1. Mild TBI and Persisting PCS (Post Concussion Syndrome) Mary Pepping, Ph.D. Dept. of Rehabilitation Medicine University of Washington School of Medicine

2. Classic MTBI Significant blow to head or whiplash MVA, Falls, sports concussion Brief loss of consciousness < 20-30 min Initial disorientation and confusion Nausea and vomiting soon thereafter Glasgow Coma Scale score 13-15 Brief anterograde or retrograde amnesia

3. Complicated Mild TBI All of classic MTBI signs + any below: Fractured skull Contusion on MRI or CT Hemorrhage on MRI or CT Shear injury Seizure in aftermath of injury History of documented prior severe TBI History of documented multiple prior concussions

4. No MTBI > Blow to Head No loss of consciousness Atypical disorientation Atypical amnesias Heightened emotional distress evident early in process Person may be in shock from accident, not from injury

5. Classic PCS symptoms Headache and/or neck pain Attention and memory problems Increased irritability Mental or physical fatigue Visual disturbances Sensitivity to light, noise Balance/vertigo problems Sleep disturbance

6. Persisting PCS > 3 months Symptoms maintained or worsened over time Degree of impairment in daily function greatly exceeds tested impairments Test or exam scores exceptionally impaired Person does better on hard tests, worse on easy tests Validity problems on testing Somatoform personality vulnerabilities present

7. Somatoform Personality Style Strengths Conscientious, hard working Cheerful, nice to others Extremely generous of time and energy Highly emotionally sensitive Weaknesses Gives too much for too long, can’t say “No” Not aware of own needs Tends to channel stress physically & cognitively Highly emotionally sensitive

8. Persisting PCS Risk Factors May include any or all of the following: Age at injury > 40 years Prior TBI or learning disability or ADHD Prior psychiatric hospitalization Prior treatment of depression or anxiety History of abuse or PTSD Personality style Difficulties with work supervisor or job demands Financial and/or personal disincentives for RTW

9. Summary of subgroups MTBI without Persisting PCS MTBI with Persisting PCS Non-MTBI with PCS symptoms

10. Neuropsychological Evaluation and MTBI > 3 or more months post-injury Includes detailed review of records Comprehensive interview with pt and family Standardized tests: pattern of neurocognitive and neurobehavioral abilities and deficits Explores personality features Can serve as template for treatment plan

11. MTBI: Neurocognitive effects Complex attention Memory retrieval Mild changes in speed of processing Executive function changes possible Planning and organizing Drawing inferences or conclusions Flexibility of thinking

12. Cognitive effects of PPCS Simple attention significantly disrupted Memory recognition profoundly impaired “Near miss” errors on simple math Forgets alphabet, can’t count 20 to 1 Forgets date of birth or mother’s name Profound impairments in speed Global decline on testing, including IQ

13. Mood Disturbances in PPCS Reactive emotional issues Depression Anxiety Irritability Frustration Shame or Embarrassment Social withdrawal Reduced self-esteem

14. Personality issues in PPCS Natural tendency to channel distress into physical & cognitive symptoms Very vulnerable to intensification or worsening of all symptoms over time Often does not feel severely depressed, but feels pain, fatigue, weakness, stomach upset Trouble expressing anger directly and appropriately - all or none approach Prefers medical explanations for problems Vulnerable to “last straw” phenomenon

15. Psychotherapeutic interventions Acquaint person with their many strengths Educate them re: nature of vulnerability, e.g. tend to repress “unacceptable” emotions, have “all or none” reactions, lack of self-care, paced activities, setting limits with others Teach person skills to handle stress so pain and cognitive problems are not worsened Support time-limited and gradual increase in appropriate psychotropic medications

16. Neuro-Rehabilitation critical for recovery with PPCS Medical and PT interventions Vocational Rehab as part of Team Tx Job Station, Individual Counseling Cognitive Rehabilitation & Higher ADLs Individual and Group formats - SP and OT Psychotherapy with Rehab Emphasis Individual, Group and Family Interventions