The Rural Veterans Health Access Project presents Dr. Amy Murphy

Certified Brain Injury Specialist

So You’ve Been Diagnosed With a Brain Injury – What

Next?

The RVHAP is part of the Health Planning and Systems Development Section, Division of Public Health, Alaska Department of Health and Social Services. Funded

by the HRSA Office of Rural Health Policy Grant # H3GRH26369-02-00

Tenakee Springs-One of the SE Alaska rural communities served by RVHAP

The objective of the Rural Veterans Health Access Project (RVHAP) is to increase access to and quality of health care to Veterans and other rural residents in South East Alaska through the development of a demonstration Telehealth network (TH) including behavioral health and primary care

RVHAP Sponsored TBI WebinarTraumatic Brain Injuries are a risk

for Veterans who are the primary focus of the RVHAP and rural veterans have less access to services

Alaska has a higher rate of TBI than the national average among the general community which is the secondary focus for the RVHAP’s telehealth services

Training medical and behavioral practitioners in the diagnosis, assessment and treatment of TBI enhances the health care provided for Alaskans with TBI, in particular rural residents.

For more information on the Rural Veterans Health Access Program contact the Program Director:

Susan Maley, MPH, Ph.D. susan.maley@alaska.gov, 907-269-

2084http://dhss.alaska.gov/dph/HealthPlanning/Pages/

veterans/default.aspx

Funding provided by the Health Resources and Services Administration’s Office of Rural Health

PolicyOffice for the Advancement of Telehealth

Grant number H3GRH26369

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So You’ve Been Diagnosed With a Brain Injury - What

Next?Amy L. Murphy, DO

Brain Injury Medicine SpecialistProvidence Medical Group Brain Injury Services

Providence Alaska Medical Center

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Objectives• Definition• Assessment

• Neurologic, cervicogenic, vestibular, ocular, cognitive

• Common issues• Headache, Fatigue, Mood, Sleep, Cognition, MSK

• Treatment• Referrals• Follow-up care

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DefinitionsWHO (2004) MTBI is an acute brain injury resulting from mechanical energy to the head from external physical forces. Operational criteria for clinical identification include (1) 1 or more of the following: confusion or disorientation, LOC for 30 min or less, posttraumatic amnesia for less than 24h, and/or other transient neurological abnormalities such as focal signs, seizure, and intracranial lesion not requiring surgery; (2) Glasgow Coma Score of 13-15 after 30min post injury or later upon presentation for healthcare. These manifestations of MTBI must not be due to drugs, alcohol, medications, caused by other injuries or treatment for other injuries, caused by other problems or caused by penetrating craniocerebral injury.

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Assessment• Misdiagnosed, misunderstood, mismanaged• Lack of education, increased psychosocial stressors• No consistent tools being used- but they are out

there!• OSU screening tool, SCAT3, MACE• Rivermead, Neurobehavioral Symptom Inventory

• Development of chronic symptoms, PCS• Referrals to the services that fit the symptoms

• Behavioral health• Pain management

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Assessment• ED/non-treating evaluation

• OSU TBI short form- http://ohiovalley.org/tbi-id-method• Rivermead postconcussion symptom questionnaire

(RPSQ)• SCAT3/IMPACT• MACE- military acute concussion evaluation

• Evaluation by treating provider• ACE- acute concussion evaluation- CDC site

• Further assessment tools for treating provider• Neurobehavioral symptom inventory (NSI)

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Assessment• Complete history- especially risk factors,

previous tx• Full exam- focused neurologic and

musculoskeletal assessment• Gait evaluation• Balance evaluation (BESS)• Overview of laboratory studies, prior

radiologic studies, any other notes/studies pertinent

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Common IssuesHeadache• #1 complaint• Post-

traumatic headache

• Treat as primary headache dx

• No great studies for PTH subtypes

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Common IssuesFatigue/Sleep

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Common IssuesMood• PTSD• Depression• Anxiety• Mania• Frustration• Anger• Overwhelm

ed

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Common IssuesCognition

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Common IssuesMusculoskeletal/Cervicogenic

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Common IssuesVestibular/Ocular

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TreatmentHeadache Manageme

nt

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TreatmentFatigue and Cognition

• Medication list should be completed prior to initiating pharmacologic therapy, also any drug or alcohol use• Stopping sedating meds may remove the need for

medication, significantly decrease dose• Weaning benzodiazepines or alcohol, slowly• Work in combination with therapies- SLP, neuropsychology,

psychology• Check for mood!

• In rare cases, zolpidem has had a paradoxical response

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Treatment- Sleep• Non-pharmacologic management should be used as

much as possible after a brain injury.• Environment- adequate exposure to sunlight, reduced noise and

distractions at night.• Cognitive behavioral-cognitive therapies- later in course• Ensure that activating medications are reduced or given early

• If environmental and behavioral interventions are maximized and need for pharmacologic intervention is necessary, melatonin supplementation/agonists or trazodone should be considered for first line management to avoid cognitive sequelae

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TreatmentMood

• Therapy, neurofeedback, sleep, pain• Adjunct if medications are needed

• Benzodiazepines- decreased functional recovery in animals and extends post-traumatic amnesia

• Maximize treatment with multi-use medicines• Potential side effects should be considered carefully • Assess any recreational drug use and refer

accordingly for services• Drug use, alcohol, supplements- many can interfere

with medications- get an adequate history

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TreatmentMusculoskeletal/Cervicogenic

• Assess for injuries, imaging as needed• Referrals

• Orthopedics, Pain management• PT, OT• Naturopath, Osteopath, Acupuncturist

• Non-pharmaceutical management• Trigger point management• Nerve blocks• Appropriate stretching and exercise

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TreatmentVestibular/Ocular

• Referrals• Optometry- specializing in vision rehab• PT- specializing in vestibular therapy

• Medications• Meclizine- hallucinations, blurred vision, drowsiness• Scopolamine- dizziness, dry mouth/eyes, restlessness• Dimehydrinate- dizziness, drowsiness, dry mouth

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Treatment planning• Further work-up

• Imaging• Laboratory Studies• Sleep studies• EEG

• Referrals• PT, OT, SLP• Optometry• Behavioral health- counseling, neurofeedback• Other medical specialty- pain, sleep, primary care,

orthopedics

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Follow-up Care• Education and Prevention are KEY!• Working as an interdisciplinary team-

communication!• Initially schedule close follow-up care

• Return to play• Return to school• Return to work

• Work on most debilitating symptoms first- headache, sleep, mood

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Summary• Standardized assessments are available

• Under utilized! • Validated assessments can help with prognosis• Leads to better individualized treatment based on risk

• Treatment is individualized• Evidence based when you have it• Best practices when you don’t• Education, education, education

• An interdisciplinary team approach is needed• Goals- previous function, reduced risk,

prevention

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References• Watanabe, T.K. et al. Systematic Review of Interventions for Post-traumatic

Headache. PM R. 4, 129-140. (2012).• Hou, L. et al. Risk Factors Associated with Sleep Disturbance following

Traumatic Brain Injury: Clinical Findings and Questionnaire Based Study. PLoS One. 8(10), e76087. (2013)

• Thiagarajan, P & Ciuffreda, K. Effect of oculomotor rehabilitation on vergence responsivity in mild traumatic brain injury. JRRD. 50(9), 1223-1240. (2013)

• Ponsford J, Ziino C, Parcell D et al. Fatigue and Sleep Disturbance Following Traumatic Brain Injury- Their Nature, Causes and Potential Treatments. J Head Trauma Rehabil. 27(3), 224-233 (2012).

• Shekleton JA, Parcell DL, Redman JR et al. Sleep disturbance and melatonin levels following traumatic brain injury. Neurology. 74, 1732-1738 (2010).

• Larson E, Zollman F. The Effect of Sleep Medications on Cognitive Recovery From Traumatic Brain Injury. J Head Trauma Rehabil. 25(1), 61-67 (2010).

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References• Perna R. Brain Injury: Benzodiazepines, Antipsychotics, and

Functional Recovery. J Head Trauma Rehabil. 21(1), 82-84 (2006).• Mysiw WJ, Bogner J, Corrigan J et al. The impact of acute care

medications on rehabilitation outcome after traumatic brain injury. Brain Injury. 20(9), 905-911 (2006).

• Erickson JC, Neely ET, Theeler BJ. Posttraumatic Headache. Continuum Lifelong Learning Neurol. 16(6), 55-78 (2010).

• Kaniecki R. Tension-type headache. Continuum Lifelong Learning Neurol. 18(4), 823-834 (2012).

• Petraglia, A.L. et al. From the Field of Play to the Field of Combat: A Review of the Pharmacological Management of Concussion. Neurosurgery. 70:1520-1533 (2012).

So You’ve Been Diagnosed With a Brain Injury - What Next?

Questions?