Assessment and Treatment of Assessment and Treatment of Traumatic Brain Injury within the Traumatic Brain Injury within the

ECHCS Polytrauma System of CareECHCS Polytrauma System of Care

Estela Bogaert-Martinez, Ph.D.Estela Bogaert-Martinez, Ph.D.

Director, Traumatic Brain Injury TeamDirector, Traumatic Brain Injury Team

AcknowledgementAcknowledgement

Thanks to Rod Vanderploeg, PhD Thanks to Rod Vanderploeg, PhD Neuropsychologist, Polytrauma Center Tampa Neuropsychologist, Polytrauma Center Tampa VAMC , and to Michael Craine, Ph.D., Co-VAMC , and to Michael Craine, Ph.D., Co-Director, VISN19 Polytrauma Network Site, for Director, VISN19 Polytrauma Network Site, for contributions to this material.contributions to this material.

BackgroundBackground

Many of those returning from current Many of those returning from current conflicts had experiences that put them at conflicts had experiences that put them at risk for TBI.risk for TBI.

Mild symptoms of TBI may be difficult to Mild symptoms of TBI may be difficult to recognize, or confused with other recognize, or confused with other conditions.conditions.

Treatment of symptoms may be very Treatment of symptoms may be very different for TBI patients.different for TBI patients.

War Injuries:War Injuries:Explosive BlastsExplosive Blasts

• Most common cause of injuryMost common cause of injury• 64% of war injuries caused by blasts64% of war injuries caused by blasts• 41% of blast injured at WRAMC had 41% of blast injured at WRAMC had

TBI (01/05 - 02/06)TBI (01/05 - 02/06)

Key Iraq wound: Brain trauma By Gregg Zoroya, USA TODAY

“A growing number of U.S. troops whose body armor helped them survive bomb and rocket attacks are suffering brain damage as a result of the blasts. It's a type of injury some military doctors say has become the signature wound of the Iraq war.”

Traumatic Brain InjuryTraumatic Brain Injury Insult to the brain caused by an external physical Insult to the brain caused by an external physical

forceforce Produces a diminished or altered state of Produces a diminished or altered state of

consciousnessconsciousness• Dazed and confused for several minutes or Dazed and confused for several minutes or • Knocked out / Rendered unconscious and/orKnocked out / Rendered unconscious and/or• With With memory gapsmemory gaps for some or all of the immediate for some or all of the immediate

period after the eventperiod after the event Results in impairments in physical, cognitive, Results in impairments in physical, cognitive,

behavioral, and/or emotional functioningbehavioral, and/or emotional functioning

Consequences of TBIConsequences of TBI

CognitiveCognitiveMemory deficits, poor concentration, thinking Memory deficits, poor concentration, thinking problemsproblems

Emotional-BehavioralEmotional-BehavioralDepression, anxiety, irritability, mood swingsDepression, anxiety, irritability, mood swingsImpulsivityImpulsivity, apathy, agitation, aggressionapathy, agitation, aggression

PhysicalPhysicalHeadache, dizziness, fatigue, noise/light Headache, dizziness, fatigue, noise/light intolerance, insomnia/sleep disturbance intolerance, insomnia/sleep disturbance

Levels of SeverityLevels of Severity

• MildMild• Complicated MildComplicated Mild• ModerateModerate• SevereSevere

3

Cogni t ive

Leve l

Preinjury Functioning

PTAComa

INJURY

Retro-Grade

Amnesia Months

6 9 12

Mild TBI

Moderate TBI

Severe TBI

Ongoing Cognitive Problems

Brief PTA

PTAOngoing Cognitive Problems

TBI Treatment ConsiderationsTBI Treatment Considerations

Treatment varies based upon:Treatment varies based upon: Severity of injurySeverity of injury Time since injuryTime since injury Constellation of impairmentsConstellation of impairments

Continuum of Care for TBI / PolytraumaContinuum of Care for TBI / Polytrauma

Trauma Care

Long-Term Care

Subacute Rehab

Acute Rehab Post-Acute Rehab

Community Rehab

Outpatient Specialty

Care

Interdisciplinary Traumatic Brain Injury Team Interdisciplinary Traumatic Brain Injury Team - an Interdisciplinary Rehabilitation Approach- an Interdisciplinary Rehabilitation Approach

• Rehabilitation medicine physicianRehabilitation medicine physician• Physical therapistPhysical therapist• Occupational therapistOccupational therapist• Speech TherapistSpeech Therapist• Supported employment/Vocational rehabilitation Supported employment/Vocational rehabilitation

specialistspecialist• Social WorkerSocial Worker• Rehabilitation PsychologyRehabilitation Psychology• NeuropsychologyNeuropsychology

• TBI Education & SupportTBI Education & Support• Cognitive Deficits: Cognitive Deficits:

Compensatory Training/Cognitive RemediationCompensatory Training/Cognitive Remediation

Stimulant Medications; physical activationStimulant Medications; physical activation

• Vocational Rehablitation/ Supported EmploymentVocational Rehablitation/ Supported Employment • Stress Management TrainingStress Management Training• Social Skills Training Social Skills Training • Specialty Treatment for Secondary Conditions:Specialty Treatment for Secondary Conditions: PTSD, Depression, Anxiety, Chronic Pain, HA, etc.PTSD, Depression, Anxiety, Chronic Pain, HA, etc.

TBI Rehabilitation Interventions to TBI Rehabilitation Interventions to Support Reintegration to Family, Support Reintegration to Family,

Community and WorkCommunity and Work

Follow-up Additional Specialized Follow-up Additional Specialized Assessments and TreatmentAssessments and Treatment

TBI:TBI: TBI Team TBI Team

PTSD:PTSD: PTSD Program, Mental Health PTSD Program, Mental Health

Chronic Pain:Chronic Pain: Pain Program, PM&RS Pain Program, PM&RS

Depression, Anxiety, Stress:Depression, Anxiety, Stress: Mental Health Mental Health

Seizures, Neurologic Conditions:Seizures, Neurologic Conditions: Neurology Neurology

What to Know: What to Know: Relevant BackgroundRelevant Background

Mild TBI SymptomsMild TBI Symptoms There is There is no symptomno symptom that is that is uniqueunique to or to or

diagnosticdiagnostic of mild TBI of mild TBI Many postconcussion symptoms occur in Many postconcussion symptoms occur in

normal healthy individualsnormal healthy individuals All symptoms/problems overlap with one or All symptoms/problems overlap with one or

more other conditions (PTSD, Depression, more other conditions (PTSD, Depression, Anxiety, Chronic Pain, Somatoform Disorder, Anxiety, Chronic Pain, Somatoform Disorder, chronic health conditions)chronic health conditions)

+ PTSD + PTSD Re-experiencingRe-experiencing

AvoidanceAvoidance Social withdrawal Social withdrawal

Memory gapsMemory gapsApathyApathy

? Mild? Mild TBITBIResidualResidual

Difficulty with decisionsDifficulty with decisionsMental slownessMental slowness

ConcentrationConcentrationHeadachesHeadaches

DizzyDizzyAppetite changesAppetite changes

FatigueFatigueSadnessSadness

ArousalArousal

Sensitive to noiseSensitive to noise ConcentrationConcentration

InsomniaInsomniaIrritabilityIrritability

+ Depression+ Depression