Diagnosis and Treatment of
Traumatic Brain Injury
Angela Colantonio, PhD, OT Reg. (Ont.)
Carolyn Lemsky, PhD, C. Psych.
Catherine Wiseman Hakes, PhD Candidate, Reg. CASLPO
Diagnosis & Treatment of
Traumatic Brain Injury
 March is National Brain
Injury Awareness Month
 Traumatic Brain Injury
(TBI) is a serious public
health problem
 TBI: It’s not just an
injury
Presenters
Angela Colantonio, PhD, OT
Reg.


Saunderson Family
Chair in Acquired Brain
Injury (ABI) Research,
Professor at University
of Toronto
Leads an internationally
recognized program of
research on ABI
Carolyn Lemsky, PhD,
C. Psych.


Clinical Director at
Community Head Injury
Resource Services of
Toronto
Director of the
Substance Use and
Brain Injury (SUBI)
Bridging Project
Catherine Wiseman-Hakes,
M.Sc. Reg. CASLPO


Registered Speech
Pathologist and a doctoral
candidate, University of
Toronto
Specializes in the
assessment and treatment
of children & adults with
cognitive communication
impairments secondary to
TBI
Goals of the Session
1. Prevalence and history of TBI among
the homeless population
2. Clinical manifestations of TBI
3. Screening tools for TBI
4. Treating TBI and co-morbidities (e.g.,
substance abuse)
5. Communicating with someone with TBI
Improvement in Quality
of Life in Adults with ABI
ABI in the Population
Intervention
Studies
Providers
Consumers /
Caregivers
Students, Trainees,
Visiting scholars
Aging with TBI
Knowledge
Transfer
Gender Issues
Collaborative links:
- Local
- Provincial
- National
- International
Acquired Brain Injury
TRAUMATIC
NON-TRAUMATIC
 Open






 Closed
Anoxia
Aneurysms
Brain Tumors
Encephalitis
Meningitis
Metabolic
Encephalopathy
 Stroke with
Cognitive Disabilities
Brain
Injury
isisathe
leading
ofdeath
death
Brain
Injury
leadingcause
cause of
and disability
and worldwide.
disability worldwide.
Injuries
thebrain
brain are
thethe
most
likelylikely
to
Injuries
totothe
areamong
among
most
result in death and permanent disability
to result in death and permanent disability
International Brain Injury Association
International Brain Injury Association
Extent of TBI
TBI is more common than breast cancer,
spinal cord injury, HIV/AIDS and multiple
sclerosis combined
Estimated prevalence, 2% of population
Definition of TBI
An alteration in brain function, or other
evidence of brain pathology, caused by
an external force…”
Brain Injury Association of America
The effect of TBI on the health of the homeless
(Hwang, Colantonio et al, 2008)
Number of Injuries over Lifetime
40
30
 Have you ever had an
injury to the head which
knocked you out or at
least left you dazed,
confused, or disoriented?
% of All*
Respondents
(N=475)
20
10
0
1
2
3
4
Number of Injuries
Severity of Worst TBI
Yes: 53% (of 904 participants)
% of All*
Respondents
70
60
50
40
30
20
10
0
Mild
ModSevere
Unknown
Severity of Injury
5+
TBI in the Homeless Population
Age at Time of First TBI (Any Severity):
Mean (SD): 18 years (13 Years)
 70% prior to first episode of homelessness
Persons with a history of TBI compared
to persons without a history had
significantly higher levels of:
– Seizures
– Mental health problems
– Alcohol problems
– Drug abuse problems
The risk of these conditions increased
significantly with severity of injury
Diagnosis
 History of TBI
 Length of unconsciousness, post
traumatic amnesia
 Physical examination
 Imaging: CT, MRI
 Neuropsychology
Measuring Severity/Level
of Consciousness
Glasgow Coma Scale:
 Eye Opening (1-4)
 Best Motor Response (1-6)
 Verbal Response (1-5)
Scoring:
 Mild 13-15
 Moderate 9-12
 Severe <12
American Congress of Rehabilitation
Medicine definition of mTBI
A traumatically induced physiological disruption of brain function, as
manifested by at least one of the following:
1. Any loss of consciousness;
2. Any loss of memory for events immediately before or after the
accident;
3. Any alteration in mental state at the time of the accident (e.g.
feeling dazed, disoriented, or confused); and
4. Focal neurological deficit(s) that may or may not be transient;
but where the severity of the injury does not exceed the
following:
 Loss of consciousness of approximately 30 min or less;
 After 30 minutes, an initial Glasgow Coma Scale (GCS) of
13-15; and
 Posttraumatic amnesia (PTA) not greater than 24 hrs.
Katy, et al. (1993)
Consequences of TBI
Cognition:
concentration, memory, judgment,
communication, sleep.
Movement
abilities:
strength, coordination, balance, fatigue.
Sensation:
tactile sensation, vision, hearing, headaches.
Emotion:
instability, impulsivity, mood.
Community
integration: impacts family, work, economic/
social wellbeing
Clinical Sequelae




Highly variable presentation depending on
area of the brain affected
TBI survivors described like “snowflakes”
e.g., frontal lobe damage can affect social
behaviour
Occipital lobe damage may affect vision
Women and TBI
Impact on reproductive health, women with TBI vs.
women without TBI:

68% of women 5-10 years post TBI reported
their cycles were irregular after injury

46% experienced amenorrhea

No significant differences in conception but
more post partum difficulties

Significantly more mental health issues
Colantonio et al., 2010
SCREENING TOOLS
Survey Questions to Identify
Traumatic Brain Injuries
Background of Surveys to
Identify TBI
Many surveys exist. Some examples are:
 Ohio State University TBI Identification
Method
 Brain Injury Screening Questionnaire
 HELPS Brain Injury Screening Tool
Ohio State University TBI
Identification Method (OSU TBI-ID)
Inter-rater reliability and predictive validity have
both proved acceptable when tested in a
substance abuse population:
– IR (r=0.849-0.951)
– Intra-class correlation coefficient all above
0.80, with 6/7 above 0.90
Bogner J, Corrigan JD. (2009). Reliability and predictive validity of the Ohio State University
TBI identification method with prisoners. J Head Trauma Rehabil, 24:279-291.
Corrigan JD, Bogner J. (2007). Initial reliability and validity of the Ohio State University TBI
identification method. J Head Trauma Rehabil, 22:318-329.
Definition of Brain Injury in Context
of the Survey
 Self-identification of an injury to the head
(Questions 1-5)
PLUS
 An Affirmative Answer to one of 6-8
 Confirmation of head injury and loss of
consciousness or episode of blacking out
Neuropsychological Evaluation


Typically involves many hours of testing
Repeatable Battery for Assessment of
Cognition (RBANS) is a short test
Treatment

Referral for further evaluation and
treatment

Multidisciplinary rehabilitation

Wide range of treatments with emerging
evidence

Follow up for disability support
services/payments
CMHA Kelowna and Brain Trust Canada
partnership: ABI Outreach Services

Aims to secure residential settlement

ABI Outreach Worker provides the knowledge
required to maintain a productive lifestyle, including
budgeting, dealing with mental health problems,
drug addiction and other physical issues.

ABI Tenant Support Worker assists in providing
access to non-emergency medical support, basic
needs such as nutritious food, and support with
coping skills, personal health practices, etc.
Research Based Theatre

Based on focus groups with consumers, family
members and health care providers

Translated key elements on experience of TBI and
experiences with providers

AFTER THE CRASH www.ruckusensemble.com
Carolyn Lemsky, PhD, C. Psych.
Models of ABI Intervention
Overview
 Models of community-based care for ABI
 Cognitive compensation (adapting
substance use/mental health
interventions)
 Principles for working with people living
with acquired brain injury
Integration of substance use and mental
health intervention in the continuum of
Rehabilitation care
Time of Injury
ER
Acute
Care
----or---mild Follow-up
Clinic
Acute
Rehab
Post-Acute
Rehab
CommunityBased Supports
moderate
Severe
Education of Staff/Patient/Family
Psycho-educational materials
Referral to appropriate programming
Active treatment
Education
Harm Reduction
Case management
Supporting people with ABI
in the community
Whatever it Takes
1. No two people with brain injury are alike
2. Skills are more likely to generalize when
taught in the environment where they will
be used.
3. Environments are easier to change than
people.
4. Community integration should be holistic.
5. Life is a place-and-train venture.
Willer and Corrigan (1994)
…Cont’d
6. Natural supports last longer than
professionals.
7. Interventions must not do more harm
than good.
8. Service delivery systems present many
of the barriers to community integration
9. Respect for the individual is paramount.
10. Needs of the individuals last a lifetime,
so should their resources.
Case Example
Tom’s goal: Get a job
Problems Observed:



Poor hygiene
Limited compensation for memory
impairment
Socially inappropriate behaviour
Learn and then Place…
Stop Problem
Behaviour
Learn a New
Skill
Get a
Job
Improve
Cognitive
Compensation
Place and Learn
See first hand
why behaviour
interferes with
work
Get a job
Learn that
your boss
demands good
hygiene
Keep Job
Maintain
Change
Good morning, Tom.
Your shower is getting
warm…
I’m going
to get
them to
stop
I don’t
have to be nagging
anywhere me….
GET OUT OF
HERE!!!
Hey Tom,
Good morning,
your shower is
getting warm…
I don’t feel
like it, but I
do have to
go to work
My morning
routine may
be a pain,
but it helps
me meet
my goal.
I’m getting
to work on
time, well
groomed
and ready.
“In the absence of meaningful, chosen life activities, all
interventions are doomed to failure” Ylvisaker, 1998
Restorative
Compensatory
Environmental
Behavioural
Restorative
Therapy activities designed to promote
return of function:


Attention training
Aphasia therapies
Compensatory
Learning a way to get around the existing
impairment:



Memory books, notes, alarms
Meta-cognitive strategies (planning)
Routines
Environmental

Reminder signs

Locks

Staff member provides a cue

Routine that is driven by others in the
environment
Behavioural
Using behavioural strategies to train a skill:




Modeling
Rehearsal
Chaining
Errorless learning
Program Modifications




Smaller sessions
Simplified materials
Flexible programming
(breaks/shortened sessions)
Integrating rehabilitation workers into
treatment
Why some clients don’t
compensate




Lack of awareness
Feeling that compensating means
‘giving up’ on progress
Stigma and shame
Impaired cognition
What does the literature say about
treatment of substance abuse
after ABI?
Simplified Program Model
Brain injury
Mild
Mild
Community Based
CHIRS - Based
Psycho-educational
Approach
Psycho-educational
CAMH – Based
Severe
Severe
Case Management
CHIRS –Based CAMH support
Harm reduction
CHIRS Support
Intensive Case Management
Adapted from Corrigan (2004)
From the literature…
ABI-Specific Treatment Models
Common Characteristics:

Engagement in meaningful activity
(incompatible with substance use and
addresses mood/behaviour)

Skills training

Treatment may begin before insight/readiness
to change
Case Management Models



Access to substance abuse
services/mental Health Services
ABI consultation

Explain Neuro-cognitive Impairment

Adapt treatment plans

Trouble-shoot
Assist with access to other support
services
Case Management Outcomes
(Heinemann, Corrigan, & Moore, 2004)
Compares 2 intensive Case management programs
with typical care offered at a major rehab centre:

No changes in substance use at 9 months follow-up

Earlier referral was associated with better outcomes

No differences in community integration

Small changes in health-related QOL

Life satisfaction /family satisfaction improved
Motivational Interviewing


Main Goal: To produce an internal drive
to change, using non-confrontational
techniques
Main Method: Evidence of the negative
consequences of the behaviour are
elicited from the client, so that the client
sees and accepts the advantages of
change
Structured Motivational
Interviewing
Cox, Heinemann et al. (2003):
Outcome after 12 sessions of Motivational
Interviewing – follow-up (mean = 9 months)

Improved Motivational Structure

Reduced negative affect

Reduced substance use
Ohio Valley TBI Network Model
Consumer and professional education
 Intensive Case Management
 Consultation to Substance Abuse
Services

www.ohiovalley.org
Corrigan Review (2005)



Treatment is likely to be protracted
Successful programs will address
engagement in treatment
Early intervention is important
Findings
90%
N=195 (138, male; 57
female)
Mean age = 36.6 (range
= 18 to 72)
Mean time since injury =
8.0 (range = 3 weeks to
55 years)
83%
80%
74%
70%
Attn. Control
60%
50%
45% 45%
40%
30%
20%
10%
0%
% Complete ISP In 30 days
Motivational
Interview
Barrier
Reduction
Financial
Incentive
6-Month Follow-up Data



By 6-months over 30%
had terminated
therapy
50% improvement
over control for Barrier
Reduction and
Financial Incentives
Brief phone
intervention makes a
big difference
90%
84%
79%
80%
70%
66%
Attn. Control
60%
53%
50%
40%
30%
20%
10%
0%
Still in treatment or
successfully terminated
Motivational
Interview
Barrier
Reduction
Financial
Incentive
Why did these interventions
work?




Financial incentive participants stated
that the reward was not what made a
difference in attending appointments
Reminders to address memory issues
Transportation support to address
planning/financial issues
Learning by ‘rule’ not by consequence
Barriers to Care

Behaviour resulting from the cognitive
impairment that appears uncooperative
or unmotivated

Difficulty recalling information learned

Difficulty generalizing

Difficulty predicting and managing
behaviour
5 Principles for Working
with ABI clients






Pace communications (one concept at a time)
Repeat important concepts
Illustrate using concrete examples
Memory Aids for use in session and outside
Environmental modifications (including the
involvement of caregivers)
Re-direction sometimes necessary to move
client to problem-solve or address tangential
speech
Communication Problems
Associated with
Traumatic Brain Injury
A Guide for Working with
Homeless Persons
Catherine Wiseman-Hakes
Ph.D. Candidate, Reg. CASLPO
Speech Language Pathologist
Communication After Brain Injury
• Communication difficulties are common
• Some more obvious, and some are not!
• Subtle (but highly debilitating)
communication issues can be
misconstrued by a communication partner
reflection of poor attitude, disinterest,
disrespect, or even substance use.
Communication:
Why all the Hype???
• What exactly is communication?
• We know when we’ve been involved in
a successful communication interaction
• AND we all know what it is like to be part
of an unsuccessful communication
interaction
• SO, what exactly is involved?
Components of Communication:
Expression
• Successful communication involves an exchange by
2 or more individuals where a message or intent by 1
person is expressed clearly, and received and
understood successfully by the communication
partner(s)
• This involves speech (or other non-verbal alternative
system) which is the motor act of forming sounds
• The content is the language
• This is augmented by the equally important non
verbal communication behaviours such as body
language, eye contact and tone of voice, known as
pragmatics
Pragmatic Communication
Personality changes following TBI
involving egocentric thinking with loss of
social sensitivity may result in a selfcentered style of communication that is
lacking empathic interaction with a
conversational partner.
Pragmatic Communication
• Personality changes following TBI involving
egocentric thinking with loss of social sensitivity
may result in a self-centered style of
communication that is lacking empathic interaction
with a conversational partner
• Behavioral changes may also affect
communication. Decreased initiation may
result in sparse, uninformative interactions
whereas impulsivity may result in verbose,
tangential communication that is marred by
inappropriate remarks.
Components of Communication:
Receiving the Message
• Successful communication involves an exchange
by 2 or more individuals where a message or intent
expressed by 1 person is received and understood
clearly
• This involves hearing, and understanding
(comprehension)
• Understanding is required at all of the levels of
expression; understanding the speech,
understanding the content, both explicit and
implied, and understanding the non verbal
communication behaviours.
Cognition and Communication
Underlying successful communication are a
number of key cognitive abilities. These include:
 Attention to the speaker,
 working memory,
 long term memory, and
 information processing (this involves the speed,
amount and complexity of the information being
presented).
Communication Problems Associated
with TBI
• Slow speed of information processing: this is a
hallmark of brain injury
• May have motor speech problems, called
dysarthria, difficulty forming the words
• May have hearing problems, and or problems
picking out speech from other background noise
• Often slow to initiate, slow to understand, difficulty
with implied messages, and difficulty thinking of
quick and coherent response
• Often have word finding difficulties.
Communication Problems
Associated with TBI
• Most people with brain injury dread  and shy away
from  multi-person conversations, noisy
environments, and conversations with people they
don’t know
• Many canNOT block out extraneous stimuli; attention
is effortful and hard to sustain over time
• Easily fatigued
• Easily overwhelmed by too much information (like
someone following a conversation in a language they
are just learning...just give up and tune out).
Communication Problems Associated
with TBI: Frontal Lobe Injuries
• May be impulsive in their responses, may be
emotionally labile; difficulty monitoring context
• In contrast, they may appear flat, disinterested
with reduced affect, limited facial and vocal
expression
• They may not hear you, they may not understand
(or they think they understand, but get it
completely wrong)
• Problems reading body language, tone of voice
and facial expression
• If they have motor speech problems they may
sound like they are under the influence of alcohol
or drugs.
Consequences of Communication
Problems after TBI
• The consequences of pragmatic communication
impairments in people with TBI can be devastating.
Social communication serves to connect people to
their families, friends, and coworkers
• Many people with TBI report reduced social contacts
and rate social isolation and loneliness as their most
frequent complaint.
MacLennan et al 2002: The prevalence of pragmatic communication impairments in traumatic brain injury.
http://www.premier-outlook.com/winter_2002/prevelance_pragmatic_communication.html
How to modify your communication to
facilitate a successful interaction
• If you are having trouble understanding their
speech, assure them you ARE interested in
what they have to say, ask them to repeat,
maybe use a pen and paper
• DON’T misinterpret a slow response and or
flat affect for lack of interest or disrespect
• Speak calmly and respectfully
• Whenever possible, have a conversation in
a quieter environment (make sure there is
no TV, radio playing etc….)
Screening Tools for
Communication Problems
• Latrobe Communication Questionnaire (Douglas, J.)
• Pragmatic Communication Scale (Erlich and Sipes)
• Pragmatic Rating Scale (MacLennan et. al.)
Thank You!
Questions & Answers
Angela Colantonio, PhD, OT


Saunderson Family
Chair in Acquired Brain
Injury (ABI) Research,
Professor at University
of Toronto
Leads an internationally
recognized program of
research on ABI
Carolyn Lemsky, PhD,
C. Psych.


Clinical Director at
Community Head Injury
Resource Services of
Toronto
Director of the
Substance Use and
Brain Injury (SUBI)
Bridging Project
Catherine Wiseman-Hakes,
M.Sc. Reg. CASLPO


Registered Speech
Pathologist and a doctoral
candidate, University of
Toronto
Specializes in the
assessment and treatment
of children & adults with
cognitive communication
impairments secondary to
TBI
http://www.abiebr.com/edumodules/edumodules.html
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