Traumatic Brain Injury

1
Traumatic Brain Injury Evaluation and Treatment
Considerations

• Brian A. Boatwright, Psy.D.
• Neuropsychologist
• Director of the Neurologic Rehabilitation
  Institute

2
(No Transcript)
3
(No Transcript)
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 gt65.
• Those gt75 have highest rates of TBI related
  hospitalization and death.
• MalesgtFemales
• 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

8
(No Transcript)
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).

12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
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.

17
(No Transcript)
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

25
(No Transcript)
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

33
(No Transcript)
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

36
(No Transcript)
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)

44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
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/

50
(No Transcript)