Traumatic Brain Injury: An Overview DRAFT

1
Traumatic Brain InjuryAn OverviewDRAFT

• Anastasia B. Edmonston MS CRC
• MD TBI Projects Director
• MD Mental Hygiene Administration
• The Mental Health Management Agency of Frederick
  County, Inc. the Howard County Mental Health
  Authority

2
Training Agenda

• The incidence and prevalence of TBI
• What is brain injury?
• What are the types of brain injury?
• Common cognitive, behavioral and physical sequela
  of TBI

3
Training Agenda

• Why screening for a history of TBI is important
  in the human service setting
• Ideal rehabilitation pathways for mild, moderate
  and severe TBI
• The TBI, mental health and substance abuse
  connection
• What are the state and national resources
  available to individuals with TBI, their families
  and professionals

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Definitions How brain injury may be defined in
the Medical Record
Traumatic Brain Injury is an insult to the brain
caused by an external physical force Acquired
Brain Injury is an insult to the brain that has
occurred after birth, for example TBI, stroke,
near suffocation, infections in the brain, anoxia
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Incidence of TBI CDC 2004

• In the United States, at least
• 1.6 million sustain a TBI each year

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Incidence of TBI CDC 2004Of those 1.6 million..

• 51,000 die
• 290,000 are hospitalized and
• 1,224,000 million are treated an released from an
  emergency department

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Annual Incidence of TBI with DisabilityAN
ESTIMATED 124,000 American civilians

• Cited by Jean Langlois ScD,MPH NASHIA Conference
  2007
• Preliminary findings as analyzed by Selassie, et.
  al

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Traumatic Brain Injury and Returning Vets

• According to a Army mental health report in
  February, 11 of 2,195 soldiers surveyed in Iraq
  and Afghanistan showed signs of mild BI, but
  fewer then half were identified and evaluated in
  the field. USA Today March 17, 2008 Greg Zoroya
• As of 11.07 VA officials reported that of 61,285
  veterans screened since April 14, 2007 19
  screened positive Honolulu Star-Bulletin Nov. 4,
  2007
• Pentagon reported as of September 20, 2007, 4,471
  of 30,327 wounded troops sustained brain
  injuries.
• A September 2007 article in USA Today by Gregg
  Zoroya looked at data from a variety of military
  sources put the number as at least 5 times that
  much. (20,000)

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TBI- Signature Wound of War USA TODAY 9.07

• Blast, and multiple blast exposures
• Wave of compressed air traveling thru the brain
• Injury to brain cells/cell death
• Road side bombs cause 80 of all wounds

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Mild Traumatic Brain Injury in U.S. Soldiers
Returning from IraqHoge, McGurk, Thomas, et.al
NEJM Volume 358453-463 January 31, 2008

• 1 in 6 returning troops have had at least one
  concussion
• 4.9 reported injuries with LOC of those, 43.9
  met criteria for PTSD (3xs the rate found in
  those with other injuries)
• 10.3 reported altered mental status, of those,
  27.3 met criteria for PTSD
• TBI with LOC also associated with major depression

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Causes of TBI CDC 2006
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Who is at the Highest Risk of TBI? 2005

• Males 1.5 times as likely as females to sustain a
  TBI
• Two age groups most at risk are 0-4 year olds and
  15-19 year olds
• The elderly, 75 and older from falls
• African Americans have the highest death rate
  from TBI

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Incidence of TBI Maryland 2000 CDC Surveillance

• 5,229 Marylanders sustained a moderate to severe
  TBI
• 13 people a day
• 5 of all hospitalizations TBI related

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The Scope of the Problem

• Distribution of Severity
• Mild injuries 80(LOC lt 30 min, PTA ,1 hour)
• Moderate 10 - 13(LOC 30 min-24 hours, PTA
  1-24 hours)
• Severe 7 - 10(LOC gt24 hours, PTA gt24 hours)

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The Importance of Post Traumatic Amnesia

• PTA is the period of time after injury when a
  person is unable to lay down new memoriesfor
  example

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That first morning, wow, I didnt want to move,
I was thankful that nothings broken, but my
brain was all scrambled Ryan Church, NYT 3/10/08

• All he remembers from the collision with
  Anderson is the aftermath, being helped off the
  field by two people, although he said he did not
  know who they were until he saw a photograph
  later Ben Shpigel NYT reporter

17
2000 Epidemiological Study of Mild TBI J. Silver
of NYU, cited in WSJ by Thomas Burton 1.29.08
http//online.wsj.com/article/SB120156672297223803
.html?modgooglenews_

• 5,000 interviewed
• 7.2 recalled a blow to the head
  w/unconsciousness or period of confusion
• Follow up testing found 2x rate of depression,
  drug and alcohol abuse
• Elevated rates of panic and and
  obsessive-compulsive DO

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MHAs TBI Resource Coordination Project

• Three resource coordinators served 147 consumers
  in 6 counties 7/03-8/07
• More men than women (60)
• Average time since injury for consumers served is
  12 years
• Unemployment among consumers range at any given
  time between 67-87. The majority of those
  employed are working part-time

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Co-occurring Conditions among Consumers Served

• Drug and Alcohol use and abuse 28.5
• Mental Health 27
• Homelessness/danger of homelessness 20

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Simplified Brain Behavior Relationships BIAA 2000
BI 101
Frontal Lobe Initiation Problem solving
Judgment Inhibition of behavior
Planning/anticipation Self-monitoring Motor
planning Personality/emotions Awareness of
abilities/limitations Organization
Attention/concentration Mental flexibility
Speaking (expressive language)
Parietal Lobe Sense of touch
Differentiation size, shape, color Spatial
perception Visual perception
Occipital Lobe Vision
Cerebellum Balance Coordination Skilled
motor activity
Temporal Lobe Memory Hearing Understanding
language (receptive language) Organization
and sequencing
Brain Stem Breathing Heart rate
Arousal/consciousness Sleep/wake functions
Attention/concentration
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What happens in a TBI?

• Mechanism Acceleration/Deceleration
• Differential movement of partially tethered brain
  within the skull
• Results in
• Bruising of the brain surface
• against rough areas of the skull
• Stretching and twisting of nerve axons

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Primary Injuries
Coup-Contra Coup
BIAA 2000
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Primary Injuries
Diffuse Axonal Injuries
Rotational forces on the brain cause the
stretching, snapping and shearing of axons
BIAA 2000
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Primary Injuries
Hematoma
Epidural Hematoma
Dura
Hematoma or Blood Clot forms on top of the dura
BIAA 2000
25
Primary Injuries
Subdural Hematoma
Dura
Hematoma or blood clot forms under the dura
BIAA 2000
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Secondary Injuries
Intracerebral Hemorrhage
Hydrocephalus (enlarged ventricles
Edema (swollen brain tissue)
BIAA 2000
27
Possible Changes-Physical

• Motor skills/Balance
• Hearing
• Vision
• Spasticity/Tremors
• Speech
• Fatigue/Weakness
• Seizures
• Taste/Smell

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Possible Changes-Thinking

• Memory
• Attention
• Concentration
• Processing
• Aphasia/receptive and expressive language

• Executive skills
• Problem solving
• Organization
• Self-Perception
• Perception
• Inflexibility
• Persistence

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Possible Changes-Personality and Behavioral

• Depression
• Social skills problems
• Mood swings
• Problems with emotional control
• Inappropriate behavior
• Inability to inhibit remarks
• Inability to recognize social cues

30
Personality and Behavioral cont..

• Problems with initiation
• Reduced self-esteem
• Difficulty relating to others
• Difficulty maintaining relationships
• Difficulty forming new relationships
• Stress/anxiety/frustration and reduced
  frustration tolerance

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Lack of Awareness

• A common and difficult to remediate hallmark of a
  brain injury

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Sequelae of TBI

• What often underlies the challenges in return to
  work, school and major role are problems in
• cognition (including memory and judgement)
• impulse control
• modulation of affect
• regulation of mood. These areas are often
  referred to as the neurobehavioral cluster.

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The Relationship Between Brain Injury and Mental
Health-Depression

• Depression is the most common Axis I psychiatric
  disorder after TBI followed by alcohol abuse,
  panic disorder, specific phobia and psychotic
  disorders (Gordon et. al 2004)
• Major depressive episodes occur in 20-30 of TBI
  patients in the first year. Depressive symptoms
  occur even more commonly.

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Other Mental Health Disorders Related to TBI

• Anxiety, seems to go hand in hand with
  depression. Those with depression or anxiety
  perceive their injury and cognitive impairment as
  more severe then nondepressed individuals with
  TBI (Fann et.al 1995)
• Oquendo and colleagues (2004) found that males
  with mild TBI with a hx of substance abuse
  coupled problems of aggression and hostility were
  more likely to attempt suicide then non injured
  males

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Other Mental Health Disorders Related to TBI

• PTSD is noted in some individuals following TBI
  even if there is no memory of the incidence
  (Klein, Caspi 2003)
• Rapid cycling bipolar is rare but noted in the
  literature for individuals with temporal lobe
  damage (Murai, Fujimoto 2003)
• Psychotic syndromes occur more frequently in
  individuals who have had a TBI than in the
  general population (McAllister, Ferrell 2002)

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TBI Suicide

• The risk of attempted or completed suicide in
  neurological illness is strongly related to
  depression, feelings of hopelessness or
  helplessness, and social isolation (Arciniegas
  Anderson, 2002)
• Simpson and Tate (2002) screened 172 individuals
  for suicidal ideation and hopelessness. Findings
  using the Beck Suicide Ideation and Hopelessness
  Scales found 35felt hopeless and 23expressed
  suicide ideation. 18 had attempted suicide post
  injury

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Alcohol Use TBI-IncidenceAnalysis of the
Literature (Corrigan 1995)

• Alcohol, the drug of choice-Corrigan and his
  colleagues report that for 70 of the
  individuals they work with who use substances,
  alcohol is the preferred substance
• Intoxication at time of injury-7 studies looked
  at incidence of intoxication (BAL equal or
  exceeding 100mg.dL)at time of injury.
  Intoxication ranged from 36 to 50
• History of Substance Abuse-Findings suggest that
  for adolescents and adults in rehabilitation
  following a TBI, as much as 60 of this
  population have histories of alcohol use or
  dependence.

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Why Screen?What other TBI Screening efforts have
found
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Findings from the LiteratureCriminal Justice
System

• Researchers at Indiana State University found
  that 83 of felons studied reported a head injury
  that predated their first encounter with the law
  (1998)
• Adults who had frontal lobe damage prior to age 8
  exhibited recurrent impulsive and aggressive
  behavior
• 14 of the subjects in the Vietnam Head Injury
  Project with frontal lobe lesions engaged in
  fights or damaged property compared to 4 of
  controls without TBI

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Domestic Violence TBI Findings

• Batterers fared worse on three neuropsychological
  indicators of cognitive functioning then a
  nonbatterer control group (Cohen et. Al 1999)
• Corrigan et.al., (2003) found that of 167
  individuals treated for domestic violence related
  health issues, 30 experienced a loss of
  consciousness on at least one occasion, 67
  reported residual problems that were potentially
  TBI related
• Valera and Berenbaum, (2003) assessed 99 battered
  women. Of these, 57 had brain injured related
  symptomatology

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TBI Among Individuals with Persistent Mental
Illness

• Kathleen Torsney (2004) found in one mental
  health treatment setting 13 of individuals
  served had a history of TBI
• These same individuals had been treated in
  various mental health settings but not received
  specific brain injury treatment

42
Homelessness Brain InjuryA little studied
population, however..

• A University of Miami study found that 80 of 60
  homeless individuals had high incidence of
  neuropsychological impairment
• Researchers in Milwaukee found possible cognitive
  impairment in 80 of 90 homeless men evaluated.
• Dr. LaVecchia of the MA Statewide Head Injury
  Program reported in 2006 that of 140 homeless
  individuals evaluated, 83.6 of males and 16.4
  of females had an acquired brain injury
• Other studies in the UK and Australia show
  similar rates of brain injury among homeless
  individuals

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In Maryland- Screening Results from the MD TBI
Post Demo II Project-2005

• Summary of TBI Incidence Among all Screened at 7
  public mental health agencies in Frederick and
  Anne Arundel counties
• N190
• 39 no reported history of TBI (78)
• 58.94 of individuals with a history of TBI
  (112)
• 35.78 of individuals with a history of a single
  incidence of TBI (68)
• 23 of individuals with a history of 2 or more
  TBIs (44)

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TBI Screening, Adapted From

• Ohio Valley Center for Brain Injury Prevention
  and Rehabilitation
• John Corrigan Ph.D

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Have you ever been injured following a blow to
the head?

• As a child?
• Playing sports?
• From a fall?

46
Have you ever been hospitalized or treated in an
emergency room following an injury?

• Treated and released?
• Evaluated by a neurologist?
• Had a CAT scan, MRI or EEG done while in the
  emergency room?

47
Have you ever been unconscious following an
accident or injury?

• Have no memory for the event?
• Felt dazed or confused?
• Experienced a head ache, fatigue, dizziness, or
  changes in vision?

48
Have you ever been injured in a fight?

• Taken a direct blow to the head
• Experienced a violent shaking of the head and
  neck?

49
Have you ever been injured by a spouse or family
member?

• Pushed
• Punched
• Shaken
• Choked

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Have you ever had any major surgeries?

• Heart Bypass
• Transplant
• Brain surgery to treat a tumor, aneurysm, stroke

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Illnesses?

• Toxic Shock Syndrome
• Meningitis
• Encephalitis
• Hydrocephalous
• Seizure disorder
• Lead poisoning

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Additional comments and observations of the
interviewer

• Any visible scars?
• Walks with a limp?
• Uses a cane or walker?
• Has a foot brace?
• Limited use of one hand?
• Appears to have difficulty focusing vision?
• Difficulty answering questions?
• Answers are unorganized and/or rambling
• Becomes easily distracted, agitated or is
  emotionally labile

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What you are looking for..And Why

• Any reported or suspected functional difficulties
  that are interfering with home, work or community
  activities
• With the identification a history of brain
  injury, professionals can better support the
  individuals served and make informed referrals to
  brain injury specialists when appropriate

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Clues to the Presence of Brain Injury in the
Medical Record/History
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Has there been a Mild TBI?

• Look for history of ER visits after MVAs or
  fights/sports/ accidents
• Was the individual treated and released for a
  concussion
• Does the individual suffer from whiplash or
  complain of chronic pain?

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Ideal Rehabilitation Pathway for Mild TBI

• Diagnosed after injury and provided with
  education and follow-up
• If they are of the approximately 10 of mild TBI
  sufferers who continue to experience difficulty
  functioning, is there evidence of any
  rehabilitation treatment, neurological/neuropsychi
  atric/neuropsychol-ogical treatment or
  consultation?

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Common and Less than Ideal Pathway-Mild TBI

• Discharged and released from ER or not even seen
  in ER
• Memory, emotional lability, visual, vertigo,
  headaches and or fatigue symptoms do not resolve
  after the first few weeks following injury
• If subsequently seen by GP or in the ER often
  told to justtake it easy

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Common and Less than Ideal Pathway-Mild TBI,
cont..

• Cant function at work or home
• Spiral into depression and anxiety
• Family, friends and co-workers loose patience
• If seen by a GP or neurologist may be viewed as
  having a psychosomatic reaction or be labeled a
  malinger-inappropriately medicated

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Common and Less than Ideal Pathway-Mild TBI,
cont..

• Job loss
• Mental Health Problems
• Relationships and supports erode
• At risk for Substance Abuse
• At risk for entry into the criminal justice
  system

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Ideal Medical/Rehabilitation Pathway-Moderate to
Severe TBI

• Acute care delivered at a trauma center (Shock
  Trauma, Johns Hopkins)
• Inpatient rehabilitation at a CARF accredited
  brain injury rehabilitation hospital(Sinai,
  Kernan, Maryland General)
• Outpatient rehabilitation at a CARF accredited
  brain injury rehabilitation center offering a
  community re-entry program and individual
  therapies (Sinai, Kernan, Humanim, Total Rehab
  Care, Sky Neurorehabilitation)

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Moderate to Severe TBI Pathway cont.....

• Referral to a state vocational services
  counselor with a TBI caseload
• Vocational services as appropriate can include
  vocational evaluation, work adjustment training,
  vocational training, job placement and job
  coaching
• Support services in the community-case management
  and individual/family therapy

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Common and Less than Ideal Pathway-Mod to Severe
TBI

• Scenario I
• Discharged from Trauma or Acute due to good
  physical recovery
• Referrals not made for continuing rehabilitation
  (cognitive therapy)
• Impulse control, memory problems affect home,
  community, work and school
• Family is strained
• At risk for mental health problems, substance
  abuse, criminal behavior, entry into a state
  hospital

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Common and Less than Ideal Pathway-Mod to Severe
TBI

• Scenario II
• Injured as a child
• Go through ideal pathway thru outpatient
  rehabilitation
• Return to school, behind peers
• Struggle academically
• Act out behaviorally, if the injury several
  grades back, not recognized as TBI related

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Common and Less than Ideal Pathway-Mod to Severe
TBI

• Scenario II continued
• Trouble making the transition to post graduation
  roles and responsibilities
• Get in with the wrong crowd
• At risk for mental health issues, substance
  abuse, criminal activity, burn out families and
  supports

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There are limits to what can be changed-Staff can
accommodate the injury related behaviors by
modifying the individuals environment, and their
own interpersonal interactions with the individual

• Biological Limits to Behavioral Recovery
• Farrell Hooper (1995)

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Strategies for Remediation and Compensation

• Use of a journal/calendar
• Create a daily schedule
• To do lists and shopping lists
• Labeling items
• Learning to break tasks into small manageable
  steps
• Use of a tape recorder

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Strategies cont..

• Encourage use of rest and low activity periods
• Work on accepting feedback or coaching from
  others
• Work on generalizing strategies to new situations
• Use of a high lighter
• Alarm watch

68
Strategies cont..

• Review schedule each day
• Post signs on the wall etc.
• Try to routinize the day as much as possible

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Teach a variety of strategies for individuals to
incorporate into their daily routines

• Safety checklist (e.g. for use of
  stove)reinforces attention
• Checklists- things to do before leaving the
  house (turn off all the appliances?, lock all
  the doors?, did I take my morning medications?
  turn down the heat/turn off the air conditioner?,
  do I have money or keys?, where am I going?, how
  will I get there? What time should I leave?
  Etc.) Very good for routine tasks, reinforces
  memory
• Place visual cues in the environment (cupboard
  labels, written directions, calendars, list of
  emergency phone numbers) reinforces memory

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Even for individuals with poor new learning
capacity, the three Rs ReviewRehearseRepeat
Can lead to mastery of tasks as they eventually
enter into memory
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Resource Coordination Services in Maryland

• Charlotte Wisner, Resource Coordinator for
  Frederick Washington Counties, call
  301-682-6017
• Lauren Dorsey, Resource Coordinator for Baltimore
  Howard Counties, call 301-529-1508
• Catherine Reinhart Mello, Resource Coordinator
  for Montgomery County, call 301-586-0900
• Any questions regarding resource coordinator or
  free training on brain injury related topics,
  call Anastasia Edmonston, Project Director
  410-402-8478

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Resources

• Brain Injury Association of America 703-236-6000,
  www.biausa.org
• Brain Injury Association of Maryland
  410-448-2924, www.biamd.org
• Ohio Valley Center For Brain Injury Prevention
  and Rehabilitation, 614-293-3802,
  www.ohiovalley.org.
• www.headinjury.com. Good resource for memory
  aides and tips

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Resources

• Http//www.jan.wvu.edu/media/BrainInjury.html.
  The Job Accomodation Network offers useful
  articles about working with individuals with
  brain injury on the job, and simple
  accommodations that can be used to maximize
  success on the job
• Http//www.neuro.pmr.vcu.edu/ National Resource
  Center for Traumatic Brain Injury, developed by
  the Medical College of Virginia and Virginia
  Commonwealth University. Offers useful articles
  that are very user friendly, and a catalogue of
  nicely priced resources for working with people
  with brain injury

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Resources

• The University of Alabama Traumatic Brain Injury
  Model System has created the UAB Home Stimulation
  Program. This program offers many activities for
  use by individuals with brain injuries, their
  families and the professionals who work with
  them. The activities are designed to help
  support cognitive skills and can be done in the
  home setting. The Home Stimulation Program can
  be accessed from the Internet at
  htt//main.uab.edu/show.asp?durki49377. For
  further information contact Research Services,
  Dept. of Physical Medicine and Rehabilitation,
  University of Alabama at Birmingham, 619 19th St.
  S SRC 529, Birmingham, AL 35249-7330/
  206-934-3283. Tbi_at_uab.edu.

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Resources staff training.

• As of April 2004, the Defense and Veterans Brain
  Injury Center at Walter Reed Army Medical Center
  is offering an online learning course on
  traumatic brain injury through the Veterans
  Health Initiative. For more information
  contacthttp//www1.va.gov/vhi/docs/TBIfinal_www.p
  df
• http//www.webaim.org/simulations/cognitive -
  this is a site that can be used in staff
  training. It is a simulation of the effects of
  cognitive disabilities. You will be asked to
  complete simple tasks, but other tasks will get
  in the way.
• http//www.biausa.org/Pages/related_articles.html
  - links to many online articles, written not for
  professionals in the field, but for people
  learning about brain injury. The y cover all
  types of topics, from substance abuse and brain
  injury to cognition and brain injury. Written by
  various experts in the brain injury field.
• Certified Brain Injury Specialist (CBIS) Training
  offered through the American Academy for the
  Certification of Brain Injury Specialists,
  www.biausa.org

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Acknowlegements...This presentation is a product
of the Maryland TBI Post Demonstration Project
II, a collaboration of the MD Mental Hygiene
Administration the Mental Health Management
Agency of Frederick CountySupport is provided
in part by project H21MC06759 from the Maternal
and Child Health Bureau (Title V, Social Security
Act), Health Resources and Services
Administration, Department of Health and Human
ServicesSpecial thanks to New Hampshires
Project Response and the participating
consultants of the Maryland TBI Post
Demonstration II Project
77
Anastasia Edmonston MS CRCaedmonston_at_dhmh.stat
e.md.us410-402-8478

• Stefani ODea MS
• sodea_at_dhmh.state.md.us
• 410-402-8476