introduction to traumatic brain injury (tbi) july, 2011
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INTRODUCTION TOTRAUMATIC BRAIN INJURY (TBI)
JULY, 2011
Cheryl L. Shigaki, Ph.D., ABPP& Thomas Martin, Psy.D., ABPP
Psychologists in US Health Care
Rehabilitation Psychology – focuses on adjustment to disability, maximizing function, full-participation in life activities.
Health Psychology – focuses on the intersection between behavior and health.
Neuropsychology – focuses on cognitive and behavioral sequelae from insults to the brain.
Rusk Rehabilitation CenterColumbia, Missouri
60 inpatient beds – serves post-acute:
Brain injury Spinal Cord Injury Stroke Multi-trauma Debility
TBI and Healthcare The public and many health care
professionals have limited and/or inaccurate understanding of TBI.
Overlap between TBI and psychiatric symptoms
Benefit and challenges of screening to identify history of TBI? Benefit – Avoid misdiagnosis and promote
care “Have you ever had a head injury?” not
effective
TBI in Rwanda People with new brain injuries
Recognizing mild TBI Helping victims and families adjust to
moderate-severe TBI People with previous TBI
Understanding personality and behavior change
Supporting chronic physical, cognitive and emotional effects
TBI and Healthcare Typical rehabilitation approaches
include: Restorative strategies: Direct intervention to
improve the problem Compensatory strategies: Intervention focuses
on adapting to the problem / working around it. Psychological intervention: Address emotional
reaction to loss and/or trauma; support motivation for active recovery.
Family caregiver support: Education about what to expect, how to manage problem behaviors and advocate for their loved one, and provide support for coping with stress and loss.
The Brain and TBIThe brain weighs about 1.4
kgs, with a consistency somewhere between butter and gelatin.
TBI causes brain damage in a number of ways. Damage can be caused by both primary and secondary injuries.
Overview of the Brain CEREBRAL HEMISPHERES
Left hemisphere Right hemisphere
FOUR LOBES OF THE BRAIN Frontal lobe Parietal lobe Temporal lobe Occipital lobe
BRAIN CELLS (NEURONS)
Lobes of the Brain
CC-BY-SA-3.0; Released under the GNU Free Documentation License.
Structure of a Neuron (brain cell)
Dendrite
Soma
Nucleus
Node
Myelin sheath
Schwann cell
Axon terminal
Axon
The Corpus Callosum From Above
Image from Gray’s Anatomy.In the public domain
Good Neuroanatomy WebsiteFlorida Institute for Neurologic Rehabilitationhttp:// www. finr. Net
Note: App for iPhone now available!
Common Primary Injuries
Skull fractures Contusions (bruising) Intracranial hemorrhage
(hematomas) Diffuse axonal injury (DAI)
Contusions Contusions are hemorrhagic
lesions that typically form at the crests of gyri on the surface of the brain: Coup contusions form at the site
of cranial impact. Contrecoup contusions form
opposite the cranial impact and are typically more severe.
Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist. http://creativecommons.org/licenses/by/2.5/
The inside of the skullIs not smooth, it has sharp ridges
Hematomas
Classified by the location of bleeding; hematomas can damage the brain by exerting pressure on underlying brain structures Epidural Subdural Subarachnoid
HematomasSubdural within the layers
of brain covering Due to vein
bleeding which is slower than artery bleeding.
May not be discovered until days or weeks after the accident
Epidural Usually caused by
tears in arteries, Results in quick
blood build up between the dura mater and the skull.
Hematomas
Subdural hematoma as marked by the arrow with significant midline shift Epidural hematoma
Signs and Symptoms of Hematoma Fluctuating levels
of consciousness (or LOC)
Irritability Seizures Pain/Numbness Headache Dizziness Hearing
loss/ringing Disorientation/
amnesia
Weakness/lethargy Nausea/vomiting Loss of appetite Personality changes Difficulty speaking, slurred speech Difficulty walking Altered breathing Blurred
vision/abnormal eye movement
Diffuse Axonal Injury (DAI) Widespread neuronal axon damage is
frequently associated with “stretching” of the brain (motor vehicle accidents).
DAI is thought to contribute to LOC and prolonged coma.
The problem associated with “shaken baby syndrome”
Common Secondary Injuries Ischemia – lack of blood/oxygen in
area leading to cell death Elevated intracranial pressure
(swelling) & diminished blood flow Neurochemical events – blood is
toxic to brain tissue Posttraumatic epilepsy Cerebral infection
Elevated Intracranial Pressure (ICP)
The cranium is inflexible, increased pressure compresses brain tissue. Edema Hematoma
Sharp increases in intracranial pressure can contribute to cerebral ischemia and herniation.
Management of intracranial pressure and maintaining cerebral blood flow are primary concerns.
Edema (Swelling) Cerebral edema results from
disruption of the blood-brain barrier and impairment of vasomotor autoregulation with concomitant dilation of cerebral blood vessels.
Cerebral edema can lead to compression of the ventricular system, herniation, occlusion of intracranial vessels with secondary strokes, or increased intracranial pressure.
Elevated Intracranial Pressure (ICP)
Types of brain herniation:1) Uncal2) Central3) Cingulate4) Transcalvarial5) Upward6) Tonsillar
TBI ASSESSMENT
Terminology: “Cognitive” So far, we have been using the term
“cognitive” to describe thinking styles in people with normal brain function Based on social & personal context and
habits we learn Cognitive / Cognitive-Behavioral therapies
are used to improve psychological wellbeing. Psychologists help patients explore and change thoughts and behaviors that are maladaptive
Terminology: “Cognitive” Can also be used to describe thinking
skills that are genetically/biologically driven and enhanced by opportunities for learning. Neuropsychological research has attempted
to define distinct aspects of “cognition” such as auditory & visual memory, attention, problem-solving, speed, etc.
Neuropsychological research also attempts to distinguish between normal and impaired cognition
Clinical Neuropsychologists test brain function following brain injury or disease (using tasks and questions) and make recommendations for living with impairment.
Assessment of Mild TBI Domestic violence Sports injuries Work-related injuries The effects of mild TBI can be
cumulative
“Have you ever had a head injury?” is not an effective way to evaluate.
Assessment of Mild TBI Acute Concussion Evaluation (ACE) Heads Up: Brain Injury in Your Practice
(CDC)http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html Interview and assessment of risk factors Symptom checklist Diagnostic codes (ICD) Sample follow-up plans/recommendations
Versions for return to work, school & sports
Assessment of Moderate-Severe TBI
Three pathways to assess severity of acute TBI: Depth of coma Duration of coma The inability to continually register new
experiences (Posttraumatic Amnesia or PTA)
Glasgow Coma Scale (GCS)
Glasgow Coma Scale (GCS) Mild
Glasgow Coma Scale (GCS) score 13-15 Loss of consciousness (LOC) < 20 Minutes Posttraumatic amnesia (PTA) <24 hours
Moderate GCS score 9 – 12 LOC 20 - 36 hour PTA 1 - 7 days
Severe GCS score 3-8 LOC > 36 hours PTA > 7 days
Note: A GCS score can be broken down, for example: GCS 12 = E4V3M5
Forms and training scripts can be found at: http://www.chems.alaska.gov/ems/documents/GCS_Activity_2003.pdf
Rancho Los Amigos:Level of Cognitive Functioning Scale Helpful in assessing the patient in the
first weeks or months following an injury. Does not require cooperation from the
patient Rancho “levels” are based on
observations of the patient’s response to external stimuli & provide a descriptive guideline of the various stages of brain injury.
Forms and descriptions can be found at: http://tbims.org/combi/lcfs/
Galveston Orientation & Amnesia Test (GOAT) The GOAT can be used to
track how much a person is recovering while in the hospital (no longer in a severe coma).
Requires patient cooperation. Score is 100 MINUS error
points. Score of 78 or more on three consecutive occasions/days indicates that patient is out of post-traumatic amnesia (PTA).
Galveston Orientation & Amnesia Test (GOAT) What is your name? (2) When were you born? (4) Where do you live? (4) Where are you now? (5) City, (5) Hospital On what date were you admitted to this hospital?
(5) How did you get here? (5) What is the first event you can remember after the
injury? (5) Can you describe in detail the first event you recall
after the injury? (5)
Galveston Orientation & Amnesia Test (GOAT)
Can you describe the last event you recall before the accident? (5)
Can you describe in detail the first event you can recall before the injury? (5)
What time is it now? (-1 for each 30 min incorrect, up to -5)
What day of the week is it? (-1 for each day incorrect, -3)
What day of the month is it? (-1 for each day incorrect, -5)
What is the month? (-5 for each month incorrect, -15)
What is the year? (-10 for each year incorrect, -30)
Levin, H.S., O'Donnell, V.M., & Grossman, R.G. (1975). The Galveston orientation and amnesia test: A practical scale to assess cognition after head injury. Journal of Nervous and Mental Diseases, 167, 675-684.
TBI OUTCOMES
Consequences of TBI The brain controls every aspect of
our being and a traumatic brain injury has the capability of impacting any aspect of a person’s physical, cognitive, or psychological functioning.
In-depth evaluation of these skills is the domain of Neuropsychologists.
Impact of Mild TBI Mild TBI is typically associated with
modest and temporary changes in functioning, while severe TBI is associated with enduring changes and sometimes mortality.
Reductions in attention and information processing speed and efficiency are the most frequent cognitive consequences following mild TBI.
Physical Functioning: Mod-Severe TBI
Arm/leg weakness & paralysis Compromised speech and
swallowing ability Dizziness & dyscoordination Diminished sense of smell and taste Hearing (e.g., tinnitus) and visual
disturbance (e.g., diplopia) Sleep disturbance and fatigue Chronic headaches and pain Sexual dysfunction
Cognitive Impact: Mod–Severe TBI Although severe TBI
can impact any aspect of cognition, the high incidence of orbitofrontal (front of the brain, around eye sockets) and anterior temporal lobe (tips of the temporal lobes) contusions often produces a constellation of symptoms that includes:
Cognitive Impact: Mod–Severe TBI Slow speed of cognitive processing
(functional) Slowed behavioral responding (functional) Attention deficits Impaired learning & memory (need more
exposures) Behavioral symptoms:
impulsivity Perseveration initiation deficits planning and organization
Cognitive Impact: Mod-Severe TBI
TBI does not typically compromise intelligence in mild-moderate cases.
The Thinker – Musée Rodin, Paris
Speed of Processing Speed of processing (reaction time)
is very sensitive to any brain insult Following a brain injury, it often
takes longer to take information in and react to events
Reduced speed of processing can compromise other cognitive abilities
Degree of impairment may render the patient dysfunctional in daily activities.
Learning/Memory Memory problems are the most
common cognitive complaint following a TBI
Short term vs. long term memory Verbal memory vs. visual memory Explicit memory (e.g., experiences,
facts, events) vs. implicit (e.g., skills, habits) memory
Research suggests deficit is in learning
Attention Attention is on a continuum and task
specific: Simple Attention: Ability to register and
attend to (e.g., focus on a noise) Focused Attention: Ability to focus on
important information while ignoring irrelevant information
Sustained Attention: Ability to focus for extended period
Divided Attention: Shift attention between tasks (e.g., cook & talk on the phone)
Executive Functions Executive Functions – Skills
necessary for complex goal-directed behavior and adaptation to changes Planning and organization ability Problem-solving ability Ability to initiate and sustain action and
anticipate consequences Ability to benefit from feedback and
adjust behavior
Personality Changes Impulsivity Grandiosity Apathy / lack of initiative Impaired ability to evaluate risk
and need for safety measures (meta-awareness, metacognition)
They don’t know what they don’t know
Personality changes Impulsivity Grandiosity Apathy / lack of initiative Inability to be empathic / self-focused Impaired ability to evaluate risk; judge
one’s physical, cognitive and emotional functioning Thinking about thinking - They don’t know
what they don’t know
Psychiatric/Behavioral Impact
Altered mood, behavior, and personality are common following TBI; even mild TBI has been associated with significant affective disturbance.
Reactive, “organic” or both?
Psychiatric/Behavioral Impact Rates of psychiatric disorders
following TBI: Major depression (44%) Substance abuse/dependence (22%) Post-traumatic stress disorder (14%) Panic disorder (9%) Generalized anxiety disorder (9%), Obsessive compulsive disorder (6%) Bipolar disorder (4%) Schizophrenia (0.7%) van Reekum et
al., (2000)
Psychiatric/Behavioral Impact Diminished tolerance for
frustration Decreased social skills Adjustment disorders and
emotional lability Aggressive behavior (verbal and
physical), particularly when overwhelmed
Increased rates of alcohol and substance abuse and risk of suicide
Psychiatric/Behavioral Impact
Symptom overlap between TBI and PTSD: Memory / attention Sensory changes (sensitivity) Depression/poor emotional
control Headache, fatigue, other
physical or sensory problems Co-occurrence can make
diagnosis difficult
TBI and Post-traumatic Stress Self-report study (N>3000)
4 Groups Multi-trauma, with no TBI Multi-trauma, with TBI (mild, mod, severe)
Telephone survey, 12 months post-injury Asked about cognition and PTSD
symptoms
Zatzick, Rivara, Jurkovich et al. Arch Gen Psychiatry. 2010;61:1291-1300
TBI and Post-traumatic Stress More severe TBI was related to
diminished signs and symptoms of PTSD Due to impaired consolidation of traumatic
memories Those with facial injuries and spinal cord
injuries (SCI) showed increased risk for PTSD symptoms
At all levels of TBI, those with PTSD symptoms reported the greatest levels of impairment Cognition, physical health, and functioning
in everyday activities
TBI and Post-traumatic Stress
In studies where cognition was tested
Individuals exposed to combat, rape and childhood abuse have demonstrated difficulty with verbal learning.*
Adults with chronic PTSD were found to have volume and activity differences in the brain (hippocampus)**Bremner JD. The Relationship between cognitive and brain changes in
Posttraumatic stress disorder. Ann NY Acad Sci 2006;1071: 80-86.
Working with individuals who have TBI
and their families
Outcomes Following TBI Severity of injury is the best predictor of
outcome Age also noted to be a independent
predictor Other factors that contribute to outcome
include: prior history of TBI, history of substance abuse, PTSD, vocational history, and adequacy of social relationships
Larger brain volume and higher educational level are known to exert a positive influence
Genetic factors also play a role.
General Cautions for Healthcare
TBI can impact sensory functioning (e.g., diplopia and altered vision, ringing in ears, and decreased balance)
TBI can contribute to the development of medical disorders such as sleep disturbance and substance abuse issues.
Communication deficits can be a significant source of frustration and disability.
General Cautions for Healthcare
Many medical conditions can exacerbate TBI symptoms including sleep disorder, infection, and pain.
Use of alcohol or other substances may have a worse effect or lead to worse consequences for individuals with TBI.
Individuals with a history of TBI are at increased risk for future TBI. Cumulative effect of multiple concussions.
Recommendations for Working with Individuals with TBI
Allow adequate time to process information and respond
Appreciate that the injured brain is easily overwhelmed by multiple stimuli (noise, lights, activity)
Maintain a supportive setting that utilizes structure and avoids dramatic changes in routine
Potential for behavioral problems increases when the individual is physically, cognitively or emotionally stressed (e.g., fatigue, pain) and with experience of expressive language dysfunction
Recommendations for Working with Individuals with TBI
Provide information in multiple modalities in a concrete and brief manner with limited distraction.
Focus on one task at a time / limit multitasking.
Memory for visual and verbal information may be individual strength.
Diminished initiation can easily be mistaken for depression, apathy or resistance.
Recommendations for Working with Individuals with TBI
Receptive Language Deficits Speak slowly, using short phrases and
sentences Use gestures with your speech; use visual
cues Repeat your message in different ways Do not rush-allow time for response,
alleviating pressure to speak and allowing time to process information
Use an alternate communication system when appropriate (i.e., pictures)
Include the individual in conversation, but don’t overload them with information
General Recommendations For Expressive Language Deficits
Ask one-part yes/no questions Acknowledge and discuss the frustration the
person might be having when communication attempts are made
Allow adequate time for the individual to speak
Involve the individual in decision making whenever possible, practicing expressive reasoning and review of steps one might make to achieve a desired outcome
Continue normal daily routines and encourage use of learned strategies (e.g., over-articulation and increased volume)
Cheryl L. Shigaki, Ph.D., ABPP
Associate ProfessorUniversity of MissouriDepartment of Health PsychologyDc116.88One Hospital DriveColumbia, MO 65212 USAshigakic@health.missouri.edu
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