Traumatic Brain Injury – Evaluation and Treatment Considerations

1. Traumatic Brain Injury – Evaluation and Treatment Considerations Brian A. Boatwright, Psy.D. Neuropsychologist Director of the Neurologic Rehabilitation Institute

4. Epidemiology • National Estimates – 1.7 million individuals sustain a head injury each year. • 52,000 die. • 275,000 are hospitalized. • 1.365 million are treated and released.

5. TBI accounts for a third of all injury related deaths in the U.S.A. • Approximately 75% of brain injuries are mild (concussion). • Number of those sustaining injury but do not seek treatment is unknown.

6. Peak occurrences: Ages 0-4; 15-19; and >65. • Those >75 have highest rates of TBI related hospitalization and death. • Males>Females • Males ages 0-4 have highest rates of brain injury E.D. visits.

7. Direct and indirect medical costs of brain injury – $76.5 billion (2000 CDC data). • Causes-Motor Vehicle Crashes and Falls. Data from Centers for Disease Control and Prevention, 2012

9. Primary Mechanisms of Injury • Impact • Contusion at point of impact • Skull Fracture with focal injury

10. Contusion • A contusion is a bruise (bleeding) on the brain. • A contusion can be the result of a direct impact to the head. • The behavioral effect depends on the size and location of the bleed.

11. Coup and Countrecoup • Head impacted at site of contact with object (causing contusion). • Brain is forced into opposite side of skull (causing contusion).

16. Diffuse Axonal Injury • A result of shaking or strong rotation of the head or by rotational forces (e.g. automobile accident). • The stationary brain lags behind the movement of the skull causing brain structures to tear. • Individual presents a variety of functional impairments depending on where the shearing (tears) occurred.

18. Secondary Mechanisms of Injury • Edema • Disruption of CSF absorption • Hypoxia • Ischemia

19. Damage Documented in Survivors • Brain swelling by CT 17-44% • Focal Lesions by CT 23-46% • Frontal MRI abnormalities 40% • Multifocal damage not detected by routine clinical studies

20. Brain Damage Survival • More people survive diseases, accidents, and other medical conditions affecting the CNS. • Consequently, more people live with chronic neurological conditions and associated impairments, including cognitive disabilities and affective/behavioral disturbance.

21. Traumatic Brain Injury • Brain injury deaths declined from 24.6 per 100,000 in 1979 to 19.3 per 100,000 in 1992, in the United States (Sosin, Sniezek, & Waxweiler, 1995)

22. Reliable estimates regarding survivors with cognitive disability are not available • One study in the Netherlands indicated that of all hospital admissions, 67% of brain injury survivors had long-term cognitive and behavioral problems • CDC-Estimates 3.17 million Americans currently require ADL assistance

23. Neuropsychological Domains • Acquired Knowledge • Attention & Memory • Language • Visual Spatial • Motor & Sensory Perceptual • Reasoning & Problem Solving

24. Executive Functions • Planning • Processing Speed • Cognitive Flexibility • Personality • Social Cognition • Motivation / Response Bias

26. TBI and Neuropsychology • Performance IQ loss is generally greater than Verbal IQ loss. • Younger the child the greater the IQ loss. • Deficits may be seen in any number of domains, dependent on lesion location. • Memory is the most prominently effected neuropsychological function but will also see marked impairment in executive functioning. • Greatest improvement seen shortly post-injury but may be two years and beyond.

27. IQ Distributions

28. Basic Neuroanatomy and Functional Localization • Frontal Lobes • Attention • Planning • Sequencing • Organization • Mental Flexibility • Problem Solving • Impulse Control • Aspects of Memory (Executive Memory)

29. Temporal Lobes (Hippocampus, Amygdala, Basal Ganglia) • Sound recognition and processing • Comprehension and production of speech • Aspects of memory

30. Parietal Lobes • Integration of sensory information from the body • Contains primary sensory cortex • Proprioception • Spatial Functioning • Visuoconstruction • Aspects of memory

31. Occipital Lobe • Primary Visual Cortex

32. Cerebellum • Balance • Movement • Coordination • Some aspects of attention/executive functioning, frontal connections

34. Emotional and Behavioral Changes Secondary to TBI • Emotional/Behavioral sequelae may occur in the absence of neurological and neuropsychological findings. • No specific psychiatric disorder is typical. • 90% of severe and about half of moderate TBI patients have behavioral and social problems. • Hyperactive, mood, anxiety, and anger control problems all may occur.

35. Neuropsychological Assessment of TBI • Effort • Ability (Premorbid estimates and current) • Achievement • Sensory Motor/Visuospatial/Construction • Memory (Verbal and Visual) • Executive Functioning • Affect/Personality

37. Treatment Modalities • Physical Therapy • Occupational Therapy • Speech Therapy • Neuropsychology • Cognitive Rehabilitation • Psychotherapy

38. Psychotherapy: Treatment Considerations • Previously, psychotherapy thought to be less important due to TBI patient deficits (e.g. anosognosia, poor insight, memory problems, perceptual disturbance, language impairment). • With improved therapies in other modalities and compensatory strategies, psychotherapy currently viewed as very beneficial.

39. Therapy Issues • Consider neurocognitive strengths and weaknesses when formulating approach to patient and treatment planning • Impairments in concentration, memory, general ability to sustain focus and effort throughout sessions • Strengths-Maximizing intact abilities (e.g. verbal or visual memory) • When in doubt, spell it out • Contracting for treatment

40. Therapeutic relationship, may take time, exercise patience. • Cicerone and Prigatano-therapeutic relationship is important when working with problems of self-awareness. • Prigatano and Klonoff-therapeutic alliance with patient and family predictive of client productivity as far out as 11 years.

41. Presenting Problems • Behavioral dyscontrol (e.g. anger, irritability, impulsivity, self-awareness) • Depression • Mania • Alcohol Abuse and Dependence • Anxiety Disorders (PTSD, Social phobia, GAD, Panic Disorder) • Personality Changes • Recalling what happened

42. New role (Social, family, educational, etc.) • Employment • Sleep • Appetite • Libido • Medications • Family Support

43. Final Notes • Psychotherapy beneficial for helping patient and family adjust. • Collaborate with other providers (e.g. ST, OT, Neuropsychologist, Physicians/Psychiatrist, PCP)

47. References • American Psychological Association (2011). Rehab for the brain after traumatic injuries, five questions and answers about traumatic brain injury. • Burg, J.S., Williams, R., Burright, R.G., & Donovick, P.J. (2000). Psychiatric treatment outcome following traumatic brain injury. Brain Injury, 14, 513-533. • Coetzer, R. (2007). Psychotherapy following traumatic brain injury: Integrating theory and practice. Journal of Head Trauma Rehabilitation, 22, 39-47. • Jorge R. & Robinson, R.G. (2003). Mood disorders following traumatic brain injury. International Review of Psychiatry, 15, 317-327.

48. References, cont. • Schoonover, C. (2010). Portraits of the mind. New York, NY:Abrams. • Senathi-Raja, D., Ponsford, J., & Schonberger, M. (2010). Impact of age on long-term cognitive function after traumatic brain injury. Neuropsychology, 24, 336-344. • Sherer, M., Evans, C.C., Leverenze, J., Stouter, J., Irby Jr, J.W., Lee, J.E., & Yablon, S.A. (2007). Therapeutic alliance in post-acute brain injury rehabilitation: Predictors of strength of alliance and impact of allegiance on outcome. Brain Injury, 21, 663-672. • Sosin, D.M., Sniezek, J.E., & Waxweiler, R.J. (1995). Trends in death associated with traumatic brain injury, 1979 through 1992. Journal of the American Medical Association, 273, 1778-1780.

49. Resources • www.traumaticbraininjury.net • www.braininjury.com • www.traumaticbraininjury.com • www.pbs.org/wnet/brain/3d • www.g2conline.org • www.cdc.gov/traumaticbraininjury/