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LEARNING OBJECTIVES:

1. Recognize the characteristics of mild traumatic brain injury (MTBI).
2. Determine the appropriate clinical pathway for treatment during the acute phase of MTBI thereby avoiding neuropsychological deterioration in daily functioning.
3. Understand the impact of iatrogenic contributions affecting the patient's recovery.
4. Recognize the importance of neuropsychological treatment recommendations.

CASE SUMMARY:

Beginning January 2015, a pharmaceutical representive slipped and fell on black ice striking her head. There was brief loss of consciousness (LOC), nausea, blurred vision and dizziness. She was brought to CentraState Medical Center ER, treated and released. CAT scan of the head was negative. She was seen by Meridian Occupational Health (MOH) and cleared neurologically. She was referred to Neuropsychology with the neuropsychological examination placed on hold due to the recency of the injury. A Montreal Cognitive Assessment was given demonstrating cognitive problems (22/30). Psychological screening measures reflected general autonomic arousal. Medical adjustment counseling (MAC) was recommended two times a week with biofeedback due to anxiety and restoration of control. The MAC addressed educational facts of the recovery process and the normalcy of her symptoms. MOH was kept abreast of developments. The patient progressed unremarkably. By the end of March 2015, she was mainstreamed back to work part-time, then full-time with no decompensation in her daily functioning.

CLINICAL CONCLUSIONS:

This patient incurred a grade III concussion. Epidemiologically, it is estimated that 1.3 million individuals sustain a MTBI each year in the United States, with 10-20% presenting with chronic difficulties. Problems arising from MTBI are superimposed over normal life problems. The way patients coped before, predicts how they will recover after MTBI.

The interaction of physical, emotional, and cognitive disturbances is at the heart of a clinical neuropsychological approach. This woman had healthy psychological resources, bright, and with the adjustment strategies applied immediately after her injury via the MAC, her outcome was excellent.

The key is management on an immediate basis in terms of neuropsychological prophylaxis. Physicians and neuropsychologists need to coordinate methods by which they can separate those patients who will: (a) most likely have a positive recovery from short-term immediate intervention and (b) those that potentially have a poor recovery due to their psychological profile requiring an altered approach in neuropsychological care.

Failing to correctly identify a MTBI, and instead dismissing it as within normal limits, or psychiatric, or a general medical condition can result in endless doctor shopping, significant psychological deterioration, and lost wages.

An accurate and early diagnosis with neuropsychological treatment is the best way to control costs and expedite return to previous levels of productivity. We should also be cognizant of the complex interactive effect of the physical, psychological, and cognitive deficits of the patient in the larger context of the extrapersonal sources affecting the patient's outcome.

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Robert B. Sica, PhD, FACPN is a Neuropsychologist specializing in Clinical and Forensic Neuropsychology. Dr. Sica is a staff clinical neuropsychologist in the Neuroscience Division at Jersey Shore University Medical Center (JSUMC) and Riverview Medical Center, both members of the Meridian Health Care System, where he treats patients along with his academic responsibilities of teaching medical students, residents, and neuropsychological interns.

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