Interdisciplinary rehabilitation of mild TBI and PTSD: a case report.

BACKGROUND: Prevalence of mild traumatic brain injury (mTBI) or concussion on the battlefield in Iraq/Afghanistan has resulted in its designation as a 'signature injury'. Civilian studies have shown that negative expectations for recovery may lead to worse outcomes. While there is concern that concussion screening procedures in the Veteran's Affairs Healthcare System and the Department of Defence could fuel negative expectations, leading to negative iatrogenic effects, it has been difficult to document this in clinical settings. The aim of this report is to describe the case of a veteran with comorbid mTBI/PTSD with persistent symptoms of unknown aetiology and the effects of provider communications on the patient's recovery. METHODS: Case report of a veteran with reported mTBI, including provider communications, neuropsychological test results and report of functioning after changes in provider messages. RESULTS: Two-years post-mTBI, the patient attributed cognitive difficulties to his brain injury, but neuropsychological assessment found that his cognitive profile was consistent with psychological rather than neurological dysfunction. After providers systematically emphasized expectations of recovery, the patient's daily functioning improved. CONCLUSIONS: This case illustrates difficulties in mass screening for and treating mTBI. Recommendations for improvement include clinician training in effectively communicating positive expectations of recovery after concussion.

Cognitive rehabilitation in traumatic brain injury.

OPINION STATEMENT: Traumatic brain injury (TBI) is a major public health problem with neurobehavioral sequelae contributing to the long-term disability that is often associated with the moderate to severe levels of injury. Rehabilitation of cognitive skills is central to encouraging the full participation of the individual in home, vocational, and social roles. The review of available evidence points to four major recommendations for the rehabilitation of cognition following brain injury: 1) Access to subacute rehabilitation that is holistic in nature and involves a multidisciplinary or transdisciplinary team to work in an integrated fashion to support physical, cognitive, and social skill retraining is vital to support positive outcome following TBI. The collaborative effort of these individuals allows for continual reinforcement and evaluation of treatment goals and will often involve the family and/or important others in the individual's life to prepare for community re-entry. 2) Trials of medication, especially methylphenidate, to assist individuals with significant attention and memory impairment appear well supported by the available evidence. Though some data suggest that the use of cholinesterase inhibitors may be of use for individuals with memory impairments, there is less support for this practice and there are indications that it may worsen the behavioral sequelae of the injury. 3) Randomized controlled trials demonstrate the utility of specific rehabilitation approaches to attention retraining and retraining of executive functioning skills. Future research is needed on rehabilitation techniques in other domains of cognition. 4) Training in the use of supportive devices (either a memory book or more technologically enhanced compensatory devices) to support the individual's daily activities remains central to the independent function of the individual in the community. Though emerging treatments (eg, virtual reality environments) show relative degrees of promise for inclusion in the rehabilitation of the individual with TBI, these need further evaluation in systematic trials.