Treatment of Mild Traumatic Brain Injury
using an Interdisciplinary Approach
Presented by:
• Helen Mathison MA, CCC-SLP
• Nova McNally OTR/L
• Danielle Potokar PhD, LP
• Sarah Rockswold M.D.
• James Thomson PhD, LP
Traumatic Brain Injury:
Magnitude of Problem
• Occurs every 15 seconds in the U.S.
• Death occurs every 5 minutes
• Permanent disability occurs every 5 minutes
Traumatic Brain Injury:
Magnitude of Problem
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1.7 million brain injuries per year
1.0 million emergency department visits
500,000 hospitalizations
50,000 deaths
Direct & indirect costs of $60 billion
TBI Statistics
• Major issue is premature death and
disability
• TBI is a disease of the young
– 84% of the 1.7 million TBIs are sustained by
people age 64 or less
• Prevalence of long term disability due to
TBI in the U.S. is over 3 million people
TBI: Definition
• A traumatically induced physiological
disruption of brain function manifested by:
– Loss of consciousness
– Amnesia – retrograde and/or anterograde
– Confusion
– Delayed verbal or motor responses
TBI: Mechanism
• The head being struck
• The head striking an object
• The brain undergoing an accelerationdeceleration movement without direct trauma
to the head
Mild Brain Injury
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GCS score = 14 to 15
Post-traumatic amnesia < 24h
Mild brain injury = negative CT scan
Mild complicated brain injury = positive CT
scan
Epidemiology
• Mild TBI constitute vast majority of brain
injuries within the U.S.
• Incidence of 1.2 million cases of mild TBI in
the United States yearly
• Account for 290,000 hospital admissions per
year
Concussion
Concussion = mild or moderate
traumatic brain injury
Pathophysiology
• May be metabolic rather than structural in
nature
– Traditional neurodiagnostic techniques not
sensitive
– PET scan, fMRI, Diffuse Tensor Imaging
Metabolic brain dysfunction
following traumatic brain injury
GCS 15
GCS 5
GCS 15
Bergsneider, Hovda, et.al. J Neurotrauma 2000
Why is follow-up important?
• Symptoms will resolve within 2 weeks in 85%
of patients with mild TBI
• If the symptoms do not resolve, a chronic post
concussive syndrome can develop which can
cause significant occupational, social, and
personal problems
Why is follow-up important?
• Prevention of multiple TBIs is vital
• Repetitive mild TBI results in more persistent
cognitive impairments and physical symptoms
• Ongoing symptoms need to be recognized
more readily
Postconcussion Syndrome
• Cognitive
– Attention and concentration difficulties, memory
impairment, efficiency
• Affective
– Irritability, depression, anxiety
• Somatic
– Headache, dizziness, insomnia, fatigue, sensory
disturbances
Evaluation
• History is key
– What are the problems?
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Cognition
Headache
Musculoskeletal complaints
Dizziness
Sleep
Psychosocial
Evaluation
• History
– What is their occupation?
– What are their hobbies?
– What is their living situation?
• Physical Exam
– Cognitive screen
– Balance and coordination
Management
• Interdisciplinary approach is key!
• All physical, cognitive, and emotional
disturbances must be identified and
addressed for good recovery
Management
• Based on history, social situation, and physical
examination
– Neuropsychological testing
– SLP, PT, OT
– Clinical Psychology
– Therapeutic Recreation
– Vestibular clinic
– Medications
Management
• Rest of absolute nature
– Symptoms aggravated by exertion, both physical
and cognitive
– Time away from school or work
– Discontinue fitness activities, aerobic activities
and exertional activities of daily living
Management
• As symptoms improve with treatment,
patients can slowly be returned to their
activities, i.e. school, work, sports
Conclusion
• Mild/moderate TBI patients’ needs have
traditionally been underserved
– “Since CT scan normal, patient must be normal”
• On the contrary, mild TBI is a challenging
diagnosis
• Individualized management utilizing an
interdisciplinary team is essential
Case Report #1
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19 y/o male who fell after syncope
+ LOC
Seen at outside hospital in Denver
CT of brain: (-)
GCS score not recorded
Case Report #1
• PmHx: 6 previous TBIs, ADHD, Bipolar
disorder, dyslexia, htn
• Meds: Trazadone, metroprolol
• Social Hx: Sophomore at U of Denver
• Sent home from ED with primary care followup
Case Report #2
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29 y/o male who fell 25 feet at work
- LOC
Admitted to HCMC
CT of brain: (cerebral contusionn, frontal sinus
fracture)
• GCS score 15 at admission
Case Report #2
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PmHx: mild TBI as infant
Meds: none
Social Hx: welder, workmans comp case
Seen in outpatient TBI clinic approx 1 month
after hospital discharge
Neuropsychological Evaluation
Chart Review
Interview
Testing
Feedback
Education
Diagnosis
Recommendations
Chart Review
Medical History
Academic Reports
Psychology/Psychiatry Reports
Neuropsychology Evaluations
Legal Reports
Diagnostic Interview
Current Information
– Symptom Review
– Concurrent Issues
– Current Activities
– Coping Strategies
– Goals and Plans
Diagnostic Interview
Social History
– Childhood
– Academic Achievement
– Occupational History
– Leisure Activities
Neuropsychological Testing
Cognitive Domains
– Perception
– Memory
– Learning
– Reasoning
– Executive Abilities
– Language
– Achievement
– Motor Coordination
Neuropsychological Testing
Behavior Observations
– Affect
– Appearance
– Motivation
– Rapport
– Engagement
– Attention
– Organization
– Frustration Tolerance
– Personality
Feedback and Clarification
Review Results
Answer Questions
Clarify Diagnostic Issues
Education
Brain Structure and Function
Review of CT and MRI Data
Shearing Effects
Implications of Symptoms and Results
Natural History of TBI
Expectations for Recovery
Diagnosis
Extent of Brain Injury
– Rate of Recovery
– Prospects
– Problems
Re-diagnosis
Co-diagnosis
No diagnosis
Malingering
Recommendations
Cognitive Rehabilitation (SLP/OT)
PT
Psychotherapy
Psychiatry
Feedback to MD or MDs
Recommendations
Driving
Work
School
Change in Supervision
Return to Normal Life
Follow-up
Continued Involvement with Team
Return for Re-evaluation
Return for Education
Later Contacts
– New Problems
– Re-entry to Hospital
– Seeking Community Contacts
– Support and Reassurance
Case Report
Neuropsychological Results
Occupational Therapy
Our Role within the TBI clinic
Assess:
-functional visual processing
-ability to participate in daily activities
including work, school, driving, and home
management
Occupational Therapy and Visual
Processing
• Changes in visual processing are a common complaint
after a head injury.
• 20/20 vision does not equal good visual processing.
• OT will perform a specialized visual processing screen
to look for deficits.
• A comprehensive eye examination, performed by a
neuro-ophthalmologist, is needed to properly diagnose
these deficits.
Common Complaints
• Headaches
• Double vision +/or blurry vision
• Vertigo/dizziness
• Nausea
• Inability to focus (visual attention
which will impact concentration)
Common Complaints
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Movement of print when reading
Difficulty visually tracking
Photophobia
Visual overstimulation (feeling
overwhelmed in a busy
environment like a grocery store or
riding in a car.)
How These Symptoms Can Impact Every Day Life
• Blurred vision when looking from near to far
or far to near as needed for driving or taking
notes in class
• Headaches, eye strain, pulling sensation
around the eyes
• Reading problems, movement of the print
while reading, skipping lines or re-reading
lines
Functional Impact continued
• Avoidance of reading and other close work
• Fatigue and sleepiness
• Loss of comprehension over time, decreased
short term memory, no retention of new
information
• Difficulty with ADL’s that require sustained
close work/attention
Occupational Therapy
Intervention
• Treatment will focus on retraining the visual
processing system with specially designed
exercises and activities.
• Symptom and energy management
• Client and family education
• Teaching compensatory strategies as needed
• Pre-drive screen
• Assist with the transition back to work or school
• Monitor return to exercise/physical activity
Challenges of OT Treatment
• Client awareness and insight into their deficits
• Compliance with home exercises and energy
management strategies
• Under reporting of symptoms
» Direct communication with the
interdisciplinary team for quality continuum of
care.
Speech Pathology’s Role
• Assessment of Cognitive-Linguistic Abilities
• Intervention
– Direct Treatment
– Awareness Training
– Compensation Training
– Adjustment to Cognitive Changes
– Return to Work / School
Speech Pathology Assessment
• In depth interview
– Diagnostic interview
– Post concussive symptom questionnaire
• Formal cognitive-linguistic assessment
– Observe behaviors & symptoms
– Observe strategy use
• Informal evaluation of multi-processing
abilities
Challenges of SLP Assessment
• Most formalized tests are often not sensitive
enough with mTBI
• Informal evaluation of multi-processing
abilities in distracting environments essential
• In depth interview & direction observation
also essential
Effective Treatment
• Awareness training is a key element
• Goals must relate to complex activities in life
and work
• Regular interdisciplinary communication is
needed
Main SLP Goal Areas
• Time and Energy Management
• Awareness Training & TBI Education
• Attention & Memory Compensation
Techniques
• Organizational Skills
• Word Retrieval & Pragmatic Language Skills
• Return to Work/Study Skills
Time and Energy Management
• Client keeps daily log
– Energy level, pain level, cognitive “success,” mood
• SLP reviews log with client
– Summarizes trends/progress
– Helps client become own expert at compensating
successfully
Awareness Training
• Train client to be own expert
• Client gives own assessment of performance
• SLP gives assessment, comparison of
discrepancies, feedback
• Continuous education helps generalization of
strategies
Memory Compensation
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Increased Active Attention
Increased Organization
Use of External Aids
Increased Awareness/Self-testing
Rehearsal
Elaboration
Association
Organizational Skills
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Set Location for Important Items
Increased Use of Writing
More Methodical Approach
Successful Use of Planners, Alarms,
Smartphones and Other External Aids
Return to Work
• Simulate work tasks
• Plan and discuss recommended
accommodations
• Possibly educate employer &/or peers
• Overlap treatment with RTW to provide
feedback & problem solving
Return to School
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Achievement Testing
Teach or Review Study Skills
Teach Organizational Skills
Focus on Awareness (e.g. need for strategies,
rest)
• Provide Guidance about Choosing Classes
(Amount/Type)
Common Emotional Changes post mild TBI
• Increased irritability (“short fuse”)
• Crying (more often, without being able to control it
at times)
• Sadness
• Anxious, nervous or feeling “edgy”
• Increased worry thoughts
• Overwhelmed
• Hopeless about future
• Wishing you had died in the accident
• Feeling you are a burden to your family
Typical areas of focus in psychological
work with TBI patients:
– Adjusting to life changes because of TBI
– Improving Sleep
– Relaxation strategies
– Improving Mood
– Decreasing Anxiety
– Improving Relationships
– Identity and other Existential Issues
Common Diagnoses
• Adjustment Disorders
– With Depression
– With Anxiety
• Anxiety Disorders
– Anxiety NOS
– Post-traumatic Stress Disorder (PTSD)
– Generalized Anxiety Disorder (GAD)
• Mood Disorders
– Depression NOS
– Major Depressive Disorder
• Substance Use Disorders (LESS COMMON)
Therapeutic Approaches
• Cognitive-Behavioral Therapy (CBT)
• Acceptance and Commitment Therapy (ACT)
• Interpersonal Process Therapy (IPT)
General Objectives for Therapy
• Educate patients on the interaction between
thoughts, feelings, and behaviors
• Assist patients in heightening their awareness of
symptoms (post-concussive and mental health) in
vivo
• Assist patient in learning ways to react to their
symptoms in ways that lead to better outcomes
• Provide patients with tools to catch, check and
cope with negative self-statements that
contribute to downward spiral of depression and
anxiety
General Objectives for Therapy
• Assist patient in reconciling multiple views of self
(“old me” vs. “new me”)
• Assist patient in processing the losses that arise
from sustaining a TBI
• Assist patient in articulating values and assisting
patient work towards those values
Challenges when working with TBI
patients in Psychotherapy
• Stigma of “psychological help” can deter people
from seeking or completing treatment
• Attention and memory deficits can lengthen
treatment
• Visual challenges can impact ability to complete
homework assignments
• Heightened emotionality can lead to avoidance of
therapy or homework