UncategorizedAssessment of Mild Traumatic Brain Injury-Diagnostic Protocol

May 19, 2017

Definition: A traumatic brain injury (TBI) can be classified as mild if loss of consciousness and/or confusion and disorientation is shorter than 30 minutes. While MRI and CAT scans are often normal, the individual has cognitive problems such as headache, difficulty thinking, memory problems, attention deficits, mood swings and frustration. These injuries are commonly overlooked. Even though this type of TBI is called “mild”, the effect on the family and the injured person can be devastating.

Also 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. Post traumatic amnesia (PTA) not greater than 24 hours.

What Are The General Diagnostic Protocol?

Determine whether or not consciousness was lost
Determine the duration (or estimate) of loss of consciousness
Determine whether there was an alteration of consciousness (dazed, stunned, confused)
Determine duration of altered consciousness
Characterize, in detail, the specifics of how the injury occurred
Document key information pertaining to the biomechanics of the injury (amount of force, rotatory forces present, accompanied by fall, size and speed of vehicles or objects struck by or against, damage to vehicles or objects struck by or against, detail all other bodily injuries sustained)
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 attention deficit disorder or learning disabilities
Determine social/legal history


The term “concussion” should be avoided and replaced with the term “mild traumatic brain injury” (MTBI) (American Congress of Rehabilitation Medicine, 1992[3])

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 and nicotine usage and chronicle any changes since injury
Determine past medical history
Determine family medical history
Determine past medications
Determine current medications; chronicle changes in medications
Check neuroendocrine function: FSH, LH, IGF-1, T3, T4, TSH, free testoserone, total testoserone, estradiol, progesterone, cortisol
Check for hypercholsteremia, weight gain and exercise intolerance
Correlate symptomatology with medications. Review possible side effects. Determine use of over-the-counter medications/vitamins/supplements
Review EEG’s
Review CT and MRI scans of the head. Note MRI strength. Review sinuses
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 protected 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.
Review ENG’s
ADL’s (Activities of Daily Living)

Characterize the individual’s daily routine.


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

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

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.

Credit: 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.

Photo credit: Brain hub all other respective owners.

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