SCI and Co-Occurring TBI
Janet P. Niemeier, Ph.D., ABPP
Professor, Director of Research
Carolinas Rehabilitation
Charlotte, NC
Disclosure of PI-RRTC Grant
James S. Krause, PhD, Holly Wise, PhD; PT, and
Elizabeth Walker, MPA have disclosed a research
grant with the National Institute of Disability and
Rehabilitation Research
The contents of this presentation were developed
with support from an educational grant from the
Department of Education, NIDRR grant number
H133B090005. However, those contents do not
necessarily represent the policy of the Department
of Education, and you should not assume
endorsement by the Federal Government.
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The Medical University of South Carolina is accredited by the
Accreditation Council for Continuing Medical Education (ACCME) to
provide continuing medical education for physicians. The Medical
University of South Carolina designates this live activity for a
maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians
should claim only the credit commensurate with the extent of their
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In accordance with the ACCME Essentials &Standards, anyone
involved in planning or presenting this educational activity will be
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Disclosure of Presenter
Dr. Janet Niemeier does not have any
financial disclosures.
Continuing Education
Conflict of Interest
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Learning Objectives
Attendees will be able to discuss:
1. The epidemiology of co-occurring SCI
and TBI
2. TBI symptoms and challenges and how
these complicate recovery from SCI
3. Best practices for identification and
treatment of patients with both SCI and
TBI
Separate Epidemiology
Traumatic Brain Injury 1.7 million a year
SCI 11,000 a year
– 82% male,
– Average age 31
– 52% paraplegic, 47% quadriplegic
Military study, OIF/OEF -- 10%, from
blasts (Bell et al., 2009) and combat
injuries
(CDC)
Causes of SCI
(LeGrand, 10/16/10, C3/C4)
Causes of SCI
SCI/TBI Epidemiology
Estimates vary depending on method of data
collection, i.e., ICD-9 codes, neuroimaging, length of
coma
24-59% (Sommer & Witkiewicz, 2004)
25% GCS (Wagner et al., 1984)
42% PTA/LOC (Davidoff et al., 1992)
46.7%; most mild (Hagen et al., 2010)
56% Neuropsychological test data (Wilmot et al., 1985)
60% GCS NIDRR diagnostic criteria, neurocognitive tests, PTA (Macchiocchi et al.,
2008)
74% ACRM diagnostic criteria, diagnostic imaging
Incidence is increasing
(Telenon et al., 2007)
Injury Variables Associated with CoOccurrence of TBI & SCI
Cause –MVAs, falls, assaults, sports, combat
SCI Level--Most common
–
–
–
–
C5-8, Asia Grade A-C
T 1-8, Asia Grade A-C
T 9-12, Asia Grade A-C
Completeness of injury
Severity – Many with SCI have mild TBI
Length of PTA, long is worse
(Macchiocchi et al., 2008)
Injury Variables Associated with CoOccurrence of TBI & SCI
NIDRR classifications:
– Mild (GCS = 13 – 15)**
– mild complicated (cerebral pathology, contusion,
hemorrhage, skull fx)
– Moderate (GCS = 9 – 12)
– Severe (GCS = 3 – 8)
Gender male
Ethnicity White
Significant problem: Lack of ER, acute records
CLASSIFICATIONS OF TBI
Mild – GCS 13 – 15, ? To Min. LOC, ≤12
hours PTA, “post concussive syndrome”
Symptom overlap with PTSD
Moderate – GCS 9 – 12, ≤ 30 minutes
LOC, ≤ 24 hours PTA
Severe – GCS 3 – 8, > 30 minutes LOC,
>24 hours PTA
Co-Occurrence Risk Factors
ETOH
Completeness of Traumatic SCI
Gender male
Involvement in sports
Professions or occupations requiring work
at significant heights
Combat exposure
Early Assessment Tools
and TBI Facts
TBIMS Definition: Damage to brain tissue
caused by an external mechanical force as
evidenced by loss of consciousness or
post traumatic amnesia (PTA) due to brain
trauma, or by objective neurological
findings
Causes of TBI
TBI Facts
Annual incidence >1.5 million
“Signature Wound” of global war on
terrorism, >1,700 U.S. military (64%) since
beginning of Middle Eastern conflict
$4 million lifetime costs per person
Greatest risk ages <5 and > 85
MVAs cause most severe injuries
TBI Research Timeline
First review of literature on TBI rehabilitation in
1998 (Cicerone, et al.)
– Very little clinically useful work on efficacy of
treatment
– We need tested interventions, but most of
the research studies and articles have
focused on impairments, course of
recovery, and ways to measure post-TBI
function.
Early Assessment Tools
Length of coma*
Time to commands*
GCS*
Admission FIMTM *
InterD baseline evals
Lots of challenges for examiners of acute patients
Wiser make long-term recs based on
evals completed during post acute phase
*Assessment of Severity.
Inpatient Baseline Evaluations
Discipline specific:
Speech
Vision
Hearing
Practic functions/Sensory motor abilities
Balance
Gross motor/walking/wheel chair
Endurance
Cognitive status:
Level of Agitation
Social and emotional status
Common Symptoms and Issues after TBI
Symptoms
Physical
Perceptual
Emotional
Behavioral
Social
Cognitive
Issues
Pain
Premorbid
Comorbid
Psychosocial
The Scientific TBI Literature Tells Us…
Primary Needs after TBI:
Mild—Injury and coping Knowledge,
reassurance, time, rehab for disruptive deficits,
counseling (especially if PTSD)
Moderate, Severe—Early and intensive rehab,
knowledge, compensatory skills, opportunity for
purpose and QOL, community and family
supports
The Scientific TBI Literature Tells Us…
Factors in Long-term outcome:
Age
Gender
Ethnicity
Level of education
Violence
Severity
Support network
Family involvement
LOC
early rehab
GCS on admit
Site of injury
Premorbid factors
ER care
Relationship stability
The Scientific TBI Literature Tells Us…
Evidence-Based, Effective Interventions:
In General: Early, comprehensive
Cognitive Rehabilitation:
Visual scanning training
Speech language therapy
Problem Solving training
Memory Retraining
Electronic Assistive Devices
Outcomes assessed with real world tasks practice
The Scientific TBI Literature Tells Us…
Post Injury employment outcomes affected
most by:
Premorbid employment status
Ethnicity
Functional status at rehab D/C
Cognitive functioning
Vocational rehabilitation
Supportive employment
No “gold standard” for defining productivity
The Scientific TBI Literature Tells Us…
Variables Associated with Quality of Life
Outcomes:
Being employed
Activity
Social integration
Less severe injury
Challenges to InterD Evaluations
Polytrauma, medical problems
Pain
Reduced endurance
Reduced time for assessment
Less insurance coverage
Symptom overlap
Medication Effects
Agitation, behavior problems
Cultural Issues
Setting priorities
Perceptual, language, and motor deficits
Limited Literature about Dual Dx
Studies looking at long-term consequences of
TBI and SCI
Moderate/severe TBI + SCI = more personal and family
adjustment difficulties than mild TBI and SCI (Richards et al.,
1991)
Fewer functional gains from pre- to post-treatment on
FIM for SCI + TBI vs. SCI only (Macchiocchi et al., 2004)
Worse neuropsychological test performance, more
psychopathology and behavioral problems, greater
demands on clinician resources, increased rehab
costs (Bradbury et al., 2008)
Limited Literature
Small sample sizes
Variation in methodologies
Mostly epidemiological and descriptive
Need more research on variables associated
with outcome, best interventions
Inconsistent information in acute or ER
records—true of military records as well
Persons with mild TBI often do not recall being
injured or losing consciousness
Military Co-Occurrence
Military Study of Impact Blast and
military grade weaponry on CNS (Bell
et al., 2009)
n = 40/408 (9.8% co-occurring SCI and
TBI)
No stratification in looking at outcomes,
level of injury
Challenges to Dual Diagnosis
Often missed in ER
Acute charts often have no information
Motor performance is required on many
cognitive tests
Cognitive deficits can impair ability to
follow test instructions
Challenges to Treatment of DD
Cognitive deficits Lead to:
– Poor recall of therapists’ instructions and
teaching/training
Forgetting to do critical self care:
– Pressure releases
– Exercise
– TLSO compliance
– Forgetting precautions, getting up impulsively, and risking
further injury
Challenges to Treatment of DD
Inability to retain vital educational portions of
rehabilitation of the SCI due to cognitive
deficits:
 B&B
 Nutrition
 Sexuality
 Avoidance of medical complications
Challenges to Treatment
Behavioral issues
Agitation
Aggression
disinhibition
initiation
Social pragmatics
Treatment disrupted
Poor problem solving
Aphasia—hard to make needs and feelings known
Hard to understand therapists
Challenges to Treatment
Mood and coping issues are common in SCI
– Depression, suicidal ideation
– lethality worse after TBI
Impaired self-awareness
endangering self with impulsive behavior
Losses doubled
– Grief further complicate emotional responses to
disability
– Patients overwhelmed with 2 disorders to accept
Major Issue: Psychotherapy helps with adjustment
but is a talking enterprise – conceptually complex
Challenges to Treatment
Failure to educate staff, patients, and family
about cognitive assessment findings
Cognitive disability is overshadowed due to
paralysis
Patients can be labeled unmotivated,
noncomplaint -- misinterpretation of their
neurobehavioral symptoms
Therapists frustrated by need to repeat info
Variables Affecting Outcomes
Type, severity, and number of
neurobehavioral deficits
Location of injury
Cause
Family support
Social adjustment
Treatment Recommendations
NEED SPECIALIZED TREATMENT
Neuropsychological assessment
Carefully check acute and ICU record to confirm TBI, type and
severity
– Some biomarkers identified that can distinguish TBI +
polytrauma from polytrauma alone
Educate team, family and patient
Normalize TBI symptoms, feelings
Family hands-on training
Behavior management
Chemical restraints
Treatment Recommendations
POA and decision-making issues clarified
Train patient in purposive and consistent use of
compensatory cognitive strategies
Repeat instructions and provide written backup
Use of schedule, calendar, memory log (if able)
Link patient and family with community
resources
Manage pain effectively
Treatment Recommendations
Reduce size of education and support groups—
two leaders
If possible, match group members by cognitive
level
Simplify language
Consider education on an individual basis
Visual aids
Opportunities to practice, apply concepts and
skills
Dry Erase board
Treatment Recommendations
Gently redirect if attention wanders
Awards/incentives for compliance
TBI focus in education first….as cognition
improves, then start SCI ed
Have Dual Dx patients attend educational
series more than once
Use of task analysis to train
Use consulting experts on both diagnoses
Predictors of Outcomes
Length of Post traumatic amnesia (PTA)
>14 days, or time to commands
Severity of cognitive deficits
Violence associated with Injury
Early rehabilitation
Vocational rehabilitation
Gender
Ethnicity
(Heineman et al., 2002; Macchiocchi et al., 2008; Williams-Gary et al., 2009; )
Clinical and Economic
Consequences
Economic as well as clinical burden
Increased rehabilitation costs
Increased burden on clinician resources
and time
More nursing care
Longer LOS-More time needed to achieve
comparable gains
(Bradbury et al., 2008)
Further Research
Intervention studies
Translational research
Protocol or manualization/critical path with
specialized assessment and interventions
Prevention
Improved informatics to track trends and
associations that will help us learn more
Care at ERs and in the field to carefully
assess for and note both disorders
Thank you and
Janet.niemeier@carolinashealthcare.org