Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine (1993). Definition of mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 8(3), 86-87.
Definition: A patient with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function as manifested by at least one of the following:
1. any period of loss of consciousness;
2. any loss of memory for events immediately before or after the accident;
3. any alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused);
4. focal neurological deficit(s) that may or may not be transient but where the severity of the injury does not exceed the following:
a. loss of consciousness of approximately 30 minutes or less;
b. after 30 minutes, an initial Glasgow Coma Scale (GCS) of 13-15; and
c. posttraumatic amnesia (PTA) not greater than 24 hours.
General
Determine whether or not consciousness was lost.
Determine duration of unconsciousness.
Determine whether or not there was an alteration of consciousness.
Determine duration of altered consciousness.
Characterize, in detail, the specifics of how the injury occurred.
Determine the history of previous head injury or concussion by interview with the patient and family.
Determine previous alcohol use.
Determine previous substance use.
Determine previous vocational pursuits, positions, and durations.
Determine previous leisure pursuits, to include hobbies, athletics, and other recreational pursuits.
Determine and, if possible, obtain academic record and rule out pre-existence of attentional deficit disorder or learning disabilities.
Determine social/legal history.
Medical
Determine current sleep patterns ? time to bed, time to sleep, times awake, activities during wakefulness, rise time, and restedness upon awakening.
Determine dietary habits.
Determine exercise routine.
Determine caffeine usage and chronicle any changes since injury.
Determine past medical history.
Determine family medical history.
Determine past medications.
Determine current medication; chronicle changes in medications.
Correlate symptomatology with medications. Side effects. Determine use of over-the-counter medications/vitamins/supplements.
Review EEG's.
Review CT scans of the head.
Review skull x-rays.
Review cervical x-rays, CT's, and MRI's.
Review headache history. Characterize headaches to differentiate for sinusitis, tension, TMJ dysfunction, medication/substance withdrawal, migraine. Headaches should be fully characterized and described.
Characterize and describe all visual complaints. Differentiate blurred vision from diplopia. Evaluate visual fields and ocular motor skills. Determine presence of photophobia, image suppression, image persistence.
Characterize and describe all pain complaints as well as past/current treatments for same.
Characterize complaints of dizziness, imbalance, and dyscoordination.
Evaluate balance by single-foot standing, Romberg, star-march.
Evaluate history of balance in low-light conditions.
Evaluate for perilymphatic fistula, cupulolithiasis, and cervical dizziness.
Evaluate cardiac status and serum glucose levels as possibly contributory to dizziness.
The term "concussion" should be avoided and replaced with the term "mild traumatic brain injury" (MTBI) (American Congress of Rehabilitation Medicine, 1992[3]).
Review ENG's.
ADL's (Activities of Daily Living)
Characterize the individual's daily routine.
Vocational
Fully describe the individual's vocational history.
Fully describe the individual's current job description. Include whether or not the work is full-time, part-time, seasonal.
Determine the presence or absence of a supplemental disability insurance income.
Determine workers' compensation TD payment level.
Determine presence of salary continuation agreement.
Determine status vs. wage loss compensation.
Psychosocial
Evaluate for anxiety, depression, panic attacks, somatization, hypochondriasis, malingering.
Evaluate for issues of secondary gain.
Evaluate for family system adaptation/adjustment.
Differentiate psychiatric symptoms from iatrogenic or seizure-induced symptoms.
Physical Therapy
Evaluate for overall fitness and conditioning, muscular strength, range of motion, sensation, proprioception.
Characterize pain complaints.
Balance/coordination diagnostics.
Testing
Tests to be considered: MMPI-II, Beck's Depression Inventory, Taylor-Johnson Temperament Analysis, FIRO-B, Woodcock-Johnson Psychoeducational Battery, Detroit Tests of Learning Aptitudes, Booklet Category Test, Wisconsin Card Sort, Trails-A, B Neuropsychological Battery, Wide Range Achievement Test, Motor Free Visual Perception Test, Test of Visual Perception Skills, and the Santa Clara Valley Perceptual Motor Evaluation.
