Treatment of Mild Traumatic Brain Injury using an Interdisciplinary Approach

Presented by:• Helen Mathison MA, CCC-SLP• Nova McNally OTR/L• Danielle Potokar PhD, LP• Sarah Rockswold M.D.• James Thomson PhD, LP

Traumatic Brain Injury: Magnitude of Problem

• Occurs every 15 seconds in the U.S.• Death occurs every 5 minutes• Permanent disability occurs every 5 minutes

Traumatic Brain Injury: Magnitude of Problem

• 1.7 million brain injuries per year• 1.0 million emergency department visits• 500,000 hospitalizations• 50,000 deaths• Direct & indirect costs of $60 billion

TBI Statistics

• Major issue is premature death and disability

• TBI is a disease of the young– 84% of the 1.7 million TBIs are sustained by

people age 64 or less• Prevalence of long term disability due to

TBI in the U.S. is over 3 million people

TBI: Definition

• A traumatically induced physiological disruption of brain function manifested by:– Loss of consciousness– Amnesia – retrograde and/or anterograde– Confusion– Delayed verbal or motor responses

TBI: Mechanism

• The head being struck• The head striking an object• The brain undergoing an acceleration-

deceleration movement without direct trauma to the head

Mild Brain Injury• GCS score = 14 to 15• Post-traumatic amnesia < 24h• Mild brain injury = negative CT scan• Mild complicated brain injury = positive CT

scan

Epidemiology

• Mild TBI constitute vast majority of brain injuries within the U.S.

• Incidence of 1.2 million cases of mild TBI in the United States yearly

• Account for 290,000 hospital admissions per year

Concussion

Concussion = mild or moderate traumatic brain injury

Pathophysiology

• May be metabolic rather than structural in nature– Traditional neurodiagnostic techniques not

sensitive– PET scan, fMRI, Diffuse Tensor Imaging

GCS 15 GCS 5

Metabolic brain dysfunction following traumatic brain injury

GCS 15

Bergsneider, Hovda, et.al. J Neurotrauma 2000

Why is follow-up important?

• Symptoms will resolve within 2 weeks in 85% of patients with mild TBI

• If the symptoms do not resolve, a chronic post concussive syndrome can develop which can cause significant occupational, social, and personal problems

Why is follow-up important?

• Prevention of multiple TBIs is vital• Repetitive mild TBI results in more persistent

cognitive impairments and physical symptoms• Ongoing symptoms need to be recognized

more readily

Postconcussion Syndrome

• Cognitive– Attention and concentration difficulties, memory

impairment, efficiency• Affective

– Irritability, depression, anxiety• Somatic

– Headache, dizziness, insomnia, fatigue, sensory disturbances

Evaluation

• History is key– What are the problems?• Cognition• Headache• Musculoskeletal complaints• Dizziness• Sleep• Psychosocial

Evaluation

• History– What is their occupation?– What are their hobbies?– What is their living situation?

• Physical Exam– Cognitive screen– Balance and coordination

Management

• Interdisciplinary approach is key!• All physical, cognitive, and emotional

disturbances must be identified and addressed for good recovery

Management

• Based on history, social situation, and physical examination– Neuropsychological testing– SLP, PT, OT– Clinical Psychology– Therapeutic Recreation– Vestibular clinic– Medications

Management

• Rest of absolute nature– Symptoms aggravated by exertion, both physical

and cognitive– Time away from school or work– Discontinue fitness activities, aerobic activities and

exertional activities of daily living

Management

• As symptoms improve with treatment, patients can slowly be returned to their activities, i.e. school, work, sports

Conclusion

• Mild/moderate TBI patients’ needs have traditionally been underserved– “Since CT scan normal, patient must be normal”

• On the contrary, mild TBI is a challenging diagnosis

• Individualized management utilizing an interdisciplinary team is essential

Case Report #1

• 19 y/o male who fell after syncope• + LOC• Seen at outside hospital in Denver• CT of brain: (-)• GCS score not recorded

Case Report #1

• PmHx: 6 previous TBIs, ADHD, Bipolar disorder, dyslexia, htn

• Meds: Trazadone, metroprolol• Social Hx: Sophomore at U of Denver• Sent home from ED with primary care follow-

up

Case Report #2

• 29 y/o male who fell 25 feet at work• - LOC• Admitted to HCMC• CT of brain: (cerebral contusionn, frontal sinus

fracture)• GCS score 15 at admission

Case Report #2

• PmHx: mild TBI as infant• Meds: none• Social Hx: welder, workmans comp case• Seen in outpatient TBI clinic approx 1 month

after hospital discharge

Neuropsychological Evaluation

Chart ReviewInterviewTestingFeedbackEducationDiagnosisRecommendations

Chart Review

Medical HistoryAcademic ReportsPsychology/Psychiatry ReportsNeuropsychology EvaluationsLegal Reports

Diagnostic Interview

Current Information– Symptom Review– Concurrent Issues– Current Activities– Coping Strategies– Goals and Plans

Diagnostic Interview

Social History– Childhood– Academic Achievement– Occupational History– Leisure Activities

Neuropsychological Testing

Cognitive Domains– Perception– Memory– Learning– Reasoning– Executive Abilities– Language– Achievement– Motor Coordination

Neuropsychological Testing

Behavior Observations– Affect– Appearance– Motivation– Rapport– Engagement– Attention– Organization– Frustration Tolerance– Personality

Feedback and Clarification

Review ResultsAnswer QuestionsClarify Diagnostic Issues

Education

Brain Structure and FunctionReview of CT and MRI DataShearing EffectsImplications of Symptoms and ResultsNatural History of TBIExpectations for Recovery

Diagnosis

Extent of Brain Injury– Rate of Recovery– Prospects– Problems

Re-diagnosisCo-diagnosisNo diagnosisMalingering

Recommendations

Cognitive Rehabilitation (SLP/OT)PTPsychotherapyPsychiatryFeedback to MD or MDs

Recommendations

DrivingWorkSchoolChange in SupervisionReturn to Normal Life

Follow-up

Continued Involvement with TeamReturn for Re-evaluationReturn for EducationLater Contacts– New Problems– Re-entry to Hospital– Seeking Community Contacts– Support and Reassurance

Case Report

Neuropsychological Results

Occupational TherapyOur Role within the TBI clinic

Assess:-functional visual processing-ability to participate in daily activities including work, school, driving, and home management

Occupational Therapy and Visual Processing

• Changes in visual processing are a common complaint after a head injury.

• 20/20 vision does not equal good visual processing.• OT will perform a specialized visual processing screen

to look for deficits.

• A comprehensive eye examination, performed by a neuro-ophthalmologist, is needed to properly diagnose these deficits.

Common Complaints

• Headaches• Double vision +/or blurry vision• Vertigo/dizziness• Nausea• Inability to focus (visual attention

which will impact concentration)

Common Complaints

• Movement of print when reading• Difficulty visually tracking• Photophobia• Visual overstimulation (feeling

overwhelmed in a busy environment like a grocery store or riding in a car.)

How These Symptoms Can Impact Every Day Life

• Blurred vision when looking from near to far or far to near as needed for driving or taking notes in class

• Headaches, eye strain, pulling sensation around the eyes

• Reading problems, movement of the print while reading, skipping lines or re-reading lines

Functional Impact continued

• Avoidance of reading and other close work • Fatigue and sleepiness• Loss of comprehension over time, decreased

short term memory, no retention of new information

• Difficulty with ADL’s that require sustained close work/attention

Occupational Therapy Intervention

• Treatment will focus on retraining the visual processing system with specially designed exercises and activities.

• Symptom and energy management• Client and family education• Teaching compensatory strategies as needed• Pre-drive screen• Assist with the transition back to work or school• Monitor return to exercise/physical activity

Challenges of OT Treatment

• Client awareness and insight into their deficits• Compliance with home exercises and energy

management strategies• Under reporting of symptoms

» Direct communication with the interdisciplinary team for quality continuum of care.

Speech Pathology’s Role

• Assessment of Cognitive-Linguistic Abilities• Intervention– Direct Treatment– Awareness Training– Compensation Training– Adjustment to Cognitive Changes– Return to Work / School

Speech Pathology Assessment

• In depth interview– Diagnostic interview– Post concussive symptom questionnaire

• Formal cognitive-linguistic assessment– Observe behaviors & symptoms– Observe strategy use

• Informal evaluation of multi-processing abilities

Challenges of SLP Assessment

• Most formalized tests are often not sensitive enough with mTBI

• Informal evaluation of multi-processing abilities in distracting environments essential

• In depth interview & direction observation also essential

Effective Treatment

• Awareness training is a key element• Goals must relate to complex activities in life

and work• Regular interdisciplinary communication is

needed

Main SLP Goal Areas

• Time and Energy Management• Awareness Training & TBI Education• Attention & Memory Compensation

Techniques• Organizational Skills• Word Retrieval & Pragmatic Language Skills• Return to Work/Study Skills

Time and Energy Management

• Client keeps daily log– Energy level, pain level, cognitive “success,” mood

• SLP reviews log with client– Summarizes trends/progress– Helps client become own expert at compensating

successfully

Awareness Training

• Train client to be own expert• Client gives own assessment of performance• SLP gives assessment, comparison of

discrepancies, feedback• Continuous education helps generalization of

strategies

Memory Compensation

• Increased Active Attention• Increased Organization• Use of External Aids• Increased Awareness/Self-testing• Rehearsal• Elaboration• Association

Organizational Skills

• Set Location for Important Items• Increased Use of Writing• More Methodical Approach• Successful Use of Planners, Alarms,

Smartphones and Other External Aids

Return to Work

• Simulate work tasks• Plan and discuss recommended

accommodations• Possibly educate employer &/or peers• Overlap treatment with RTW to provide

feedback & problem solving

Return to School

• Achievement Testing• Teach or Review Study Skills• Teach Organizational Skills• Focus on Awareness (e.g. need for strategies,

rest)• Provide Guidance about Choosing Classes

(Amount/Type)

Common Emotional Changes post mild TBI

• Increased irritability (“short fuse”)• Crying (more often, without being able to control it

at times)• Sadness• Anxious, nervous or feeling “edgy”• Increased worry thoughts• Overwhelmed• Hopeless about future• Wishing you had died in the accident• Feeling you are a burden to your family

Typical areas of focus in psychological work with TBI patients:

– Adjusting to life changes because of TBI– Improving Sleep– Relaxation strategies– Improving Mood– Decreasing Anxiety– Improving Relationships– Identity and other Existential Issues

Common Diagnoses• Adjustment Disorders

– With Depression– With Anxiety

• Anxiety Disorders– Anxiety NOS– Post-traumatic Stress Disorder (PTSD)– Generalized Anxiety Disorder (GAD)

• Mood Disorders– Depression NOS– Major Depressive Disorder

• Substance Use Disorders (LESS COMMON)

Therapeutic Approaches

• Cognitive-Behavioral Therapy (CBT)

• Acceptance and Commitment Therapy (ACT)

• Interpersonal Process Therapy (IPT)

General Objectives for Therapy

• Educate patients on the interaction between thoughts, feelings, and behaviors

• Assist patients in heightening their awareness of symptoms (post-concussive and mental health) in vivo

• Assist patient in learning ways to react to their symptoms in ways that lead to better outcomes

• Provide patients with tools to catch, check and cope with negative self-statements that contribute to downward spiral of depression and anxiety

General Objectives for Therapy

• Assist patient in reconciling multiple views of self (“old me” vs. “new me”)

• Assist patient in processing the losses that arise from sustaining a TBI

• Assist patient in articulating values and assisting patient work towards those values

Challenges when working with TBI patients in Psychotherapy

• Stigma of “psychological help” can deter people from seeking or completing treatment

• Attention and memory deficits can lengthen treatment

• Visual challenges can impact ability to complete homework assignments

• Heightened emotionality can lead to avoidance of therapy or homework