to view the PowerPoint on Traumatic Brain Injury

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. 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 

Impact – Contusion at point of impact – Skull Fracture with focal injury

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.

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 





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    

Edema Disruption of CSF absorption Hypoxia Ischemia

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 



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 

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     



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 









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 postinjury but may be two years and beyond.

IQ Distributions 160

Normal THI-VIQ THI-PIQ

0 100

Dennis 1985

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



Cerebellum – Balance – Movement – Coordination – Some aspects of attention/executive functioning, frontal connections

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       

Effort Ability (Premorbid estimates and current) Achievement Sensory Motor/Visuospatial/Construction Memory (Verbal and Visual) Executive Functioning Affect/Personality

Treatment Modalities     



Physical Therapy Occupational Therapy Speech Therapy Neuropsychology Cognitive Rehabilitation Psychotherapy

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 





 

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 



  

 

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 



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

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.

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, 17781780.

Resources      

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