Mild traumatic brain injury (TBI) continues to be a silent epidemic in the United States. It affects people of all walks of life, including military veterans, athletes and those injured at work or while driving. While awareness is gradually increasing across the country, much remains to be done in the way of prevention, early detection, education and treatment to minimize human suffering, the magnitude of dedicated health resources and lost productivity.

Most TBIs are not associated with major internal bleeding. The majority involve a bruise to the brain either from a direct impact or from a rapid acceleration-deceleration sequence similar to whiplash of the neck. Direct costs of all TBIs in the United States have reached $48.3 billion to $60 billion annually. The cost of caring for a survivor of a severe traumatic brain injury is between $600,000 and $1,875,000 with roughly 3.1 million people in the United States currently living with a lifelong disability due to TBI.

In the U.S. an estimated 1.7 million people sustain a TBI every year, and TBI is included as a contributing factor in 30 percent of all reported injury-related deaths. Locally, the Injury Prevention and Control Section at the Hawaii Department of Health estimates that in the civilian sector there are 1,500 new serious brain injuries annually.

Mild traumatic brain injury, on the other hand, is the most common combat-related injury, comprising nearly 25 percent of all combat casualties.

The long-term outcome of a TBI may be difficult to predict but can depend on the severity of impact, whether there is a history of prior TBIs and whether there was an associated loss of consciousness. As distinct from ancient hunter-gatherers or agrarian societies, the ability to function in the information age is more readily affected by a TBI.

Examples of recent mild TBI cases at Manakai o Malama Integrative Clinic include an engineer who had poor focus, impaired memory and severe headaches following a car accident. He realized that he was still healing after insisting on trying to return to work after two weeks. With an additional two weeks of treatment, he was able to return to his intellectually intensive position. He attributed his ability to return to better hydration, adequate sleep, resting when tired and helpful breathing techniques. He described the rehab process as “teaching the man how to fish rather than giving him the fish.”

In contrast, another current case involves a Ph.D. student of the life sciences who fell in the field and hit his head. Eighteen months later he is still unable to understand the first chapters of the thesis he wrote prior to the injury and has taken to listening to old audiotapes of field notes in an attempt to jog his memory.

A third recent case involves a high-level research coordinator and administrator. Several months after a mild TBI, she is still easily overwhelmed by sensory inputs — both visual and auditory — and is working to get back to her job by working from home part time.

Treatment begins with making a clear and timely diagnosis. Once a bleed has been ruled out, if necessary with a head CT, a thorough neurological exam is crucial. Severe cases require a neurosurgery or neurology referral, but mild TBIs benefit greatly from a team-based approach that includes occupational therapy and psychological services in addition to medical care.

Occupational therapists work with patients to improve participation in daily activities. Mild TBI patients are often limited by symptoms of dizziness, nausea, headaches, memory or poor focus that make everyday tasks more challenging. OTs help assess the patient’s current cognitive status and educate them on what to expect over the course of their recovery. This early education allows for improved awareness, and in turn, patients begin to respond more effectively to their symptoms. Rest and gradual return to activity are essential elements of a successful recovery. When patients listen to their symptoms, their recovery is often quicker, according to Hilary Valentine, lead occupational therapist at Manakai.

The concussion management program supported by the state’s Neurotrauma Special Fund, in association with the Department of Health and Department of Education, has studied the incidence and treatment of the problem while focusing on improving the awareness of coaches and trainers of school-age athletes.

The DOH has budgeted $50,000 to conduct planning for a 2016 Neurotrauma Summer Institute. The funding will be used for contracts to create an educational program for professional development in the area of neurotrauma and for educational and awareness activities that support survivors of neurotrauma and their families.

Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrated Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Submit your questions to info@manakaiomalama.com.