Traumatic Brain Injury –
Evaluation and Treatment
Considerations
Brian A. Boatwright, Psy.D.
Neuropsychologist
Director of the Neurologic
Rehabilitation Institute
Epidemiology
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National Estimates – 1.7 million
individuals sustain a head injury each
year.
52,000 die.
275,000 are hospitalized.
1.365 million are treated and released.
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TBI accounts for a third of all injury
related deaths in the U.S.A.
Approximately 75% of brain injuries
are mild (concussion).
Number of those sustaining injury but
do not seek treatment is unknown.
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Peak occurrences: Ages 0-4; 15-19;
and >65.
Those >75 have highest rates of TBI
related hospitalization and death.
Males>Females
Males ages 0-4 have highest rates of
brain injury E.D. visits.
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Direct and indirect medical costs of
brain injury – $76.5 billion (2000 CDC
data).
Causes-Motor Vehicle Crashes and
Falls.
Data from Centers for Disease Control and Prevention, 2012
Primary Mechanisms of
Injury
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Impact
– Contusion at point of impact
– Skull Fracture with focal injury
Contusion
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A contusion is a bruise (bleeding) on
the brain.
A contusion can be the result of a
direct impact to the head.
The behavioral effect depends on the
size and location of the bleed.
Coup and Countrecoup
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Head impacted at site of contact with
object (causing contusion).
Brain is forced into opposite side of
skull (causing contusion).
Diffuse Axonal Injury
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A result of shaking or strong rotation of the
head or by rotational forces (e.g.
automobile accident).
The stationary brain lags behind the
movement of the skull causing brain
structures to tear.
Individual presents a variety of functional
impairments depending on where the
shearing (tears) occurred.
Secondary Mechanisms of
Injury
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Edema
Disruption of CSF absorption
Hypoxia
Ischemia
Damage Documented in
Survivors
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Brain swelling by CT 17-44%
Focal Lesions by CT 23-46%
Frontal MRI abnormalities 40%
Multifocal damage not detected by
routine clinical studies
Brain Damage Survival
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More people survive diseases,
accidents, and other medical
conditions affecting the CNS.
Consequently, more people live with
chronic neurological conditions and
associated impairments, including
cognitive disabilities and
affective/behavioral disturbance.
Traumatic Brain Injury
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Brain injury deaths declined from 24.6
per 100,000 in 1979 to 19.3 per
100,000 in 1992, in the United States
(Sosin, Sniezek, & Waxweiler, 1995)
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Reliable estimates regarding survivors
with cognitive disability are not
available
One study in the Netherlands indicated
that of all hospital admissions, 67% of
brain injury survivors had long-term
cognitive and behavioral problems
CDC-Estimates 3.17 million Americans
currently require ADL assistance
Neuropsychological
Domains
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Acquired Knowledge
Attention & Memory
Language
Visual Spatial
Motor & Sensory Perceptual
Reasoning & Problem Solving
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Executive Functions
– Planning
– Processing Speed
– Cognitive Flexibility
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Personality
Social Cognition
Motivation / Response Bias
TBI and Neuropsychology
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Performance IQ loss is generally greater
than Verbal IQ loss.
Younger the child the greater the IQ loss.
Deficits may be seen in any number of
domains, dependent on lesion location.
Memory is the most prominently effected
neuropsychological function but will also see
marked impairment in executive functioning.
Greatest improvement seen shortly postinjury but may be two years and beyond.
IQ Distributions
160
Normal
THI-VIQ
THI-PIQ
0
100
Dennis 1985
Basic Neuroanatomy and
Functional Localization
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Frontal Lobes
– Attention
– Planning
– Sequencing
– Organization
– Mental Flexibility
– Problem Solving
– Impulse Control
– Aspects of Memory (Executive Memory)
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Temporal Lobes (Hippocampus,
Amygdala, Basal Ganglia)
– Sound recognition and processing
– Comprehension and production of speech
– Aspects of memory
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Parietal Lobes
– Integration of sensory information from
the body
– Contains primary sensory cortex
– Proprioception
– Spatial Functioning
– Visuoconstruction
– Aspects of memory
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Occipital Lobe
– Primary Visual Cortex
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Cerebellum
– Balance
– Movement
– Coordination
– Some aspects of attention/executive
functioning, frontal connections
Emotional and Behavioral
Changes Secondary to
TBI
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Emotional/Behavioral sequelae may occur in
the absence of neurological and
neuropsychological findings.
No specific psychiatric disorder is typical.
90% of severe and about half of moderate
TBI patients have behavioral and social
problems.
Hyperactive, mood, anxiety, and anger
control problems all may occur.
Neuropsychological
Assessment of TBI
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Effort
Ability (Premorbid estimates and current)
Achievement
Sensory Motor/Visuospatial/Construction
Memory (Verbal and Visual)
Executive Functioning
Affect/Personality
Treatment Modalities
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Physical Therapy
Occupational Therapy
Speech Therapy
Neuropsychology
Cognitive Rehabilitation
Psychotherapy
Psychotherapy:
Treatment Considerations
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Previously, psychotherapy thought to
be less important due to TBI patient
deficits (e.g. anosognosia, poor
insight, memory problems, perceptual
disturbance, language impairment).
With improved therapies in other
modalities and compensatory
strategies, psychotherapy currently
viewed as very beneficial.
Therapy Issues
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Consider neurocognitive strengths and
weaknesses when formulating approach to
patient and treatment planning
Impairments in concentration, memory,
general ability to sustain focus and effort
throughout sessions
Strengths-Maximizing intact abilities (e.g.
verbal or visual memory)
When in doubt, spell it out
Contracting for treatment
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Therapeutic relationship, may take
time, exercise patience.
Cicerone and Prigatano-therapeutic
relationship is important when working
with problems of self-awareness.
Prigatano and Klonoff-therapeutic
alliance with patient and family
predictive of client productivity as far
out as 11 years.
Presenting Problems
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Behavioral dyscontrol (e.g. anger, irritability,
impulsivity, self-awareness)
Depression
Mania
Alcohol Abuse and Dependence
Anxiety Disorders (PTSD, Social phobia,
GAD, Panic Disorder)
Personality Changes
Recalling what happened
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New role (Social, family, educational,
etc.)
Employment
Sleep
Appetite
Libido
Medications
Family Support
Final Notes
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Psychotherapy beneficial for helping
patient and family adjust.
Collaborate with other providers (e.g.
ST, OT, Neuropsychologist,
Physicians/Psychiatrist, PCP)
References
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American Psychological Association (2011). Rehab for the
brain after traumatic injuries, five questions and answers
about traumatic brain injury.
Burg, J.S., Williams, R., Burright, R.G., & Donovick, P.J.
(2000). Psychiatric treatment outcome following traumatic
brain injury. Brain Injury, 14, 513-533.
Coetzer, R. (2007). Psychotherapy following traumatic brain
injury: Integrating theory and practice. Journal of Head
Trauma Rehabilitation, 22, 39-47.
Jorge R. & Robinson, R.G. (2003). Mood disorders following
traumatic brain injury. International Review of Psychiatry, 15,
317-327.
References, cont.
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Schoonover, C. (2010). Portraits of the mind. New York, NY:
Abrams.
Senathi-Raja, D., Ponsford, J., & Schonberger, M. (2010).
Impact of age on long-term cognitive function after traumatic
brain injury. Neuropsychology, 24, 336-344.
Sherer, M., Evans, C.C., Leverenze, J., Stouter, J., Irby Jr,
J.W., Lee, J.E., & Yablon, S.A. (2007). Therapeutic alliance in
post-acute brain injury rehabilitation: Predictors of strength of
alliance and impact of allegiance on outcome. Brain Injury,
21, 663-672.
Sosin, D.M., Sniezek, J.E., & Waxweiler, R.J. (1995). Trends in
death associated with traumatic brain injury, 1979 through
1992. Journal of the American Medical Association, 273, 17781780.
Resources
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www.traumaticbraininjury.net
www.braininjury.com
www.traumaticbraininjury.com
www.pbs.org/wnet/brain/3d
www.g2conline.org
www.cdc.gov/traumaticbraininjury/