Traumatic Brain Injury: Screening

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Traumatic Brain InjuryScreening

• Ohio Valley Center for Brain Injury Prevention
  and Rehabilitation
• Department of Physical Medicine and
  Rehabilitation
• The Ohio State University
• and
• Brain Injury Association of Ohio
• Supported in part by a grant from the US
  Department of Health and Human Services, Health
  Resources and Services Administration (HRSA)

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Why Screen for TBI?

• TBI is usually not a visible disorder
• Some people may not know that they have had a TBI
• Documentation of a history of TBI may not be
  found in medical records
• The effects of a TBI can have a significant
  impact on responsiveness to standard services or
  treatment methods

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Its not enough to simply know whether or not
someone has had a TBI

• Better to know lifetime history
• how many, of what severity
• when they occurred (developmental how recent)
• what effect they had, or are having

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OSU TBI Identification Method

• Structured interview designed to elicit lifetime
  history of TBI.
• Avoids misunderstanding about what a TBI is by
  eliciting. injuries, then determining if TBI may
  have occurred.
• Provides richer information about history than
  simple yes/no (e.g., number, severity, effects,
  timing, etc.)

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Administration Instructions

• The following slides provide instructions in the
  administration and scoring of the OSU TBI-ID
  Short Form.

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T-B-I Screening

• Trauma an injury that includes a blow to the
  head, the head having impact with another object
  (e.g., the ground, a windshield) or substantial
  shaking without impact.
• Behavioral effect immediately an altered state
  of consciousness evident in confusion, impaired
  memory for events around the injury, or loss of
  consciousness.
• Impact on everyday function Following the
  injury, new onset or exacerbation of symptoms
  (e.g., headaches, dizziness, fatigue,) or
  function (e.g., ADLs, managing money,
  employment).

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T-B-I Screening using the OSU TBI-ID Short Form

• Trauma
• Step 1 Questions 1-5. The goal of this step is
  to help the respondent recall injuries to the
  head or neck by reminding them about hospital
  visits and probing for common causes of TBI.
• Do not be concerned about whether a TBI
  occurred, only if it was possible.

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Questions 1-5

• 1. Have you ever been hospitalized or treated in
  an emergency room following an injury to your
  head or neck? Think about any childhood injuries
  you remember or were told about.
• Answer YES (notes car crash age 17, broken
  leg, hit head on windshield)

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Questions 1-5

• 2. Have you ever injured your head or neck in any
  other car accident or some other moving vehicle
  accident? For example, have you ever been in an
  accident involving a motorcycle or ATV?
• Answer NO

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Questions 1-5

• 3. Have you ever injured your head or neck in a
  fall or by being hit by something? For example,
  have you ever fallen from a horse, fallen while
  rollerblading, fallen on ice or been hit by
  something, like a rock? Have you ever been
  injured playing sports or on the playground?
• Answer YES, fell on ice.

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Questions 1-5

• Have you ever injured your head or neck in a
  fight, from being hit by someone, or from being
  shaken violently? Have you ever been shot in the
  head?
• Answer YES, bar fights in his 20s and 2 recent
  assaults on the street

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Questions 1-5

• 5. Have you ever been nearby when an explosion or
  a blast occurred? If you served in the military,
  think about any combat-related incidents.
• Answer NO

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Question 6

• If any of questions 1-5 were answered YES, then
  proceed to Question 6 for each injury that was
  mentioned
• Were you knocked out or unconscious following any
  of the injuries that you mentioned before (do NOT
  include loss of consciousness due to overdose or
  choking here, see question 7).
• If there was loss of consciousness, ask the
  person to estimate how long
• If there was no loss of consciousness, ask the
  person if he or she was dazed or confused, or had
  gap in memory
• Record age

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Question 6

• Were you knocked out or unconscious following any
  of the injuries you mentioned before? Were you
  knocked out when you
• Were in the car crash at age 17, hitting your
  head on the windshield and breaking your leg?
• Answer YES
• How long were you knocked out?
• Answer 15 minutes (we already know he was 17)

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Question 6

• Were you knocked out when you fell on ice
• Answer NO
• Were you knocked out in any of the bar fights in
  your 20s?
• Answer YES, many of them (Proceed to 7B)
• Do you recall any of the fights in detail?
• Answer NO, they are blurred together
• Can you tell me the longest time period that you
  were knocked out?
• Answer 5 MINUTES (never longer than)
• At what age did the fights start and end
• Answer 20-30

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Question 6

• Were you knocked out when you were assaulted on
  the street recently?
• Answer Not the first time, but YES for the 2nd
  assault.
• How long were you knocked out?
• Answer ONE HOUR
• How old were you at the time?
• Answer 67

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Question 7

• Have you ever lost consciousness from a drug
  overdose or being choked?

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• Impact on everyday function
• Step 3 eliminated from the short form.
• Can be explored in clinical interview with a
  question like After that injury at age ___ did
  you have any problems caused by the injury that
  you didnt have before or that got worse due to
  the injury?
• For any problems identified, ask Is that still
  a problem now?

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Special Interviewing Issue Multiple Mild TBIs

• Some people have had multiple, mild injuries in a
  short period of time, due to a single cause
• They will have problems remembering the details
  of those injuries, including how many
• It may be enough to know that there was a period
  like this, when it was, and how severe the worst
  injury was during this time
• Note that some people may have had more than one
  of these periods in their life
• In terms of treatment, knowing the cause of these
  injuries may be helpful

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Scoring

• TBI-LOC (number of TBIs with loss of
  consciousness from 6)
• TBI-LOC 30 (number of TBIs with loss of
  consciousness 30 minutes from 6)
• age at first TBI-LOC (youngest age from 6)
• TBI-LOC before age 15 (if youngest age from 6 lt
  15 then 1, if 15 then 0)

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Scoring (continued)

• Worst Injury (1-5)
• If responses to 1-5 are no classify as 1
  improbable TBI.
• If in response to 6 reports never being dazed
  or having memory lapses classify as 1 improbable
  TBI.
• If in response to 6 reports being dazed or
  having a memory lapse classify as 2 possible
  TBI.
• If in response to 6 loss of consciousness (LOC)
  does not exceed 30 minutes for any injury
  classify as 3 mild TBI.
• If in response to 6 LOC for any one injury is
  between 30 minutes and 24 hours classify as 4
  moderate TBI.
• If in response to 6 LOC for any one injury
  exceeds 24 hours classify as 5 severe TBI.
• anoxic injuries (sum of incidents reported in
  7)

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Age at which an injury occurs may be an important
aspect of lifetime history of TBI

• Age at first injury with loss of consciousness
  demonstrated the largest number and magnitude of
  relationships with current cognitive performance
  and self-reported behavioral problems
• Symptoms experienced initially after injury,
  especially childhood injuries, were found to be
  associated with adult impairments
• Results suggested a relationship between number
  of lifetime injuries and childhood developmental
  and adult medical conditions

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Number and Severity of Injuries

• Three scores focus on either a combination of
  number and severity of injury, or severity of the
  worst injury
• These scores have been found to be associated
  with cognitive and behavioral difficulties.

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Example Scoring

• TBI-LOC 3
• TBI-LOCgt30 1
• Age at first TBI-LOC 17
• TBI-LOC before age 15 0
• Worst injury 4
• anoxic injuries 0

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Interpretation of Scores

• The scores that Jack received indicate that there
  is a high likelihood that he was exposed to
  multiple TBIs in his lifetime. Exposure seemed
  to have begun by late adolescence. The worst
  injury was of moderate severity and was within
  the past year.

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Interpretation of Scores

• The indicators of exposure to TBI discussed in
  the previous slide suggest that it is likely that
  Jack is experiencing cognitive and behavioral
  consequences from his injuries. Some of the
  consequences may have been present for some time,
  while others may have occurred as a result of the
  most recent injury. Some effects of previous
  injuries may have worsened after the most recent
  injury.

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Resources

• www.ohiovalley.org
• www.tbinetwork.org
• www.biaoh.org
• www.biaa.org
• www.brainline.org
• www.cdc.gov

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Thank you.

• Jennifer Brello, M.Ed., CCC-SLP
• Program Director
• Ohio Valley Center for Brain Injury
• Prevention and Rehabilitation
• Brello.1_at_osu.edu