By Gregory L. Goodrich, Ph.D., Vision Rehabilitation Research Consultant.
Editor’s note: March is Brain Injury Awareness Month. We have asked Dr. Greg Goodrich, recently retired from the Veterans Administration, to kick off the month with a post about Traumatic Brain Injury (TBI) and its implications in the civilian world.
TBI Can Be Challenging
Traumatic brain injury, or TBI, of whatever severity, can be challenging to patients, their caregivers, and clinicians.
Seek Immediate Medical Care
Immediate medical care is the first step in treatment. For individuals for whom there are no lasting deficits beyond the first few hours, days, or weeks, that becomes the end of the story. For others, rehabilitation can become a daily or weekly routine. Fortunately, the effectiveness of rehabilitation has improved greatly in the past 10+ years, thanks, in large part, to the need to treat thousands of military troops who sustained a brain injury in Afghanistan or Iraq.
Deficits Resulting from a TBI
Some deficits resulting from a TBI are relatively straightforward in diagnosis and treatment. For example, in cases of paresis following brain injury, which causes weakness or partial paralysis, the result is visible and treatment and rehabilitation relatively straightforward. This does not minimize the potential consequences for the individual, their families, or the challenges to physicians and therapists. However, the cause, effect, and treatment are clearly outlined.
In many others the consequences of, and resulting treatment for, are often much less clear making it difficult to sort out what rehabilitation is needed for what deficit. Difficulty reading, for example, may occur due to cognitive loss, memory impairment, motivation deficits, visual impairment or other factors or some combination of factors. In short, sorting the causes so that proper treatment and rehabilitation can be provided is challenging.
A Study of Vision Impairment Associated with TBI
A few years ago, I and my colleagues looked at data from a study of vision impairment associated with TBI in two matched groups of veterans (one resulting from a blast event and others from non-blast events). Blasts from improvised explosive devices and other weapons are known to cause more complex injury patterns than non-blast sources of trauma such as motor vehicle accidents, falls, assaults, and so on.
Self-Reported Light Sensitivity Much Greater in the Blast Group
What caught our attention was that the nature of vision impairment in the two groups was virtually identical with equal frequencies of hemianopsia, visual acuity loss, and visual dysfunctions. However, self-reported light sensitivity was much greater in the blast group than in the non-blast group. Light sensitivity is usually, but not always, associated with vision. As we pondered what might cause the greater frequency of light sensitivity in the blast group, one of my colleagues mentioned that in her experience patients with posttraumatic stress disorder (PTSD) in general reported higher rates of a wide variety of visual symptoms.
Having PTSD and A TBI More Likely to Lead to Light Sensitivity
This observation led us back to re-examine our original data that confirmed TBI patients with PTSD do indeed report more visual symptoms than do patients without PTSD. To specifically look at light sensitivity we excluded medications (which can cause visual symptoms) and found that having PTSD and a TBI is more likely to lead to light sensitivity than TBI alone. While light sensitivity sounds benign (just wear sunglasses), many of our patients were so sensitive to light that even at home they did not want house lights on. This degree of light sensitivity is debilitating. And this is consistent with other symptoms of PTSD. Our research suggests that in addition to prescribing sunglasses or other tinted lenses they might also want to refer TBI patients with this symptom to neuropsychologists to evaluate for PTSD. Successfully treating PTSD may also reduce light sensitivity.
PTSD Can Occur in Civilian Life
PTSD is not limited to combat troops, it can occur in civilian life as well. Experiencing injury in a car or workplace accident can lead to PTSD as well as a TBI. When this happens the individual, family, and clinicians need to sort out both the deficits and their treatment. Both the Departments of Defense and Veterans Affairs have responded to this by increasingly specialty screening returning service personnel, for example PTSD. This screening helps point to optimum treatment. In the civilian sector vision and PTSD screening may be less routine and caregivers may need to advocate for comprehensive testing to determine the diagnosis.
TBI can be a complex injury to diagnose, treat, and manage in everyday life. The above example of light sensitivity and PTSD is only one possible combination of deficits that can be difficult to sort out. As stated previously, the primary message for caregivers with loved ones who retain symptoms following a TBI is to seek out the most comprehensive rehabilitation services available. Such services are more likely to be able to make a differential diagnosis and prescribe appropriate rehabilitative care. An early, correct diagnosis leads to the most favorable outcomes. In short, comprehensive rehabilitation facilities can help “sort things out.”
Resources
Questions to ask your doctor about concussion or brain injury
Veterans program to improve visual function for individuals with hemianopsia