Mild head injury: How mild is it?

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1 Mild head injury: How mild is it? Carly Dutton; Gemma Foster & Stephen Spoors Sunderland and Gateshead Community Acquired Brain Injury Service (CABIS), Northumberland, Tyne and Wear NHS Foundation Trust #theotshow #theotshowselfie

2 Mild Head Injury - How Mild is it?

3 Outline Understanding of head injury versus brain injury Prevalence, Trends and Data Role of Occupational Therapy Evidence Based Practice Case studies

4 Head injury vs Brain Injury Head Injury usually refers to Traumatic Brain Injury, but is a broader category because it can involve damage to structures other than the brain, such as the scalp and skull.

5 Prevalence Each year in England and Wales, around 1.4 million people attend emergency departments with a head injury. Of these, over 80% only have a minor injury. It is estimated to represent 10% of all emergency department cases. Head injury is the commonest cause of death and disability in people aged 1 40 years in the UK. The most common causes of head injuries are falls, assaults and road traffic collisions. Children are more likely to sustain a minor head injury because they have high energy levels and little sense of danger (approx % 15 and under). (Head Injury, NICE Guidelines, 2014)

6 Facts and Figures Of 1000 patients with Mild Head Injury attending ED: 1 will die 9 will require neurosurgery or other intervention 80 will have a CT brain lesion 80 will likely need inpatient care (Geijerstam & Britton, 2003)

7 (Waljas, M. et al 2014) Diagnostic Criteria - Mild Head Injury Post Traumatic Amnesia (PTA) < 24 hours Glasgow Coma Scale (GCS) Loss of consciousness < 30 minutes

8 Post Concussion Symptoms Dizziness Nausea Head ache Blurred vision Fatigue Sleep disturbance Poor memory Memory difficulties Slowed information processing

9 Trends & Indicative data 368 Admitted (8%) 254 Re-attended ED 2556 Aged 16 and over 4539 (All age groups) (ED City Sunderland Hospital: presenting with Head Injury, 2014)

10 Number of Re-Attendances 368 Re-Attendances (City Hospital Sunderland, 2014)

11 Why do we need a service..there is increasing awareness of a high level of disability following minor/mild head injury. The provision of diagnostic and treatment services could bring great benefits to patients who would otherwise spend prolonged periods off work or be dependent on others. (Head Injury, NICE Guidelines, 2014)

12 What we see Incident Symptoms Assaults Vomiting Falls Tearful RTC Agitated Trauma to the head e.g. hitting head off something Sport Forgetful Acutely unwell - flu like symptoms Headaches Confused / disorientated Psychological effects Low mood Dizziness Cognitive changes

13 Why OT? Activity Analysis Grading Core Skills Environmental Adaptations Person Centred

14 Role of OT Early Intervention Individual Rehab Programmes Advice / Education Goal setting Standardised Assessments

15 Intervention ADL Practice Cognitive Rehab Confidence Building Social Integration Vocational Rehab

16 Vocational Rehab Supporting people who have illness or disability to access, maintain or return to employment. OTs core skills of activity analysis & graded approach assist with this process Ability to complete standardised & non-standardised assessment to support recommendations

17 Case Study While in a store cupboard and small box dropped off the top shelf and hit her on the right side of the head parietal area Only attend ED as stipulated by trust Neuro and physical examination completed all negativ e and returned to work with head injury and post-concussion adv ice Returned to ED 6 weeks post injury with the following difficulties Headaches not touched by codeine Concentration difficulties Falls CT scan completed, negative results Discharged home with reiteration of concussion adv ice

18 Case Study Continued Returned to ED a further 6 weeks later hysterical, screaming that she could not find her children and did not know how to get to their school to collect them Rescanned after discussion with ED consultant negative scan Family member contacted regarding current incident out of character Referred to Head Injury Nurse Specialist at Regional Trauma Centre OUTCOME Returned to work as a band 5 nurse completing generic duties and reduced responsibilities.

19 What could be offered? Early intervention alongside medical practitioners Standardised and functional assessment Advice and Education Recovery model that can be changed to compensatory if required Establish routine and strategies in daily living Vocational rehabilitation

20 Case Study 28 year old lady, referred by GP 2 weeks after hitting head off bathroom cabinet No LoC, no pre/post amnesia, vomited following - mild head injury, not scanned Returned to work (3 days post) unable to perform duties, sent home after 2 weeks GP recommended rest, but felt deskilled with lack of activity

21 Case Study Continued Experiencing persistent headaches, sleep disturbance, fatigue, visual disturbance, reduced concentration, forgetfulness & dizziness on physical exertion. Attempting to push through symptoms education & fatigue management Assessment/screens complete MoCA 22/30 & EQ 5D 5L Health Questionnaire

22 Treatment & Outcome Compensatory strategies to return to basics Vocational rehab meeting with employers Working from home with strict schedule Took scheduled holiday Returned to work in phased capacity Symptoms and anxieties reduced Eventually returned to full time employment with no long term effects

23 Evidence Based Practice Studies have shown that although the majority of people make a full recov ery within the expected time frame a substantial minority estimated to be at least 15% continue to report problems beyond the typical 1-3 month recov ery period The findings also suggest that factors other than neurological damage may contribute to the dev elopment of long term PCS. It has been suggested that psychological factors may play an important role in the dev elopment and maintenance of cognitiv e complaint after MTBI. Individuals with elev ated lev els of depression and anxiety tend to hav e heighten lev els of cognitiv e complaint and other PCS.

24 Summary National Issue High demand and evidence base for service need Don t judge a book by its cover OT the best for the job!

25 Any Questions

26 References Bramley D et al (2014) Mild to Moderate Head Injury: Evidence Based Pathway Design. City Hospitals Sunderland Clarke L A et al (2012) Long-term cognitive complaint and post-concussive symptoms following mild traumatic brain injury: The role of cognitive and affective factors. Brain Injury, March 2012; 26(3): Geijerstam J L, & Britton M (2003) Mild Head Injury mortality and complication rate: meta analysis of findings in a findings in a systematic literature review. Acta Neurochir (Wien) 145 (10): NICE Guidelines: Head Injury Triage, assessment, investigation and early management of head injury in children, young people and adults (2014) Waljas, M et al (2014) Return to Work Following Mild Traumatic Brain Injury Head Trauma Rehabilitation Journal 29 (5) pg

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