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