Assessment and Treatment of TBI

for Mental Health Practitioners

Jim Messina, Ph.D. Assistant Professor, Troy

University, Tampa Bay Site

Goal of Workshop

Help you better understand What is TBI How TBI is assessed What the issues are facing clients

with TBI Mental Health Tools to be utilized

with patients with TBI

What is a TBI?

TBI occurs when a sudden trauma such as a blow or jolt causes damage to the brain

There are two types: Focal: damage to one area of brain Diffuse: damage in more than one

area of brain

Categories of TBI

1. Closed head injury: results from any trauma that causes the brain to be violently shaken inside of the skull such as a “blast” injury

2. Penetrating injury: when object goes through the skull & enters the brain.

1. Skull fracture2. Brain contusion3. DAI (Diffuse axonal injury) over 50%

of TBI

1. Intracranial hemorrhages2. Brain edema3. Increase of ICP (Intracranial

pressure)4. Infections5. Delayed lesions6. Long term effects

Primary lesions

Resultantconcerns

HEADINJURY

Results of TBI

1. Can cause nerve cells in brain to stretch, tear, or pull apart, making it difficult or impossible for cells to send messages from one part of brain to another & to rest of body

2. Can interfere with how brain works, including thinking, remembering, seeing & controlling movements

Causes of TBI

1. Brain injuries can occur when the head strikes an object such as a windshield or the ground at a fast rate of speed

2. When a flying or falling object strikes the head

3. Can occur without a direct blow to head as in cases of severe "whiplash"

Most Common Causes of TBI for Military

Bullets, fragments, blasts Motor vehicle-traffic crashes Falls Assaults Blasts are a leading cause

of TBI for active duty military personnel in war zones.

Resultant injury from explosive devices

Primary Injury–overpressure

Secondary injury–secondary wave-shrapnel

Tertiary injury-person blown into objects

Quaternary-heat and gas

Ranges of TBI

Traumatic brain injury can range from mild to very severe depending on many things including: Force of the trauma Previous brain injuries How quickly emergency medical

treatment is given

TBI Definitions:Concussion/Mild TBI

A confused or disoriented state lasting 24 hours or less

Loss of consciousness for up to 30 minutes

Memory loss lasting less than 24 hours.

Moderate TBI:

A confused or disoriented state that lasts more than 24 hours

Loss of consciousness for more than 30 minutes, but less than 24 hours

Memory loss lasting greater than 24 hours but less than seven days

Severe TBI

A confused or disoriented state that lasts more than 24 hours

Loss of consciousness for more than 24 hours

Memory loss for seven days or more

Penetrating TBI or Open Head Injury

The outer layer of the brain is penetrated by a foreign object

DoD Numbers on TBI 2000-2011

Mild: 175,647 76%Moderate: 38,235 16.7%Severe: 2,360 1%Penetrating: 3,378 1.6%Not Classifiable: 9,099 4%Total: 229,106

TBI By Military Service2000-2011

Army 57%Active: 100,373 Guard: 22,489 Reserves: 9,415Navy 13.9%Active: 29,597 Reserves: 2,325

Air Force 13.8%Active: 27,305 Guard: 2,659 Reserves: 1,611Marines 14.5%Active: 30,473Reserves: 2,859

Who are Highest Risk for TBI?

Males are about 1.5 times as likely as females to sustain a TBI

Military duty increases risk of sustaining a TBI

Signs & symptoms of mild TBI or concussion Headaches Dizziness Excessive fatigue (tiredness) Concentration problems Forgetting things (memory problems) Irritability Sleep problems Balance problems Ringing in the ears Vision changes

Signs & symptoms of moderate and severe TBI

coma severe headaches seizures/convulsions nausea/vomiting inability or difficulty

speaking, understanding &concentrating

confusion, restlessness or agitation

loss of or changes in coordination

memory loss/amnesia vision changes or loss of vision paralysis and/or muscle

spasticity chronic pain sleep disturbances inability or changes in ability

to use senses of taste, touch, sight, sound, smell & taste

loss of bowel and/or bladder control

Common Late Symptoms of Concussions

Persistent Headache Lightheadedness and/or dizziness Decreased attention and

concentration Poor memory Easy fatigability Anxiety or depressed mood Sleep disturbance

How long do Symptoms Last?

Symptoms of mild TBI or concussion often resolve within hours to days & almost always improve over 1-3 months

Patients with moderate to severe TBI often have long-term medical problems requiring specialized attention

Symptoms & effects will vary greatly from one patient to another, depending on severity of TBI & location of injury

Long Term Impact of Single Concussion or mTBI

A single traumatic brain injury may prompt long-term neurodegeneration (Johnson, V.E., Stewart, W. & Smith, D.H. (2011). Widespread Tau and Amyloid-Beta Pathology Many Years After a Single Traumatic Brain Injury in Humans. Brain Pathology (22) 142-149)

Tau tangles & amyloid-beta plaques were present years (1-47 years) after just one Traumatic Brain Injury (concussion) so could be precursor to Alzheimer's or other neurodegenerative conditions

Do Disabilities Come from TBI?

Disabilities from a TBI depend upon1.Severity of injury2.Location of the injury3.Age & general health of the patient

What are the Possible Disabilities?

1. Problems with cognition (thinking, memory, and reasoning)

2. Sensory processing (sight, hearing, touch, taste, and smell),

3. Communication (expression and understanding)

4. Behavior or mental health (depression, anxiety, personality changes, aggression, acting out, and social inappropriateness)

What Measures are used to assess for TBI

Military Acute Concussion Evaluation (MACE)

Brief Traumatic Brain Injury Screen (BTBIS)

Glasgow Coma Scale

Military Acute Concussion Evaluation (MACE)

Who should be evaluated with the MACE?Any one dazed, confused, “saw stars” or lost consciousness even momentarily, as a result of an explosion, blast, fall, motor vehicle crash, or other event In such event involving abrupt head movement, a direct blow to head, or other head injury

MACE Components

Standardized Assessment of Concussion (SAC): Total possible score = 30 Orientation = 5 Immediate Memory = 15 Concentration = 5 Memory Recall= 5

Orientation (1 point per question)

Orientation: Assess patients awareness of the accurate time

1. WHAT MONTH IS THIS? 2. WHAT IS THE DATE OR DAY OF THE

MONTH? 3. WHAT DAY OF THE WEEK IS IT? 4. WHAT YEAR IS IT? 5. WHAT TIME DO YOU THINK IT IS?

Immediate Memory (up to 15 points, 5 points per trial)

3 Trials with 5 words: candle, paper, sugar, sandwich, wagon

For each trial: I’M GOING TO TEST YOUR MEMORY, I WILL READ YOU A LIST OF WORDS AND WHEN I AM DONE, REPEAT BACK AS MANY WORDS AS YOU CAN REMEMBER, IN ANY ORDER.

Concentration (5 points)

I’M GOING TO READ YOU A STRING OF NUMBERS AND WHEN I AM FINISHED, REPEAT THEM BACK TO ME BACKWARDS, THAT IS, IN REVERSE ORDER OF HOW I READ THEM TO YOU. FOR EXAMPLE, IF I SAY 7-1-9, YOU WOULD SAY 9-1-7. 5-2-6 4-1-5 (1 point)1-7-9-5 4-9-6-8 (1 point)4-8-5-2-7 6-1-8-4-3 (1 point)8-3-1-9-6-4 7-2-4-8-5-6 (1 point)

NOW TELL ME THE MONTHS IN REVERSE ORDER, THAT IS, START WITH DECEMBER AND END IN JANUARY (1 point)

Delayed Recall (5 points)

DO YOU REMEMBER THAT LIST OF WORDS I READ A FEW MINUTES EARLIER? I WANT YOU TO TELL ME AS MANY WORDS FROM THE LIST AS YOU CAN REMEMBER IN ANY ORDER.

One point for each word remembered for a total of 5 possible points.

Lastly a neurological screening is done:

Neurological Screen Eyes: check pupil size & reactivity. Verbal: notice speech fluency & word

finding Motor: pronator drift- ask patient to lift arms

with palms up, ask patient to then close their eyes, assess for either arm to “drift” down. Assess gait & coordination if possible Document any abnormalities

No points are given for this section

Results on MACE

Non-concussed patients, the mean total score was 28

Scores below 25 may represent clinically relevant neurocognitive impairment and require further evaluation for the possibility of a more serious brain injury.

Brief Traumatic Brain Injury Screen (BTBIS)

The Defense and Veterans Brain Injury Center (DVBIC) has developed a simple TBI screening device also called the Brief Traumatic Brain Injury Screen (BTBIS)

The questions quickly help us to assess if the person in front of us is possibly suffering from TBI

First Question

Did you have any injury(ies) during your deployment from any of the following:1.Fragment2.Bullet3.Vehicular (any type of vehicle, including airplane)4.Fall5.Blast (Improvised Explosive Device, RPG, Land mine, Grenade)6.Other: specify

Second Question

Did any of the injury received during your deployment result in any of the following?1.Being dazed, confused or “seeing stars”2.Not remembering the injury3.Losing consciousness (knocked out) for less than a minute4.Losing consciousness for 1-20 minutes5.Losing consciousness for longer than 20 minutes6.Having any symptoms of concussion afterward (such as headache, dizziness, irritability, etc.)7.Head injury8.None of the above

Third Question

Are you currently experiencing any of the following problems that you think might be related to a possible head injury or concussion?Headaches Ringing in the earsDizziness IrritabilityMemory Problems Sleep problemsBalance Problems Other-specify

Glasgow Coma Scale

Is used to help determine severity of TBI Responses are scored using three

measures which are scored separately & then combined

n Eye openingn Best verbal responsen Best motor response

Glasgow Coma Scale ItemsEye Opening (E) Spontaneous 4 To speech 3 To pain 2 No Response 1Best Motor Response (M) To verbal command: obeys 6 To painful stimulus: localizes

pain 5 Flexion-withdrawal 4 Flexion-abnormal 3 Extension 2 No response 1

Best Verbal Response (V) Oriented and converses 5 Disoriented and converses 4 Inappropriate Words 3 Incomprehensible sounds 2 Makes no sounds 1Scoring: Eye Score (E) + Motor Score (M) + Verbal Score (V) = 3-15

Classifications of TBI by GCS

Mild TBI/Concussion GCS Score of 13-15

Moderate TBI GCS score of 9-12 Severe TBI GCS score of 8 or less

Mental Health Treatments for Clients with TBI

Goal is to:1. Reduce stress, overcome common co-

occurring conditions such as post-traumatic stress disorder, depression, chronic opioid therapy, and substance use.

2. Handle their states of anxiety, anger or depression by use of Handbooks Tools for Coping on www.coping.us

Get yourself two apps to help Your Clients with TBI

1. mTBI Pocket Guide2. Co-Occurring Conditions Toolkit Both available as free apps from

the National Center for Telehealth and Technology

Teach Clients with TBI to use Apps on their phones

1. Breath2Relax2. Tactical Breather3. Mood Tracker 4. LifeArmor5. PTSD Coach Available through The National

Center for Telehealth and Technology

Use the Tools for Coping Series on www.coping.us

Tools for Handling Loss Tools for Personal Growth Tools for Relationships Tools for Communications Tools for Anger Workout Tools for Handling Control Issue Growing Down-Healing the Inner Child Balanced Lifestyle-Weight Management

Treat Co-Morbid PTSD if present

Utilize the Evidenced Based Treatment for PTSD outlined in the VA-DOD Clinical Guidelines of 2010

Cognitive Processing Therapy Prolonged Exposure Therapy EMDR

To wrap it up we looked at:

What is TBI How TBI is assessed What the issues are facing clients

with TBI Mental Health Tools to be utilized

with patients with TBI

Thank you for your attention and interest. I hope you are motivated to get out and learn more about TBI and utilize the resources identified today

Short Course on TBI for Mental Health Counselors at:

http://coping.us/introtoneuroscience/tbicourseforcounselors.html