Post-concussion syndrome (PCS) is defined as a set of common symptoms that occur in the days or months after a mild traumatic brain injury (mTBI). These symptoms include fatigue, depression, headaches, dizziness, and cognitive problems. PCS has been a somewhat controversial topic because clinicians rely on the patient’s report of their symptoms, in absence of objective test results. In addition, research has shown inconsistent results for the prevalence of PCS after mTBI.

In a recent comparison of people with mTBI to people with no injury, researchers found that the rate of PCS was almost identical in both groups. PCS, therefore, describes a set of symptoms that are just as common in the general public as they are to people with mTBI.

However, when PCS symptoms were analyzed individually, the researchers did find differences between the groups. People with mTBI had significantly greater cognitive impairment than the cognitive impairment found in uninjured people. Additionally, people with mTBI reported their symptoms as more intense and disabling than the uninjured group.

The diagnostic criteria for PCS should be more specific than it is now, but further research is needed to define those criteria.

Dean PJA, O-Neill D, & Sterr A. Post-concussion syndrome: Prevalence after mild traumatic brain injury in comparison with a sample without head injury. Brain Injury. (January 2012).

A health care insurance plan may not deny coverage for medical or rehabilitation treatment for an acquired brain injury (ABI) at a licensed facility at which appropriate services may be provided, including, but not limited to, a hospital; an acute rehabilitation hospital; a long-term acute care hospital (LTACH); a congregate living health facility; an adult residential facility or postacute residential transitional rehabilitation facility or home and community rehabilitation program accredited by the Commission on Accreditation of Rehabilitation Facilities as a specialty brain injury rehabilitation program, such as an interdisciplinary outpatient medical rehabilitation program, a brain injury program, or a residential rehabilitation program; a medical office; or another analogous facility at which the most appropriate level of services may be provided.

A health care insurance plan may not impose time, cost or other benefit limitations in provision of treatment of Acquired Brain Injury (ABI) that are different from benefit limitations for other major medical conditions.

Acquired brain injury treatment includes items or services provided from a continuum of accredited programs and treatment settings used to restore functional capacity, minimize limitations on physical and/or cognitive functioning, and prevent deterioration of functioning as a result of an illness, injury, disorder or other health condition. Treatment settings include a hospital; an acute rehabilitation hospital; a long-term acute care hospital (LTACH); a congregate living health facility; an adult residential facility or postacute residential transitional rehabilitation facility or home and community rehabilitation program accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) as a specialty brain injury rehabilitation program, such as an interdisciplinary outpatient medical rehabilitation program, a brain injury program, or a residential rehabilitation program; a medical office; or another analogous facility at which the most appropriate services may be provided.

An acquired brain injury is a catastrophic injury to the brain which occurs after birth that disrupts the normal function of the brain and can arise from an external force applied to the brain, stroke, heart attack, near-drowning, brain tumor, infectious disease, prolonged high temperature, decrease or loss of oxygen to the brain, metabolic disorders, surgery, or toxic exposure. Acquired brain injury can result in impairments in one or more areas such as cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor abilities; psycho-social behavior; psychological functions; physical functions; information processing; and speech.

Laser therapy has been long known to heal wounds, alleviate pain, and reduce inflammation. Low level light therapy (LLLT) is considered to be a “cold” type of laser therapy because it does not emit enough power to produce significant heat—making it safe for use in most people.

More recent research has begun to narrow the science of LLLT into certain wavelengths and sources that provide the greatest benefit to specific diseases.
However, because LLLT must be given at a dosage and source that is very disease-specific to be a benefit, it has been a challenge to produce consistent results. LLLT has therefore remained a somewhat controversial and “alternative” treatment.

A recent review of LLLT has suggested that it should be seriously considered for the treatment of traumatic brain and spinal cord injuries. Animal studies of brain and spinal injury, as well as trials with stroke patients have already shown some benefits from LLLT. Very few effective therapies currently exist for brain and spinal injury, and LLLT has the potential to provide a safe method of reducing inflammation and pain.

Chung H, Dai T, Sharma SK, et al. The nuts and bolts of low-level laser (light) therapy. Annals of Biomedical Engineering. (November 2011).

Progesterone is a hormone that has been shown to have a rapid, neuroprotective effect after TBI. This effect has been strong during pre-clinical, phase I, and phase II trials, and is now in the process of both a national and an international phase III clinical trial, bringing it closer to FDA approval for clinical use. Other clinical trials have begun for the use of progesterone after pediatric brain injury, stroke, and other neurodegenerative diseases.

Some of the potential benefits of progesterone are that it can:
1. Cross the blood brain barrier
2. Be administered as long as 24 hours after the injury and still be effective
3. Reduce swelling and edema
4. Decrease inflammation
5. Protect neurons that might otherwise die
6. Enhance remyelination, the white matter of the brain
7. Reduce potential cognitive, sensory, and spatial deficits

Progesterone is a strong candidate for the acute treatment of TBI, at a time when little else is available. It is not expensive or difficult to administer, and is considered safe for most people.

Stein DG. Is progesterone a worthy candidate as a novel therapy for traumatic brain injury? Dialogues in Clinical Neuroscience. (December 2011).

Chronic traumatic encephalopathy (CTE) is a neurodegenerative syndrome that can develop from repeated impacts to the brain. CTE has been studied in sports such as football and boxing, where athletes develop a long-term pattern of symptoms that are not unlike those of Alzheimer’s syndrome.

Post-traumatic stress disorder (PTSD) has become a common diagnosis in our returning soldiers, but a recent case study suggests that the PTSD may actually be a type of CTE that develops after repeat exposures to blast explosions. In this case study, a soldier who was diagnosed with PTSD committed suicide not long after an honorable discharge. The autopsy of his brain found damage that was surprisingly indicative of CTE.

This case study is important because it may help re-direct the diagnostic guidelines for returning soldiers. It may also help researchers understand the pathology of repeated exposure to blast explosions, as well as the pathology and long-term effects of CTE.

Omalu B, Hammers JL, Bailes J, et al. Chronic traumatic encephalopathy in an Iraqi war veteran with post traumatic stress disorder who committed suicide. Neurosurgical Focus. (November 2011).

Decompressive craniectomy is a surgical procedure that removes part of the skull to allow room for brain swelling after injury. Not long ago, researchers found that this surgery, although commonly performed, did not actually improve outcome in traumatic brain injury patients. However, that study did not specifically look at the outcomes of decompressive craniectomy in children (under age 12) with traumatic brain injury.

A child’s brain is different than an adult’s in a few ways: the size is generally smaller, the head is heavier in relation to neck muscles, and the skull may not yet be completely formed. Injury to a child’s brain in likewise different than an adult’s. Smaller brains are less vulnerable to certain acceleration injuries, but a soft skull is more vulnerable to impact. (These differences are reduced as a child gets older.)

A recent review of past research in children who underwent decompressive craniectomy after a traumatic brain injury found mixed results. Some studies showed both better outcomes, and other studies showed worse. Decompressive craniectomy may remain a controversial surgery, however, some consideration should be given to differences in brain size, development, and response to injury before deciding to proceed.

Appelboom G, Zoller SD, Piazza MA, et al. Traumatic brain injury in pediatric patients: Evidence for the effectiveness of decompressive surgery. Neurosurgical Focus. (November 2011).

Organization, attention, and strategic planning are frequently problematic after traumatic brain injury. These issues reflect failures of executive function, a set of processes necessary for goal-directed behavior. Lack of executive control can complicate the recovery process for people with a traumatic brain injury; therefore, executive function should be specifically targeted for rehabilitation.

A recent study found that people with a traumatic brain injury who received goals training showed improvement in completing complex tasks. The training appeared especially strong on the protection of working memory from distractions, possibly due to the effectiveness of the mindfulness-based attention regulation techniques.

Participants reported that they were able to maintain the “Stop-Relax-Refocus” exercises in daily life. Other elements of training included goal selection, breaking down tasks into smaller subtasks, establishing a timeline, execution, error correction and adjustments, and progress review.

These findings are supported by recent research on attention and problem solving training for people with a traumatic brain injury who show improvements on functional measures and caregiver ratings.

Novakovic-Agopian, T, Chen, AJW, Rome, S, et al. Rehabilitation of executive functioning with training in attention regulation applied to individually defined goals: A pilot study bridging theory, assessment, and treatment. Journal of Head Trauma Rehabilitation. (October 2011).

Participation is defined as “involvement in a life situation.” Through this participation, children and adolescents acquire skills and competencies, and achieve physical and mental health. To increase understanding of how participation and recovery trajectories are linked in youth with acquired brain injury, researchers have recently examined available tools for measuring participation outcomes.
The study found that while some tools—like the Child and Adolescent Scale Participation and Children’s Assessment of Participation and Enjoyment (CAPE)—exist, they are underutilized in research. The study also suggests that a mixed quantitative/qualitative approach in research may provide the broadest picture of participation by ABI youth.
Consistent use of validated tools by researchers and blending qualitative and quantitative techniques will provide information on how and to what extent brain injury affects youth participation, and give providers strategies to maximize social engagement.
Van Tol, E, Gorter, JM, Dematteo, C, and Meester-Delver, A. Participation outcomes for children with acquired brain injury: A narrative review. Brain Injury. (2011).

People with traumatic brain injury often have complex problems that require multifaceted solutions. Networks, which consist of individuals, teams, and organizations that are linked together, are frequently touted as a method for addressing the difficulties these patients face in accessing resources. Networks do show promise in improving continuity of care, but some specific issues should be addressed before there is widespread implementation. To be effective, networks need to be adaptable and to have capacity.

First, expectations need to be in line with the size and scope of the network. A small committee that meets sporadically cannot handle the same tasks as a comprehensive group that meets regularly. Second, you get what you pay for. While networks may be a cost-effective way of improving services, they require economic and human resources to function. Lack of investment in design, implementation, and maintenance can be a significant problem.

Third, networks need support from stakeholders. Without buy-in from all involved, networks lack legitimacy. Finally, there must be genuine collaboration. A common language and vision must be established and maintained in order for a traumatic brain injury network to be effective.

Lamontagne, ME, Swaine, BR, Lavoie, A, and Careau, E. Analysis of the strengths, weaknesses, opportunities and threats of the network form of organization of traumatic brain injury service and delivery systems. Brain Injury. (November 2011).

Fatigue is one of the most common complaints after even the mildest of brain injuries. However, it can be difficult to assess and diagnose because it is often hidden by other common brain injury symptoms such as sleep problems, depression, or hypothyroidism.

A recent study of sport-related concussion found that complaints of fatigue not only correlated with increased errors on an attention test, it was also associated with changes in EEG activity. Increases in delta and theta rhythms on the EEG suggest decreased alertness and drowsiness. Athletes who complained of fatigue after a concussion also showed increased delta and theta rhythms on their EEG.

Fatigue is a very real and disabling problem for people a traumatic brain injury. It should be considered not only during the assessment of a concussed athlete’s return-to-sport, but also for anyone who suffers any severity of brain injury.

Barwick F, Arnett P, & Slobounov S. EEG correlates of fatigue during administration of a neuropsychological test battery. Clinical Neurophysiology. (September 2011).