Mild Traumatic Brain Injury
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Case Illustration
Allison is a 16-year-old female who was kicked in the head on a Friday night by
another soccer player during the second half of their match. Loss of
consciousness was less than a minute. The athletic trainer's examination
revealed she had a Grade 3 concussion. She was taken to the local
emergency room. On admission there she was alert and interactive but
complained of blurred vision, headaches and had vomited once. On examination
she could state her name and identify the year and the month. She could not
remember the soccer game, but could remember a pep rally that occurred four
hours before the game. The history taken by the emergency room physician
indicated an entirely normal preinjury medical and developmental history. There
was no history of previous head trauma, psychological problems or learning
disabilities. The parents indicated that she was a very conscientious student who
was involved in many school activities and was consistently on the B honor roll.
Neurological examination was normal. CT imaging of the brain and skull did not
reveal any skull fractures or damage to the brain. She was not hospitalized. By
the next day she was fully oriented to the date, but still could not remember
playing in the game nor did she remember being seen in the emergency room.
Over the weekend she had periodic headaches and slept a lot. Her blurred
vision went away. By Monday she felt well enough to return to school. However,
over the next few days, she complained of being extremely fatigued by mid
morning. During the lunch break she told her friends that the cafeteria was too
noisy and that she was distracted by all the movement around her. By
Wednesday she was reporting difficulties taking notes in her history class and
told her parents, "My teacher is talking too fast for me to take notes."
After another week of the same problems, Allison's parents took her to see a
neurologist. That examination was normal but the neurologist requested that she
be seen by a neuropsychologist for further evaluation. Subsequent
neuropsychological testing revealed abnormalities in complex attention, speed of
information processing, ability to learn new information and complex problem
solving. The problems in complex attention and processing were viewed as
contributing to the problems in new learning. As expected, the evaluation did not
show any changes in intellectual ability, academic skills, or expressive or
receptive language. Allison also indicated that she was becoming frustrated and
angry with her struggles at school and felt that she had lost control over her life.
Her parents indicated that she was moody and short tempered with her family
and friends. The neuropsychologist discussed the findings and implications with
Allison, her parents and the school counselor. It was recommended that a 504
plan be set up to provide Allison with modifications and accommodations in three
of the classes were she was having the most problems. This included extended
time to do reading assignments, and assistance taking notes in her lecture
classes.
It was also recommended that she be allowed to eat in a quiet place during lunch
to reduce the "overload" from too much noise. Previously she had reported that
she felt more fatigue when she was in noisy and crowded places. She was also
encouraged to use her assigned study hall time to rest or nap in the nurses office
if she needed. Sleep hygiene principles were taught to improve sleep onset and
maintenance since good quality sleep is viewed as essential to optimal
neuropsychological functioning. Lastly, Allison was seen by the hospital's
speech language pathologist who was experienced in neurorehabilitation to work
on organization, problem solving and memory compensation skills. This work
was done over a period of several weeks and incorporated school curriculum
materials into the treatment session.
After eight weeks Allison reported that she was returning to normal. While still
fatigued after school, she indicated that she could better handle distractions and
could keep up with the notetaking requirements of all her classes. She still used
a daily planner to help her organize and remember her activities and
assignments. Parents reported reduce mood lability at home while Allison
indicated that she felt more positive and in control of her life.