What Happens Following

Brain Injury

Professor Jennie Ponsford, PhDDirector, Monash-Epworth Rehabilitation Research Centre, Epworth Hospital;

School of Psychological Sciences, Monash University,

Melbourne, Australia

Common causes of TBI

•Motor vehicle accidents

•Falls

•Cycling accidents

•Sporting injuries (football, rugby,

boxing, horse-riding)

•Assaults

Who is injured?

•2-3 males for every female

•Most injuries occur in males aged < 30 years, or in the elderly females

•Psychiatric or substance use history more common

• Improvements in medical management have resulted in a growing number of TBI survivors

Most common sites of brain injury

following TBI

Impairment of consciousness

•May range from brief clouding of consciousness or confusion, to coma persisting for months or years

•Glasgow Coma Scale used as injury severity measure

Score

3-8 ---- Severe

9-12 ---Moderate

13-15---Mild

Post-Traumatic Amnesia (PTA)

• Period of confusion and inability to lay down new memories, following emergence from coma

• Duration of PTA is measured from the time of injury until recovery from amnesia, i.e. it includes the period of coma

• Duration of PTA is an indicator of injury severity

–PTA< 24 hours = mild

–PTA 1-7 days = moderate

–PTA 7-28 days = severe

–PTA> 28 days = very severe

Sensorimotor impairments

associated with TBI

•Motor deficits - weakness, incoordination, poor

balance, poor endurance

•Sensory disturbances - smell, vision, hearing, taste

• Speech difficulties

• Swallowing difficulties

Common Cognitive Impairments

• Fatigue

• Concentration problems

• Learning and memory difficulties

• Poor planning and organization

• Concrete thinking

• Lack of initiative

• Inflexibility

• Dissociation between thinking and doing

• Impulsivity

Behavioural Changes

• Irritability/temper outbursts

•Communication problems

•Socially inappropriate behaviour

•Self-centredness

•Emotional changes - mood swings

• Lack of awareness

Recovery from TBI

•Recovery from mild TBI generally occurs within a couple of weeks

•Recovery from severe TBI is most rapid in first 3-6 months, but continues over several years

Injury effects disrupt attainment of

important life goals….

•Gaining independence from parental support

•Completing education

•Establishing a vocation

•Establishing a social network

• Forming close personal relationships

•Create dependency on family support

• There are things we can do to address these

problems

Longitudinal Head Injury Outcome ProjectMonash-Epworth Rehabilitation Research Centre

Chief investigator: Professor Jennie Ponsford

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Purpose

To provide a comprehensive picture of the changes experienced by individuals that have sustained a traumatic brain injury and their families over a period of 20 years.

To investigate factors predicting cognitive, functional, productivity, and psychosocial outcomes.

To evaluate interventions to improve outcomes.

Project progress

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Over 2449 patients

interviewed at least once15211 14432 10323 9775 42010 11920

Car accident

56%Pedestrian18%

Motorcycle11%

Work related

4%

Bicycle4%

Other7%

Cause of injury

TAC83%

Workcover13%

Private3%

Other1%

Compensation

Injury severity

3%

25%

38%

34%

Post traumatic amnesia severity categories

Mild (PTA <day)

Moderate (PTA 1-7 days)

Severe (PTA >7-28)

Very Severe PTA >28 days)

Mobility

0 20 40 60 80 100

Low mobility

Walk Independently with aids

Walk independently but unable to run orjump

High mobility

%

1 year post injury

2 years post injury

3 years post injury

5 years post injury

10 years post injury

Controls

Independence in Activities of Daily Living

0 20 40 60 80 100 120

Public transport

Driving

Financial

Shopping

Heavy domestic chores

Light domestic chores

Personal

%

1 year post injury

2 years post injury

3 years post injury

5 years post injury

10 years post injury

Controls

Return to Previous Leisure Activities

1

%

2

%

3

%

5

%

10

%

All or most 53.4 48.3 51.0 51.9 47.7

A few or none 46.6 51.7 49.0 48.1 52.3

Employment status for those employed prior to injury

0 10 20 30 40 50 60 70 80 90 100

10 years post injury

5 years post injury

3 years post injury

2 years post injury

1 year post injury

%

Employment stability

• Of those employed at one year post-injury, 78% were employed at 5 years post-injury.

• Of those unemployed at one year post-injury, 26% were employed at five years.

Quality of Experience of Return to Work

Control

%

1 year

%

2 years

%

3 years

%

5 years

%

10 year

%

More mistakes 9.0 23.5 26.5 24.4 23.3 28.6

Problems keeping up 8.3 29.3 28.1 27.6 25.2 25.0

More fatigued 30.6 50.0 48.9 48.5 43.4 52.1

Difficulty with people 6.8 10.0 12.3 13.2 11.5 20.0

% of pre-injury students returning to study or employment

0 10 20 30 40 50 60 70

Moving to employment

Returning to study

%

1 year post injury

2 years post injury

3 years post injury

5 years post injury

10 years post injury

Quality of experience of return to study

0 10 20 30 40 50 60 70

Difficulty keeping up

Difficulty learning new information

Trouble getting on with people

Get more fatigued

%

Not at all

Small degree

Moderate degree

Extreme degree

Study mode pre- and post-injury

54.2% applied for special consideration compared with 5.8% pre-injury 36.4% of received individual tuition post-injury versus 6.5% prior to injury

0 20 40 60 80 100

Post-injury

Pre-injury

%

Part-time

Full-time

Return to Study

• With support, 86% of students returning to study passed all of their subjects

Relationship status

• Of those married/de-facto prior to injury, only 11.7% were separated or divorced at 10 years post-injury

• Of those single prior to injury 33.3% were married or de-facto at ten years post-injury

• However, 37% of the 10-year cohort reported difficulties in personal relationships and 34.9% trouble getting on with friends.

Social Isolation

• At 1 year 29.4% of TBI participants reported having lost friends or become socially isolated since the injury

• at 2 years 40.8%

• at 3 years 39%

• at 5 years 39.8%

• at 10 years 46.6%.

Sexuality

• More than 50% of people with TBI report persisting negative sexual changes post-injury

• Generally a decline in the sex drive and the frequency and quality of sexual activities

• Changes associated with fatigue, pain, depression, age, greater dependency, decline in relationship quality and self-esteem

• We need to be talking about and addressing sexual issues

Families

• There is increasing anxiety and depression 1-5 years post-injury in relatives in a direct caregiving role

• Cognitive and behavioural changes in the TBI relative are the greatest sources of stress

• Family stress is associated with unhealthy family functioning and poorer psychosocial adjustment in injured relative.

• Healthy family functioning and family support associated with resilience and better psychosocial adjustment (Perlesz et al., 1999, Douglas, 1994)

Ponsford & Schönberger (2010)JINS, 16, 306-317; Schönberger, Ponsford, Olver & Ponsford(2010) Neuropsychological Rehabilitation, 20(6):813-829 Alway, McKay & Ponsford (2012) Neuropsychological Rehabilitation, 22(2) 374-390.

WHAT FACTORS CONTRIBUTE TO REDUCED PARTICIPATION FOLLOWING TBI?

Neurological complaints

0 10 20 30 40 50 60 70

Fatigue

Balance

Hearing

Smell

Vision

Headaches

Dizziness

Epilepsy

%

1 year post injury

2 years post injury

3 years post injury

5 years post injury

10 years post injury

Cognitive & communication changes

0 10 20 30 40 50 60 70 80 90

Difficulty thinking of right word

Difficulty following conversation

Increased cognitive fatigue

Slower speed of thinking

Difficulty concentrating

Difficulty planning

Memory problems

%

1 year post injury

2 years post injury

3 years post injury

5 years post injury

10 years post injury

Controls

Behavioural changes

0 10 20 30 40 50 60 70

Inappropriate social behaviour

Impulsivity

Irritable

Self-centred

Initiative

%

1 year post injury

2 years post injury

3 years post injury

5 years post injury

10 years post injury

Controls

HADS Anxiety & Depression

Percent with clinically significant scores at each time-point post-injury

0 10 20 30 40 50 60

Controls

10 years post injury

5 years post injury

3 years post injury

2 years post injury

1 year post injury

%

Anxiety >7

Depression > 7

WHAT FACTORS ARE ASSOCIATED WITH POORER OUTCOMES?

Age Education/ IQ Psychiatric history Coping style Genetic

Injury severity (GCS, PTA)

Cognitive impairments

Other injuries

Cultural background

Family/social support

Employer support

???

Major impediments to better outcomes

1. Higher level mobility problems

2. Memory difficulties

3. Executive dysfunction

4. Reduced attention and information processing speed

5. Fatigue and sleep disturbance

6. Social communication difficulties

7. Irritability and anger management

8. Anxiety and depression

9. Family stress

What can we do to address these issues?

• Provide access to rehabilitation

• Neuropsychological assessment of cognitive and behavioural problems

• Focus on cognitive and behavioural as well as physical problems

• Provide support for return to work and study and follow-up

• Provide support for communication and relationships

• Provide support for families

• Take a very long-term view

Identify individually meaningful goals, assess and treat in the community

• Set setting personally meaningful goals in collaboration with client and family.

• Assess and treat in the community

• Consider the individual’s pre-injury activities, interests, strengths and weaknesses, motivations, psychological state, family and social relationships and build on these

Higher level mobility(Gavin Williams et al.)

• Development of scale to assess higher level mobility (HiMAT) (Williams et al. Brain Injury, 2005, 19 (10), 833-843)

• Identification contributing impairments affecting gait and running mobility (Williams et al., 2009, 2011, 2013, 2014, In Press)

• Develop and evaluate targeted interventions– Running group (Williams & Morris, Brain Injury, 2009, 23(4),

307-312)

– Training ankle power at push-off (Williams et al., 2014, In Press)

Memory difficulties

• Assessment and training in use of environmental supports/reminders ( e.g., diaries, smartphones)

• Training in internal compensatory strategies may be effective for some individuals

Executive function

• Train goal management strategies e.g., Goal-Plan Do -Check

• Simplify tasks or provide external supports /prompts

Attention

• Modify tasks and the environment

– Building in rest breaks

– Simplifying tasks, reducing need for speed

– Removing distractions from environment

• Teach strategies to manage slow thinking or difficulty staying focused

Fatigue and sleep disturbance

• Assess all contributing factors (e.g., cognitive problems, anxiety, depression, pain)

• Modify lifestyle

• Address sleep habits (e.g., napping, sleep times)

• Teach relaxation

• Experimental approaches (e.g., light therapy)

Social Communication

• Word-finding strategies

• Training in communication and motion recognition skills (Douglas et al., McDonald et al., Togher et al.)

• Communication partner training

• Work needed on facilitation of friendships and use of social media

Irritability and anger management

• Providing strategies to manage anger

• Educating others to react appropriately

• Teaching adaptive skills or providing environmental supports to build a more positive environment

Anxiety and depression

• Providing psychological therapy, adapted to needs of person with cognitive difficulties, to modify thinking patterns and teach coping strategies

Family stress

• Provide long-term support for families

• Opportunities to share their experiences with others

• Thank you

It has been good having carers here as well. I hadn’t really thought about what they are going through.

I love helping other people. I feel like everyone is always helping me, so it is good to be able to help other people through what I’ve learned.

I give her more support now. I see things from her side a lot more. I realise with a brain injury that people are not in complete control like we are. So therefore you have to be

more understanding.

Thank you

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