Management of a Patient With Slow Recovery From a Mild Traumatic Brain Injury

You are seeing a 42-year-old man for an initial office visit. He is referred to you by his primary care physician to provide treatment for headache and dizziness that arose after he was involved in a fall at work. The incident occurred 10 months ago. He was stocking shelves at a grocery store when he slipped, striking the back of his head. There was no loss of consciousness. He went to the emergency department that day with headache, nausea, and dizziness. Head computed tomography was performed and was unremarkable. The Glasgow Coma Scale score in the emergency department was 15. Tenderness was noted in the occipital area, with results of the physical examination being otherwise unremarkable. He was discharged home with standard postconcussion care instructions and a recommendation to follow up with his primary care physician in 1 week. He has not returned to work. He states that this is because he has continued to have headaches, cannot concentrate, forgets things, and feels dizzy “all the time.” The dizziness is described as feeling like he is on a boat. The headaches are described as “pressure all over” and are better when he lies down. In the intervening time since the injury, he underwent a course of physical therapy, which did not help. He thinks that it was supposed to help his balance and headaches but cannot recall what interventions were performed. He takes 400 mg of ibuprofen once or twice daily, although he does not think it helps. He wonders why his physician does not prescribe something stronger, “like hydrocodone.” His medical history is unremarkable. He denies any prior injuries and states that he was very healthy and did not have any of these symptoms before his injury. He is a high school graduate and reports that he has worked at this store for the past 5 years. He lives alone, having been divorced for 5 years. During the divorce, he was started on fluoxetine by his primary care physician and has remained on it. He states that he wants to go back to work “when he is healed,” and complains that the workers' compensation representative does not believe that he is having symptoms that should prevent him from returning to work now. During this conversation, he discloses that he has sought legal advice regarding his rights with respect to dealing with his workers' compensation claim. On examination, he is awake, alert, and fluent. He provides detailed information regarding his injury. He has pain with palpation of the occipital area as well as his neck, diffusely. He is guarded with cervical movement in all planes, but the range of motion is unremarkable. Ambulation into the room and movement from a chair to the examination table is steady. Pronator drift is not present. Finger-to-nose examination is slow, with some shaking, but accurate. Nystagmus is not appreciated, and convergence is full. He has some difficulty standing with his feet together, with significant sway. This is worse with his eyes closed, but he does not lose his balance. He has difficulty with tandem stance as well, with eyes both open and closed. Cognitively, he is fully oriented. He recalls 2 of 3 words at 5 minutes and cannot recall the third even with hints and choices. He can calculate simple change. He cannot perform serial 7s but does perform serial 3s from 50, although slowly. He can spell the word “WORLD” forward and backward. His mood is appropriate. What is your clinical approach to this patient? When symptoms persist long after the injury would have typically been expected to resolve, many questions regarding etiology and treatment may arise. This case highlights some of the dilemmas faced and our discussants, Gary Goldberg, MD, and Nathan Zasler, MD, both of whom are brain injury experts and who have much clinical experience and many publications on topics related to these challenging patients, present different perspectives and clinical strategies. Questions: Is it important to know whether there is ongoing litigation, or alternatively, might knowledge of this information bias you in your treatment of a patient who is recovering very slowly after a mild TBI? How often do you use formal or informal measures of effort in your evaluation of patients with more chronic sequelae of TBI? How important is it to develop a precise (and perhaps extensive) list of diagnoses when treating a patient with more chronic symptoms after mild TBI? My approach to this patient is most importantly guided by an ethical obligation to engage the patient in a therapeutic process that will lead to a reduction of his distress regardless of whether or not a clear, objectively verifiable pathophysiologic explanation for his symptoms can be determined. The basic premise for the encounter is that the patient is seeking assistance for relief of his symptoms and the associated suffering he is enduring. The frustration and challenge for the physician who approaches a patient such as this is that the situation does not fit cleanly into the conventional medical paradigm in which the physician elicits a verbal description of the patient's subjective experience and is able to successfully translate the described phenomenology into a specific demonstrable organic pathology that is verifiable with objective testing, clearly understood in terms of a pathophysiologic explanation, and, ideally, is readily treatable with a conventional medical intervention. This is the reductionistic paradigm that emerges from logical positivism that is imprinted in medical school, which leads to the satisfying conclusion of the transaction for the physician and possibly for the patient as well if the diagnosis leads to an effective treatment, and which is viewed as the ultimate in demonstrating the successful application of “hard” medical science to the relief of human suffering, the triumph of modern Western medicine. This is the dominant medical narrative in most of the Western world and the narrative that sets up the expectations of both patient and physician for how this process is supposed to go. It is a narrative that reduces the subjective to the objective. It is a narrative that assumes that all subjective symptoms must have an objectively verifiable causal mechanism, referred to by philosophers as the “verifiability criterion of meaning,” and that, if that explanation cannot be uncovered, then the implication is that the symptom report and the patient himself as a subjective being, are invalidated, or, worse yet, the provider projects his or her own frustration on the patient and concludes that the patient is intentionally manipulating the provider for the patient's own benefit. The end of the therapeutic alliance is thus sealed. Unfortunately, there is a significant risk that this can occur in this case. This narrative is unlikely to pan out in the context of this patient who is suffering from a variety of subjective symptoms, which may or may not have a demonstrable physiologic basis, and are being attributed to a history of a relatively remote traumatic event in which there does not appear to have been an objectively verifiable physical injury of the central nervous system, a condition that has come to be labeled by the term postconcussion syndrome (PCS), a complex disorder in which a variable spectrum of postconcussion symptoms, such as headache and dizziness, can go on for weeks and sometimes months after the initial injury event. In fact, if we seek to this in the context of the conventional medical narrative that symptoms to verifiable organic then it is very not to go well and will lead to frustration and or worse for both patient and how might we go a different narrative that can lead to a better in this How might we approach such a patient with respect and and of the symptoms the risk of the of the symptoms and the of the patient himself if we are not able to a causal explanation and the subjective experience to a verifiable organic objective mechanism, as is most to be the case in It is to develop a and of the of human that the of the as an in of subjective being that in the complex context of to and an that own of and are to and which are understood as in the of and This reductionistic approach referred to is not in satisfying the of many patients, with physical symptoms that is to and of and as a for a of medical and that the of the subjective and the and the subjective with the objective has been for treatment of such as as well as in which symptoms do not have demonstrable organic what does this in terms of the approach to this patient? 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