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Traumatic Brain Injury – Evaluation and Treatment Considerations. Brian A. Boatwright, Psy.D . Neuropsychologist Director of the Neurologic Rehabilitation Institute. Epidemiology. National Estimates – 1.7 million individuals sustain a head injury each year. 52,000 die.

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traumatic brain injury evaluation and treatment considerations

Traumatic Brain Injury – Evaluation and Treatment Considerations

Brian A. Boatwright, Psy.D.


Director of the Neurologic Rehabilitation Institute

  • 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.

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.

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.

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

primary mechanisms of injury
Primary Mechanisms of Injury
  • Impact
    • Contusion at point of impact
    • Skull Fracture with focal injury
  • 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.
coup and countrecoup
Coup and Countrecoup
  • Head impacted at site of contact with object (causing contusion).
  • Brain is forced into opposite side of skull (causing contusion).
diffuse axonal injury
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.
secondary mechanisms of injury
Secondary Mechanisms of Injury
  • Edema
  • Disruption of CSF absorption
  • Hypoxia
  • Ischemia
damage documented in survivors
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
brain damage survival
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.
traumatic brain injury
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)
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
neuropsychological domains
Neuropsychological Domains
  • Acquired Knowledge
  • Attention & Memory
  • Language
  • Visual Spatial
  • Motor & Sensory Perceptual
  • Reasoning & Problem Solving

Executive Functions

    • Planning
    • Processing Speed
    • Cognitive Flexibility
  • Personality
  • Social Cognition
  • Motivation / Response Bias
tbi and neuropsychology
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.
basic neuroanatomy and functional localization
Basic Neuroanatomy and Functional Localization
  • Frontal Lobes
    • Attention
    • Planning
    • Sequencing
    • Organization
    • Mental Flexibility
    • Problem Solving
    • Impulse Control
    • Aspects of Memory (Executive Memory)

Temporal Lobes (Hippocampus, Amygdala, Basal Ganglia)

    • Sound recognition and processing
    • Comprehension and production of speech
    • Aspects of memory

Parietal Lobes

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

Occipital Lobe

    • Primary Visual Cortex


    • Balance
    • Movement
    • Coordination
    • Some aspects of attention/executive functioning, frontal connections
emotional and behavioral changes secondary to tbi
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.
neuropsychological assessment of tbi
Neuropsychological Assessment of TBI
  • Effort
  • Ability (Premorbid estimates and current)
  • Achievement
  • Sensory Motor/Visuospatial/Construction
  • Memory (Verbal and Visual)
  • Executive Functioning
  • Affect/Personality
treatment modalities
Treatment Modalities
  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy
  • Neuropsychology
  • Cognitive Rehabilitation
  • Psychotherapy
psychotherapy treatment considerations
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.
therapy issues
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

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.
presenting problems
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

New role (Social, family, educational, etc.)

  • Employment
  • Sleep
  • Appetite
  • Libido
  • Medications
  • Family Support
final notes
Final Notes
  • Psychotherapy beneficial for helping patient and family adjust.
  • Collaborate with other providers (e.g. ST, OT, Neuropsychologist, Physicians/Psychiatrist, PCP)
  • 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.
references cont
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.