Communication: A Key to Effective Mild Traumatic Brain Injury Recovery

Mild traumatic brain injury (mTBI) covers a spectrum of injury severity. Most familiar to the public is the term “concussion,” which is another name for “uncomplicated” mild traumatic brain injury. In clinical terms, “uncomplicated” means that conventional brain imaging is normal.¹ Conversely, “complicated” mild traumatic brain injury is when neuroimaging shows skull or facial fractures, hemorrhages, contusions, or lesions that require urgent surgical attention.² An analysis of workers’ compensation claims shows that traumatic brain injury is costly, increasing, and most often occurs due to slips and falls, being struck by an object or person, or motor vehicle accidents.³

Approximately 1 in 4 mTBIs in U.S. adults occur at work and are associated with loss of productivity. Employees who are injured in the workplace face a greater risk of delayed return to work and poorer outcomes than their counterparts who were injured outside of work, researchers have concluded.⁴

In the interest of improving this outlook, in this article, we will address uncomplicated mTBI (hereafter referred to as mTBI) in the workplace and the important role of good communication among all stakeholders – the employer, payor, injured employee and their family – to achieve optimal outcomes.

Dispelling the myths is the first step

To have effective communication, all stakeholders need a clear and accurate understanding of mTBI diagnosis and treatment. Two prominent myths that have emerged are: (1) A person must lose consciousness to have had mTBI and (2) mTBI occurs only when there is a hard hit to the head.⁵

Let’s address the facts related to both myths.

Not only a bump, blow, or jolt to the head, but also quick acceleration-deceleration that moves the head rapidly back and forth, or an explosive/blast force can also cause mTBI.^6,7 In fact, any sudden movement can result in mTBI if the brain bounces and twists in the skull in a way that creates chemical changes, damaging brain cells.⁸

As to the second myth, we know that experiencing a mTBI does not necessarily involve loss of consciousness. In fact, in most mTBIs, consciousness is not lost.⁹

Symptoms and why mTBI is serious

Frequently, an mTBI is not life-threatening; however, the effects are serious because chemical changes in the brain affect how a person thinks, learns, feels, acts, and sleeps.¹⁰ The onset of symptoms can occur suddenly or gradually over ensuing days and can include any combination of the following signs.¹¹

• Headache, possibly severe
• Confusion or lightheadedness
• Fatigue or sleep disturbance
• Behavior or mood changes
• Dizziness
• Blurred vision
• Light or sound sensitivity
• Difficulty concentrating
• Nausea or vomiting

An employee with mTBI may also demonstrate impairments when the clinician conducts an objective examination of cervical (neck area of the spine) range of motion, tests of strength, balance, coordination, and gait, vision tests, and a general assessment of exercise tolerance.

Physical therapy role in immediate response to mTBI

A physician or other licensed health care professional (PLHCP) will perform a comprehensive physical examination of the employee to make the diagnosis of mTBI and determine if a referral to physical therapy is appropriate. The physical therapist’s evaluation will encompass a review of vitals (heart rate and blood pressure), subjective reports of pain, a cervical musculoskeletal exam, ocular motor screening, reflexes, balance and motor function, and aerobic capacity.

Clinicians and therapists are alert to “red flag” symptoms (danger signs and symptoms) that indicate a specialist’s immediate attention is required; if red flag symptoms are present, the injured employee should be seen in the emergency department. These red flags include a skull fracture, a brain bleed, repeated vomiting, or a headache that gets worse and does not go away.¹² After specialist care, many employees who have suffered mTBI are able to participate in physical therapy.

During the initial exam, the PLHCP also looks for risk factors of delayed recovery. These can include a history of previous head injury or mental health conditions (anxiety, depression, or attention deficit hyperactivity disorder), which can indicate a slower or more difficult recovery.^13,14

Identifying any barriers to recovery, early intervention physical therapy, and a well-managed return-to-work plan are important factors in achieving the best possible outcome.

Factors that favor an early recovery^15,16

• Symptoms are considered “low level” and present in the first 24-48 hours
• The employee can resume physical activity quickly
• There is an engaged circle of connected, well-informed stakeholders
• Fear avoidance behaviors, when identified, are successfully addressed by the physical therapist and employee working together

“Fear avoidance” is a coping style characterized by avoiding activities or situations that are perceived as provoking or worsening symptoms. Employees with chronic, more intense mTBI symptoms may be more inclined to fear avoidance, which can delay recovery.^17,18,19,20

Factors that indicate recovery may be delayed or poor^21,22

• More severe symptoms in the first 24-48 hours (such as repeated vomiting)
• Worsening headache after the first 48 hours
• Declining cognitive/neurological function after the first 48 hours
• Depression and anxiety after the first 48 hours
• Poor communication among stakeholders
• Poor psychosocial profile (such as low education and low job satisfaction)
• High inclination to fear avoidance and poor coping skills

How physical therapy promotes mTBI recovery

During the initial physical therapy evaluation, the physical therapist will determine if early participation in aerobic exercise will promote improved mTBI outcomes. The physical therapist will introduce aerobic activity gradually and progressively, at levels just below those that worsen or initiate the injured employee’s cognitive and physical symptoms. This is known as the sub-maximal symptom exacerbation threshold, and it differs for each individual.²³

After the threshold is established, the employee typically begins exercise on a stationary bike, transitioning to a treadmill when clinically appropriate, starting with 10-20 minutes of exercise at an intensity of 80-to-90% of the threshold. Exercise is gradually increased, based on the employee’s symptoms and tolerance. Considerable research from sports medicine shows that, for each individual, there is a heart rate at which their symptoms will increase, so exercise just below that level builds strength and endurance in the recovery process without triggering a worsening of symptoms. Earlier aerobic exercise (within one week) is associated with a sooner return to activity.^24,25

Keeping the employee motivated

Concentra® physical therapists are skilled in keeping the injured employee motivated and in creating treatment programs that maintain a safe functional capacity (the employee’s sub-maximal threshold). The “small successes” are simple, yet powerful, motivators. A therapist will remind the injured employee of exercise activity that previously was impossible and now can be done easily and for a longer duration.

Similarly, a therapist will call the employee’s attention to progress in the lessening of symptoms, such as dizziness, headaches, nausea – all a sign of functional recovery.

Communication is vital to good mTBI outcomes

Communication and understanding among all stakeholders are particularly important in mTBI cases because the presentation of symptoms and treatment differ from employee to employee, and recovery is not a linear progression.

Stakeholders need to understand that employees experiencing mTBI may have short-term setbacks that require adjustments in their restrictions and treatment plan. This can be difficult for the employee who is “climbing a mountain” and getting better, only to occasionally slip back. Those valleys are tough. Injured employees need to know others understand and are in their corner. Otherwise, they’re going to get angry, impatient, and frustrated. That’s another setback.

Thus, education and communication about mTBI are vital, not just to the injured employee, but also with the employer, the employee’s family, and the payor, so the employee feels supported and the recovery process is well understood by all stakeholders.

Keeping everyone in the loop can be challenging, but it’s valuable because increased awareness and effective communication mean more people will be encouraged to get the proper treatment, rather than suffer through their symptoms.

Effectively managing return to work

Work modifications, such as reduced hours, restricted duty, micro breaks, and changes in the work environment help promote full return to work.²⁶ By understanding the stimuli that worsen symptoms and looking for correlations in the employee’s job description, the physical therapist can recommend work modifications or restrictions to avoid triggering symptoms. For example, returning an employee who is light-sensitive to a work environment with a lot of light may worsen the employee’s symptoms and delay recovery. The therapist will collaborate with the PLHCP on current functional status to address the needed work modifications.

In addition to adjustments in the physical environment, there may need to be modifications in the cognitive demands of the job, such as time spent on a computer or reading, as well as avoiding distractions like noise and crowds that may interfere with focus. For example, an employee recovering from mTBI may not be able to tolerate work in a warehouse because there is a conveyor belt with all the packages flying by, and that increases dizziness. These are the types of correlations between symptoms and the job description that the therapist will discuss with the employer.

Working together – a great approach that’s working!

Five or ten years ago, there was much less knowledge about mTBI than there is today. Now, with more research and communication to raise awareness, employers are increasingly supportive of work modifications for mTBI. This is fortunate because mild traumatic brain injury is becoming more common. Employers, payors, and family members who engage with health care providers are an essential element of successful mTBI outcomes and the shift into better mTBI management.

Today, we have ways to help employees with mTBI. We just need to get them into the clinics so they can get the proper treatment.

If you are interested in learning more about Concentra injury care, physical therapy, and mTBI management, contact Concentra today.

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NOTES

1. Silverberg ND, Iaccarino MA, Panenka WJ, et al. Management of Concussion and Mild Traumatic Brain Injury: A Synthesis of Practice Guidelines. Archives of Physical Medicine and Rehabilitation. 2020;101(2):382-393.
2. Iverson GL, Lange RT, Waljas M, Liimatainen S, et al. Outcome from Complicated versus Uncomplicated Mild Traumatic Brain Injury. Rehabilitation Research and Practice. 2012. doi.org/10.1155/2012/415740.
3. “Traumatic Brain Injuries in Workers Compensation – Associated Medical Services and Costs,” by Bryanna Lum and Beverly Cordner. NCCI. February 25, 2021.
4. Terry DP, Iverson GL, Panenka W, Colantonio A, Silverberg ND. Workplace and non-workplace mild traumatic brain injuries in an outpatient clinic sample: A case-control study. PloS One. 2018;13(6):e0198128.
5. Concussion Myths Debunked. International Concussion Society. 2018.
6. Facts about Concussion and Brain Injury: Where to Get Help. Centers for Disease Control and Prevention. Accessed: December 28, 2023.
7. Silverberg ND, Iaccarino MA, Panenka WJ, et al. Management of Concussion and Mild Traumatic Brain Injury: A Synthesis of Practice Guidelines. Archives of Physical Medicine and Rehabilitation. 2020;101(2):382-393.
8. Concussion/Mild TBI. What is Brain Injury? Brain Injury Association of America. Accessed: January 3, 2024.
9. Facts about Concussion and Brain Injury: Where to Get Help. Centers for Disease Control and Prevention. Accessed: December 28, 2023.
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14. Cancelliere C, Kristma VL, Cassidy JD, et al. Systematic review of return to work after mild traumatic brain injury: results of the international collaboration on mild traumatic brain injury prognosis. Archives of Physical Medicine and Rehabilitation. 2014;95(3 Supplement):S210-S229. doi:10.1016/j.apmr.2013.10.010.
15. Iverson GL, Gardner AJ, Terry DP, et al. Predictors of clinical recovery from concussion: a systematic review. British Journal of Sports Medicine. 2017;51(12):941-948.
16. Cancelliere C, Kristma VL, Cassidy JD, et al. Systematic review of return to work after mild traumatic brain injury: results of the international collaboration on mild traumatic brain injury prognosis. Archives of Physical Medicine and Rehabilitation. 2014;95(3 Supplement):S210-S229. doi:10.1016/j.apmr.2013.10.010.
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18. Silverberg ND, Panenka WJ, Iverson GL. Fear avoidance and clinical outcomes from mild traumatic brain injury. Journal of Neurotrauma. 2018;35(16): 1864-1873.
19. Silverberg ND, Iverson GL, Panenka WJ. Cogniphobia in mild traumatic brain injury. Journal of Neurotrauma. 2017;34(13):2141–2146.
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21. Iverson GL, Gardner AJ, Terry DP, et al. Predictors of clinical recovery from concussion: a systematic review. British Journal of Sports Medicine. 2017;51(12):941-948.
22. Cancelliere C, Kristma VL, Cassidy JD, et al. Systematic review of return to work after mild traumatic brain injury: results of the international collaboration on mild traumatic brain injury prognosis. Archives of Physical Medicine and Rehabilitation. 2014;95(3 Supplement):S210-S229. doi:10.1016/j.apmr.2013.10.010.
23. Klose J, Shinost C, Morgan M, Mendez S. Early Intervention Management of Mild Traumatic Brain Injury. Academy of Orthopaedic Physical Therapy, APTA | Occupational Health. Orthopaedic Practice. 2023;35(3):50-53.
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25. Haider MN, Bezherano I, Wertheimer A, et al. Exercise for Sport-Related Concussion and Persistent Postconcussion Symptoms. Sports Health. 2021;13(2):154-160.
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