The natural recovery curve for moderate to severe head injury is 18-24 months, with further restitution of function occurring at a slow rate for years after. Most investigators agree that the majority of mild head injury patients recover in less than 3 months, and only a small percentage of these patients suffer from persistent postconcussion disorder symptoms. Therefore, what are the risk factors for slow recovery and poor long-term outcome?
The first and most obvious risk factor for poor recovery is greater severity of injury and related neurological/physiological dysfunction. A complicated mild head injury defined by positive neuroima-ging findings or a high probability of axonal shear strain injury (based on documented loss of consciousness, posttraumatic amnesia, and/or retrograde amnesia) places a patient in a high-risk category for slow and poor recovery. Other factors, such as pain (e.g., headache and back and neck trauma), depression, stress, sleep disturbance, poor premorbid health, and cognitive abilities, previous head injuries, psychiatric disorders, substance abuse, advanced age, poor social support systems, inadequate information about mild head injury recovery, and pending litigation, can all contribute to a patient's individual vulnerability to and risk for poor outcome. Given the complexity of these factors, and the previously mentioned neurocognitive deficits that may accompany these injuries, a comprehensive and interdisciplinary approach to assessment is clearly warranted in some cases. Neuropsycholo-gists, neurologists, neurosurgeons, neuropsychiatrists, physiatrists, neuroradiologists, speech and language therapists, pain and sleep management specialists, and others may be called on to evaluate the mild head injury patient with incomplete recovery.
The most effective treatment approach to most mild head injuries focuses on enhancing the natural recovery curve. Unlike more severe brain injury, significant medical intervention, cognitive rehabilitation, and physical therapy are rarely indicated. Interventions that focus on the previously mentioned individual risk factors will allow the individual to take advantage of natural recovery. Specific suggestions include increasing rest and reducing stress levels, reducing or eliminating alcohol consumption, treating depression with supportive psychotherapy and medications where warranted, assessing and treating pain and sleep disturbance, and educating the patient, family, and significant others regarding the typical mild head injury symptoms and natural recovery course. Early in the intervention process, it is important for everyone involved to have appropriate reassurances and positive expectations but an appreciation for the possible development of symptoms and an understanding that although recovery is usually swift and complete, in fact, full recovery can take weeks or months in some cases. Realistic but positive expectations can be critical for good outcome, particularly if they reduce stress and allow sufficient time for healing. Recently, researchers have begun to examine the use of pharmacological agents (e.g., psychostimulants) in the management of mild head injury. Further investigations are necessary to conclusively determine the impact of these agents on the recovery curve.
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