Federal Traumatic Brain Injury Program

1. Federal Traumatic Brain Injury Program LT Donelle D. McKenna, MHSA Assistant Director Health Resources and Services Administration Department of Health and Human Services

2. Educational Objectives • List causes, types, symptoms, outcomes, & treatment of TBI • Identify populations at risk and providers of persons w/TBI • Identify resources and services for persons with TBI

3. What is TBI? • A TBI is defined differently depending on which state or territory you reside, but CDC’s definition is: “An injury to the head arising from blunt or penetrating trauma, or from acceleration-deceleration forces.” • Blast trauma-concussive brain trauma caused by invisible force waves

4. ABOUT THE BRAIN Conscious behavior involves the entire cortex of the cerebral hemispheres in one way or another.

5. Regions of the Brain • Contains the following • Spinal Cord • Brain Stem • Limbic System • Cerebellum • Cerebral Hemisphere • Frontal lobe • Parietal lobe • Occipital lobe • Temporal lobe

6. These hemispheres cover and obscure the top of the brain stem. Each hemisphere is concerned with the functions of the opposite side of the body. Each hemisphere is divided into four sections called lobes: Frontal Lobe Parietal lobe Occipital lobe and Temporal lobe Although each lobe has unique functions, they all work together. Cerebral Hemispheres

7. Our emotional control center and home to our personality. Involved in: Motor function Problem solving Spontaneity Memory Language Initiation Judgment Impulse control and Social and sexual behavior Susceptible to injury due to its location (at the front of the brain) Frontal Lobe

8. Located on both sides of head above ears A place for primary organization of sensory input Involved in: Hearing ability Memory acquisition Some visual perceptions Categorization of objects Sexual behavior Temporal Lobe

9. Located near the back and top of the head Place for: Visual attention Touch perception Goal directed voluntary movements Manipulation of objects Integration of different senses that allows for understanding a single concept Parietal Lobe

10. Most posterior, at the back of the head Associated with: Vision Accuracy of vision Locating objects Recognizing objects Writing and reading Occipital Lobe

11. The Physical Mechanisms of Brain Injury • Impact loading – Collision of the head with a solid object at a tangible speed • Impulsive Loading – Sudden motion without significant physical contact • Static or Quasistatic loading – Loading in which the effect of speed of occurrence may not be significant

12. The 3 Basic Types of tissue deformation are: • Compressive – Tissue compression • Tensile – Tissue Stretching • Shear – Tissue distortion produced when tissue slides over other tissue

13. Types of Primary Injury • Primary Injuries can manifest as focal injuries: • Skull fracture, • Intracranial hematomas, • Lacerations, • Contusions, • Penetrating wounds, or • They can be diffuse (as in diffuse axonal injury)

14. Skull Fractures Fractures are depressed or nondepressed and may include: • Hematoma, • Cranial nerve damage, and • Increased brain injury

15. Penetrating Head Injury • Gunshot wounds and missile/non-missile projectiles cause many penetrating head injuries. • The energy dissipated on entry is equal to ½ mass x velocity squared. Therefore, high velocity missiles tend to cause the most profound damage.

16. Coup and Contrecoup

17. Epidemiology of TBI Classification of TBI: Mild, Moderate, Severe HOWEVER, Initial injury severity does not always equal severity of later symptoms 85% of TBIs are classified as Mild; 15% Moderate to Severe 15% of Mild TBIs will have lasting, possibly serious disabling consequences

18. MILD TBI or Concussion Characterized by: • Brief or no LOC • “Dazed and confused” • Unreliable memory; concentration • Headaches, dizziness, fatigue • Resolution of symptoms in weeks to months, though longer for some

19. MILD TBI • Often called mTBI or concussion • May cause brief loss of consciousness (LOC) or not but < 30 minutes • Lab tests and scans usually normal • May have memory loss called post-traumatic amnesia (PTA) lasting < 24 hrs. • Glasgow coma scale of 13-15 (mx eye-opening, verbal responses, and motor responses—not useful in dx of mTBI

20. Moderate TBI • Moderate to severe TBI accounts for 15% of all TBIs • LOC lasts for more than 30 minutes but less than 24 hours • Memory loss (post-traumatic amnesia) lasts for 24 hours to 7 days • A GCS score of 9-12

21. Severe TBI • May be closed or open • LOC is 30 minutes or longer (for Severe coma of 24 hours or more) • Post-traumatic amnesia lasting 7 days or longer • GCS score of 3-8 indicates severe TBI • Frequent sequelae of severe TBI include: lack of awareness of neurobehavioral deficits, disinhibition, irritability, increased dependence and depression

22. Closed vs. Open • When an object penetrates the skull and enters the brain—bullet, knife or explosion debris, it is an open or penetrating brain injury • Any trauma that causes the brain to be shaken violently inside the skull is called a closed brain injury • Over 90% of combat-related TBIs are closed brain injuries

23. How many people have TBI? Of the 1.4 Million who (are known to)sustain a TBI each year in the United States: • 50,000 die • 235,000 are hospitalized • 1.1 million are treated and released from an ER • The number of people with TBI who receive no care is unknown

24. TBI Among Children (0-14yrs) • According to CDC’s report: • 435,000 emergency department visits • 37,000 hospitalization • 2,685 deaths • These numbers pertain to individuals that received care and are estimates • The impairment of intellectual function and visuo-motor skills from severe TBI in a child less than 10 years is more pronounced than in those older than 10.

25. What are the leading causes? • Falls (especially among the very young and the elderly – 28% • Motor vehicle-traffic crashes – 20% • Events where one is struck by or against an object – 19% • Assaults, including domestic violence, child abuse – 11%

26. Who is most at risk? • Risk varies with age and race and gender • Males are at greater risk than females The next slide will show risk by age group and race, information courtesy of CDC, Jean Langlois and Richard Sattin

27. Risk by Age (y) and Race (x)

28. TBI Signs and Symptoms • Signs and symptoms may not appear until days or weeks after the injury • They may even be missed in the case of closed brain injury • Although children experience similar signs and symptoms as adults, they require special way of identifying

29. Common signs & symptoms of TBI • Headaches or neck pain that do not go away • Difficulty remembering, concentrating, or making decisions • Slowness in thinking, speaking, acting, or reading • Getting lost or easily confused • Feeling tired all of the time, having no energy or motivation • Mood changes for no reason • Changes in sleep patterns

30. Common signs & symptoms of TBI (Cont.) • Light headedness, dizziness, or loss of balance • Urge to vomit • Increased sensitivity to lights, sounds, or distractions • Blurred vision or eyes that tire easily • Loss of sense of smell or taste • Ringing in the ear

31. What to Look for in Children • Tiredness or listlessness • Irritability or crankiness • Changes in eating • Changes in sleep pattern • Changes in the way the child plays • Changes in performance at school • Lack of interest in favorite toys or activities • Loss of new skills, such as toilet training • Loss of balance or unsteady walking • Vomiting

32. Outcomes and Costs of TBI • Short term • Physical – symptoms as described previously • Financial – DIRECT and INDIRECT costs (including lost productivity) totaling $60 billion in the U.S. only in 2000 • Repeated mild TBI occurring within a short period of time (hours, days, or weeks) can be catastrophic or fatal.

33. Outcomes & Costs of TBI (Continued) • Long term (Lifelong) • CDC estimates at least 3.17 million Americans have lifelong need for help to perform daily activities as a result of TBI • Functional changes affecting thinking, language, emotions, behavior, and sensation • Can cause epilepsy • Increased risk for Alzheimer’s disease and Parkinson’s disease • Susceptible to brain disorders that come with age • Repeated mild TBIs occurring over an extended period of time (months or years) result in cumulative neurological and cognitive deficits

34. Coping with TBI Lots of rest – adequate time to forgo daily activities such as school or work • Avoiding secondary injuries • Getting medical advice on when it’s safe to drive a car, ride a bike, or use heavy equipment • Avoiding drugs and alcohol except for prescribed medications. • Writing things down as a memory prompt. • Getting help to re-learn lost skills

35. TBI Challenges • It is increasingly well documented that individuals with a TBI can face life-changing consequences including social failure • Children with undiagnosed or misdiagnosed TBI often “act out” their frustrations with learning; or they withdraw from trying and eventually drop out of school

36. TBI Challenges Cont. • Associated problems include alcohol and other substance abuse; • Lack of social inhibition; impulsivity; • Depression, which requires special treatment for the brain-injured • Juvenile delinquency leading to incarceration—current studies reveal rates of TBI among incarcerated adults to range from 42 to 87%* *Brewer Smyth, et al., 2004; M. Sarapata, et al.,

37. Substance Abuse and TBI • Functional deficits post-TBI can lead to a number of self-destructive behaviors, including substance abuse • While substance abuse is a risk factor for TBI, the cognitive, behavioral and emotional difficulties of having a TBI often leads to substance abuse. • From 9-37% of individuals with TBI are involved in drug abuse, not including alcohol (Corrigan, J.D., 1995

38. Consequences • Alcohol abuse is associated with risk factors leading to TBI: falls, collisions, etc. • The prevalence of depression post-TBI is as high as 77% (Malec, 2007) and treatment for this is complicated by both TBI and substance abuse • Post-TBI alcohol use is assoc. with >risk for repeat TBI; >unemployment, and > neurobehavioral problems

39. Other Issues • The risks of a decrease in earnings, unemployment and homelessness all increase for individuals with a TBI • Studies of incarcerated populations show prevalence rates of TBI from 25-85% compared to 8.5% in gen’l population (CDC) • Australian study found 82% inmates had at least one pre-prison TBI, 65% with LOC • Female inmates convicted of violent crimes are more likely to have a pre-crime TBI and/or other physical abuse

40. Shaken Baby Syndrome • Has a peak incidence at age 2 months, subsiding at 6-7 months of age. • Associated with prolonged infant crying; feelings of helplessness and anger from the parent or care giver • 20-30% of shaken babies die; as many as 80% will have lifelong disabilities • Awareness and emotional support of parents are critical to prevention

41. Burden of illness Although TBI affects more people in the U.S. each year than HIV-AIDS & Breast Cancer combined, much less federal money is spent on TBI than either of these illnesses.

42. So What are We Doing? • Centers for Disease Control and Prevention: surveillance; prevention • National Institutes of Health: ongoing funding for research on TBI and its co-morbidities; • National Institute on Disability and Rehabilitation Research : Model Systems Grants to assess rehabilitation Strategies

43. Health Resources and Services Administration (HRSA) • HRSA is charged with implementing a State Grants Program to improve access to health and other services for individuals with TBI and their families. • The Federal TBI program is housed in the Maternal and Child Health Bureau, Division of Services for Children with Special Health Care Needs • Vision of Federal TBI Program is for: All individuals with TBI and their families will have accessible, available, acceptable and appropriate services and supports.

44. Federal TBI Program • Grants to States to put in place “seamless” systems of care for individuals with TBI and their families—from acute hospital care through rehabilitation to employment, transportation, housing, and social and mental health services (aka Implementation Partnership Grants (IPG) ) • Grants to Protection and Advocacy Organizations to protect the rights of individuals with TBI (aka P&A)

45. P&A Activities Information and Referral Services Training in self-advocacy Information Disseminated to the Public Help to children and schools Assists those unfairly institutionalized Assists those in corrections system Litigation 45

46. State Activities Services Coordination aka “Resource Facilitation or Case Management” Services and Supports to individuals and families Public Awareness and Training Establishing Trust Funds Producing education materials Outreach to high risk populations (Veterans, minorities, children & youth, correctional system, etc) Screening in schools 46

47. Public Awareness/Training Highlights Maryland Department of Health & Mental Hygiene- Training counselors & employment specialists Oklahoma Department of Health- curriculum for vocational rehabilitation professionals Colorado Department of Human Services- monthly brain injury survivor series, Tele-trainings, National Brain Injury Employment Conference, outreach to Veteran & Latino circle Groups P & A grantees advocating for reasonable accommodations in employment & educational settings for persons with TBI Many grantees are providing training to athletic coaches, school nurses, and law enforcement on recognizing TBI 47

48. Resource Facilitation Highlights Alabama Department of Rehabilitation Services The Interactive Community Based Model (ICBM) of Services for Individuals with Traumatic Brain Injury The ICBM was designed to address the existing gap in services needed by people with TBI and their families in the post-acute recovery period and transition to the community. The ICBM is an interactive, criterion-based model of community reentry designed to address independence, community integration and pre-employment readiness. Program flexibility is a hallmark of the ICBM. The care coordinator is the mechanism for implementation of the ICBM. 48

49. Results of ICBM The ICBM has helped Alabamians with traumatic brain injury access community resources and enhance their opportunities to live and work in the community. The ICBM has reduced the cost of post-acute care services for survivors of TBI. Case management provided by care coordinators in the form of direct intervention and service coordination is the most frequently providedservice. 49

50. TBI Resources • Service Coordination in states/territories • Protection & Advocacy • Resource Products-include • Training material for providers • Screening tools • Care giver manual • Videos (training, family resource)