Persistent problems after traumatic brain injury: The need for long-term follow-up and coordinated care.

Henry L. Lew, MD, PhD; Coauthors include: John H. Poole, PhD; Sylvia B. Guillory, BS; Rose Marie Salerno, RN; Gregory Leskin, PhD; Barbara Sigford, MD, PhD Traumatic brain injury (TBI) is one of the leading causes of death and long-term disability in the United States [1]. Survivors of TBI experience various problems, including physical, cognitive, emotional, and community integration issues. Established in 1992, the Defense and Veterans Brain Injury Center (DVBIC) coordinates nine healthcare centers—two civilian, three military, and four Department of Veterans Affairs (VA) sites—that provide evidence-based treatment, education, and research on TBI (www.dvbic.org). Patients with TBI who are admitted to regional medical centers within the DVBIC network receive multidisciplinary assessment and rehabilitation by experts in physiatry (physical medicine and rehabilitation [PM&R]), neurology, neuropsychology, psychiatry, and other allied health professions. After discharge, DVBIC patients are also advised to return for onsite, 3-day comprehensive follow-up evaluations at 1 and 2 years postinjury. To determine the prevalence of a constellation of problems faced by the TBI patients admitted to our Palo Alto VA facility, we performed an extensive chart review on 138 patients who had sustained closed head injuries. These patients were enrolled in the DVBIC program at the Palo Alto VA from 1993 to 2003 and ranged in age from 18 to 76 (median = 27). Of these patients, 71 percent returned for either the 1 or 2 year follow-up at the Palo Alto site and 49 percent returned for both follow-ups. Compared with the patients who returned for both follow-ups, those who missed one or both follow-ups had more emotional symptoms at baseline (mean = 3.2 vs 2.4 symptoms/patient, p < 0.005) but fewer cognitive impairments (4.2 vs 5.9 impairments/patient, p < 0.001). The two groups did not differ significantly in age or the frequency of physical symptoms at baseline (4.4 vs 4.6, p = 0.5). The present analysis focused on those who returned for both follow-ups. We evaluated the patients’ problems in four areas: physical, cognitive, emotional, and community integration, using standardized neurocognitive tests and structured clinical interviews. Physical problems were mainly documented by the physiatrist and included pain, motor weakness, gait abnormality, seizure, dizziness, and fatigue. Cognitive deficits were primarily measured by the neuropsychologist and included deficits in attention/concentration, processing speed, memory, problem-solving, executive organization, and safety judgment. Emotional issues, mainly identified by the psychiatrist, included depressed mood, anxiety, posttraumatic distress, suicidal ideation, irritability, and disinhibition. Community integration issues, primarily evaluated by the occupational therapist, included problems with self-care, money management, employment, community accessibility, recreational activities, and adjustment to limitations. As Figure 1 demonstrates, 90 percent or more of TBI patients had at least one problem in each category at baseline, i.e., during the first week of their inpatient admission for acute rehabilitation. During the following 2 years, the frequency of physical problems decreased from 100 to 84 percent,