Initial Physical Therapy Management and Functional Outcomes of a Patient with Complicated Mild Traumatic Brain Injury: A Case Report

Background: The Glasgow Coma Scale is the most widely used method of traumatic brain injury classification; however, it does not provide information on the pathophysiology of the injury and can be misleading. Although most cases of mild traumatic brain injury (mTBI) result in no structural brain damage, a small percentage of these injuries can be associated with abnormal computed tomography (CT) findings. These rare cases are considered complicated injuries and the impact of the abnormal findings are not well documented. Purpose: The purpose of this report is to describe the clinical profile of a patient with complicated mTBI to improve the current understanding of the impact of positive CT findings on patient reported symptoms and acute functional outcomes. Case Description: A 56-year-old Caucasian male was admitted to the hospital for worsening headache and dizziness after suffering from blunt force trauma to the head five weeks prior. The patient underwent surgical evacuation for bilateral subdural hematomas, and subsequently participated in two weeks of physical therapy for ongoing dizziness and balance issues. Outcome Measures: The outcomes measures used in the patient’s treatment included the Berg Balance Scale and level of assist for functional mobility tasks. Discussion: There is limited and inconsistent evidence directly comparing the symptoms and functional outcomes of individuals with complicated and uncomplicated mTBIs. To contribute to available literature on this topic, this case report outlines the clinical presentation of a patient with complicated mTBI and his functional improvements following initial physical therapy treatments. Further research is needed to continue evaluating differences in clinical presentation and functional prognosis of individuals with mTBIs with and without abnormal imaging.