A Program for Providing Follow-up Services to Persons with Mild Traumatic Brain Injury

Correspondence:
Robert C. Marshall, Ph.D.
Professor, Dept. of Rehabilitation Sciences
University of Kentucky
Room 124-F
900 S. Limestone
Lexington, KY 40536-0200
rcmarsh@uky.edu

Introduction:

A 1992 report included mild traumatic brain injury (MTBI) as a subset of minor head injury (National Institute of Disability and Rehabilitation Research, 1992). It indicated that MTBI involves external trauma to the head (e.g. being struck, striking an object, undergoing a violent motion) that may result in brief loss of consciousness, resulting in a Glasgow Coma Scale (GCS) Score of 13-15, with brief or no hospitalization (Rimel, Giordani, & Barth, 1981). A 1993 interdisciplinary special interest group of the American Congress of Rehabilitation Medicine incorporated these and other features into its definition of MTBI shown in Table 1 (Special Interest Group Report, 1993). From an epidemiological standpoint, MTBI is not a trivial problem. In the USA, approximately 400,000 to 600,000 persons are hospitalized for this problem each year (Harris, 1980; Kalsbeek, McLaren, & Caveness, 1977). MTBI accounts for nearly 80% of the admissions of all traumatic brain injuries (Evans, 1992; Kraus, Black, Hessol et al., 1984). Thus MTBI could be considered its own "disease."

Determining the nature and extent of rehabilitation services required by MTBI clients is problematic. Several outcome studies have shown that deficits in memory, attention, and information processing speed, often manifested by these patients at or near the time of injury, resolve in three-to-six months. These findings do not support provision of extensive and/or long-term services (Binder, 1986; Binder, Rohling, & Larrabee, 1997; Dikmen, Machamer, & Winn, 1995; Levin, Mattis, Rufff, et al., 1987; Levin, Williams, Eisengerg et al., 1992; Ruff, Levin, Mattis, et al., 1989). However, a survey of rehabilitation professionals' perceptions of outcomes in MTBI indicates that approximately 25% of these individuals do not make a functional recovery (Harrington, Malec, Cicerone et al., 1993). Mittenberg and Strauman (2000) note that in the past 25 years there have been over 500 publications in the psychological literature on mild brain injury. Many of these highlight the persistent psychosocial and neurocognitive problems of MTBI patients that limit functional recovery (Barth, Macciocchi, Giordana et al., 1983; Bleiberg, Garmoe, Halpern, et al. 1997; Gronwall & Wrightson, 1974; Rimel et al., 1981; Wrightson & Gronwall, 1981). Some research suggests MTBI patients are at risk for developing post-concussive symptoms and/or exhibit persistent cognitive dysfunction when re-entering community and work settings (Binder & Rattok, 1987; Evans, 1992; Mandel, 1989; McGrath, 1997). The impression gleaned from these studies is that the MTBI patient should not be left to his/her own devices.

Short-term follow up services to prevent and/or minimize possible neurocognitive consequences of MTBI are a compromise between formal rehabilitation and a "no intervention necessary" policy. Representative examples include brief interventions, counseling, and education given to patients and families by neuropsychologists (Binder, 1997; Kay, 1986; McGrath, 1997; Miller & Mittenberg, 1998; Mittenberg, Tramont, Zielinski et al., 1996; Mittenberg, Zielinski, & Fichera, 1993). A health care organization's ability to offer these services can be affected by several factors. One is the patient's availability to participate in follow up services. Only about 18% of mild head trauma cases seen at medical centers are hospitalized, and when hospitalization occurs, it is brief (Fife, 1987). If follow-up contact (e.g., telephone calls, return visits) is not discussed prior to discharge, professional assistance may not be sought if/when neurocognitive problems interfere with resumption of former activities. Patients not aware that professional help is available may choose to "tough it out" and suffer needlessly. Another factor is the patient's willingness to report for follow-up. Some individuals may not return for standardized testing because they perceive testing as threatening, and as having little relationship to past experiences (Kafer & Hunter, 1997). Another consideration is availability of trained personnel to do follow-up intervention. All medical centers do not have neurocognitive services. If such services are indicated, patients must be referred out of the system which may not be feasible or convenient. Finally, the most important factor governing provision of follow-up services is cost. Over 75% of MTBI patients fail to seek treatment due to a lack of funding (Binder & Rohling, 1996). Changes in health care reimbursement policies and growth of managed care have reduced payments to rehabilitation professionals for all services, and specifically for those labeled "follow- up" as they do not often involve direct treatment (Fratali, Curl, & Bevan, 1994; White, 2001).

This paper describes a program developed at Sutter Roseville Medical Center (SMRC) for providing follow-up services to MTBI patients. The program was initiated because staff recognized these services were not being provided consistently to MTBI patients. Frequently, patients coming to the hospital did not present with obvious cognitive deficits at the time of injury. For some, cognitive limitations surfaced after they returned to the community and resumed former activities. Thus a pathway was needed to deal with these possibilities in a systematic, cost-effective fashion. Because SMRC had no neuropsychologist on its staff and funds for testing were seldom available for patients, a clinical protocol (C-PRO) was developed by the first author, a speech-language pathologist. To determine how SMRC might structure its follow up services to MTBI clients, the C-PRO was administered, without cost, to a population of MTBI patients three times in the early post-onset period. This paper (a) describes the C-PRO tasks and the rationale for their selection; (b) highlights characteristics of patient groups that performed at upper and lower levels on the protocol; and (c) overviews what was learned from repeated administration of the C-PRO to better streamline efficient follow-up services for MTBI patients.