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What is a mild traumatic brain injury, anyway?

I've been thinking about the title of my book (which is now with the printer! Just waiting for little details, like an index …). Who should read it? What do I mean by mild? I'm a little concerned that folks will hesitate to dig in if they have not been diagnosed as "mild" or if they have had a more (medically) severe injury but are trying to function in the world and are having some of the problems that I address in the book.

So, I want to talk a bit about the labels we use in the medical community to describe brain injuries.

When a person in first injured, the doctor will evaluate the severity based on several criteria.

First, loss of consciousness: A Mild traumatic brain injury involves loss of consciousness of 0–30 minutes, sometimes none at all. Moderate: LOC from 30–24 hours. Severe: >24 hours. The problem with this designation is that sometimes the patient is heavily sedated because of other injuries. How do we really know how long the loss of consciousness would be if nothing were done? The medical procedures can be life saving but they alter what the brain would do if left alone.

A second guideline: post-traumatic amnesia which refers to the length of time after the brain injury for which the person has no memory. Again, given medical procedures, this can be misleading although it continues to be a diagnostic standard. Mild: PTA of 1 day. Moderate: PTA 1–7 days. Severe: > 7 days. If a person has sustained a relatively mild brain injury, but has physical injuries requiring sedation, and the medication is something like versed which essentially wipes out memory (did you ever have a colonoscopy? right!), is it really memory loss or the effects of the medication?

You may have heard of the Glasgow Coma Scale. This is a numerical scale which describes the stages of cognitive recovery from a severe brain injury—very useful. Helps us monitor progress and predict recovery based on the stage and the rate the patient proceeds up the scale. But, it's not very useful for mild traumatic brain injury: 13–15 means "a little disoriented but pretty much OK". And as, you know, if you have an injury, you're not OK.

So, that brings us to something useful: a functional scale. My colleagues and I (at Mapleton Rehabilitation in Boulder, Colorado) argued that what's important is the level of functioning regardless of the medical severity of the initial brain injury. There are people who've had absolutely horrific brain injuries by all definitions who have resolved to "mild" functionally. For all practical purposed, they have resumed a high degree of participation in all areas of their lives. They are back to work, managing the family, have finished school, riding their bikes, etc. etc. They may have some minor cognitive "inconveniences" and they can certainly benefit from the information in the book.

On the other hand, there are those folks who have had a "ding" in a motor vehicle accident or a series of "little concussions" playing football over the years, but seem to be fine from a medical perspective. Within this category, however, there are people who have not been able to go back to work; or have become complete "ditzes", or emotional messes; or haven't been able to go back to any of their previous activities. At Mapleton, we classified these cases as functionally moderate to severe and our treatment was specifically focused on helping them resolve these issues. You see, medically, they had been "cleared" but they still needed a lot of help to get back on their feet.

When you read the book, you may notice that I avoid the word "survivor". This is deliberate. A lot of people refer to themselves as survivors of MTBI, and that's fine. Most of the people I now see have certainly been through a traumatic experience; it's true. Most of them were never medically "in danger". I think, sometimes, that others look askance at a person who looks "just fine" but is referring to himself as a survivor ("where's the scar?" "you don't talk/walk funny."). It can add to the misperception. Sometimes I think "survivor" applies more to the recovery from MTBI than the actual medically diagnosed injury. Recovery from the assault to the ego, the self-confidence, the attitudes of others … and, yes, people do survive this!