
olfactory loss.
Education
- Careful comparison to pre-injury academic skill sets should be made and
a determination of congruences with vocational accomplishments and aptitudes
should be conducted. Attention should be paid to abilities in iconic store,
echoic store, visual, attentional vigilance, reading comprehension, reading
speed, and mathematical computational abilities.
Disclaimer:The information in this section is intended only to
assist the reader utilizing this website. It is not necessarily a definitive
statement on the subject. The authors hereby disclaim any responsibility for
liability, including but not limited to liability for negligence, which might
arise due to any acts or omissions, directly, or indirectly, on the part of
the person utilizing this website. A person's needs must be assessed on an
individual basis, often in consultation with a qualified healthcare
professional, utilizing procedures appropriate to that individual's needs.
Copyright 1992, Centre for Neuro Skills
The following books on mild head injury can be ordered online: