Mild Traumatic Brain Injury 9 th Annual Fall Nursing Symposium-9/17/2008

1. Mild Traumatic Brain Injury9th Annual Fall Nursing Symposium-9/17/2008 Robert G. Kohn D.O. Neurology, Psychiatry, Neuropsychiatry 815 344 7951 www.drrobertkohn.com

2. Goals • 1. Familiarize the audience with the scope of mTBI • 2. Explain relevant brain anatomy and function impacted by TBI • 3. Provide a guideline for initial evaluation and ongoing treatment with practical resourses available in the community

3. Overview • Part I-Mild TBI, Epidemiology, Brain anatomy and function • Part II- Evaluation Process of TBI • Part III- Approach to Treatment; An Integrated Bio-Psycho-Social Model

4. SPECT normal vs TBI • Traumatic Brain Injury • Normal 3-D Surface Image

5. Traumatic Brain Injury- TBI • …with or without skull fracture is an insult to the brain caused by external physical force that may produce a diminished or altered state of consciousness. • Acquired Brain injury- not hereditary or present at birth or degenerative condition that may be due to a stroke, toxic ( alcohol, cocaine, etc ), anoxic-hypoxic ( cardiac, sepsis, metabolic, etc ). • www.biail.org fact sheet page 1

6. Mild TBI • A concussion or event that may leave a person dazed or cause a brief loss of consciousness • Any period of LOC of < 30 minutes and a GCS of 13-15 • Any loss of memory for events immediately before or after an accident with PTA <24 hours • Any alteration in mental state ( dazed, confused, disoriented ) at the time of the accident • Focal neurological deficits that may or may not be transient

7. Post Concussion Syndrome • May follow from the injury that includes a spectrum of deficits • Headache • Dizziness • Dysequilibrium • Mild mental slowing • Fatigue

8. Epidemiology of TBIPrevalence in total US Population1 1.4 million people sustain a TBI each year Distribution of Average incidence of hospitalizations, emergency department visits, and deaths between 1995-2001 As a cumulative result of TBI, an estimated 5.3 million Americans are living with a permanent disability

9. TBI Incidence by Severity in U.S. Population15 Mild TBI- 131 cases/100,000 people (397,700) Moderate TBI- 15 cases/100,000 people (45,540) Severe TBI- 14 cases/100,000 people (42,500) Mortality rates: severe TBI 33% moderate TBI 2.5% 9% 9% 82%

10. Incidence by External Cause in total US Population1

11. Some Statistics about brain injury • 1.5 million Americans sustain TBI annually • 80,000 Americans experience LTDisability • 5.3 million Americans-2% pop have TBI LTD • MVA cause 44%, Falls 26%,Assualts and Firearms 17%, sports and recreation13% • 50,000 children TBI from bicycle • 200,000 children hospitalized and 30,000 are permanent TBI injuries

12. U.S. Military Incidence and Prevalence (OEF/OIF) Head/neck injuries: 15-20% of all battle injuries2,3 Up to 28% of all war fighters4 Defense and Veterans Brain Injury Center (DVBIC) at Walter Reed Army Medical Center among OIF/OEF veterans5- 30% had traumatic brain injury (greater percentage meeting TBI criteria when injury was blast related) 56% have moderate to severe TBI 44% have mild TBI (MTBI) 10–20% of combat veterans meet the criteria for MTBI on post-deployment screening 44% 56%

13. How does TBI happen- mechanism

14. Bicycle fall head injury

15. Helmet Protection Bicycle

16. TBI proposed mechanisms • Shearing forces from rapid acceleration-deceleration disrupt molecular bonds that hold white matter fibers together • Decrease in rCBF • Decrease in Glucose availability to neurons • Cytotoxicity from Glutamate release • Thalamus injury alters pacemaker generation fails to gate cortical-subcortical firing patterns

17. White matter disruption-axonal shearing & Thalamus injury

18. Brain Anatomy and Function-Lobes-F,P,T,O,Cb

19. Cortex lobes and function • Frontal lobe-central executive, emotional executive; planning, decision making, time management, organziation, motivation,drive and reward systems for behavior, taste, smell • Temporal lobe-”what systems” for attention and language, brain dictionary, “memory” for declarative and emotional records-hippocampus and amygdala

20. Cortex lobes-function • Parietal lobe-sensory-motor cortex for visual-spatial processing, “ where” attention system and “ How “ systems for motor planning- praxis and language • Occipital lobe- primary, secondary and tertiary visual processing- faces, color, shapes, movement, etc

21. Cortex, Subcortex and brainstem • Cerebellum- balance and coordination of trunk, limbs, eye movements,” time keeper” for data sequencing- cognitive dysmetria. • Basal Ganglia • Cingulate lobe • Insula • Thalamus • Brainstem- origination of NE, 5HT,DA projection pathways, sleep circuits, etc

22. Brain Stem Spinal Cord Brain regions

23. Limbic System properties • Mental content; linking mental content to autonomic, hormonal, immunological states; coordination of affiliative behaviors related to social cohesion • Channeling emotion; drives to extrapersonal events • Includes perception of taste, smell, taste

24. Cortex Thalamus Striatum Cortical-Subcortical Loops:Thalamo-Cortical-Striatal Anatomy

25. Japanese Cherry Blossoms

26. Evaluation Process of TBI • Patient Narrative- observe, listen and ensure an open minded, patient centered space for each person to report their story • Obtain Pre and Post Injury report of functionality from patient and family, partner, children, etc • Broad framework of observation from patient report of symptoms to systems involved.

27. Assist information gathering • Provide rating forms for patient and family before patient is seen • Include • TBI patient and care giver rating form • MINI- NIMH form assessment screen for Depression, Panic, Anxiety and Substance abuse • Consider PTSD and substance screening forms

28. Collaborative History • Obtain records from other professionals if available; ie hospital emergency room • Legal status; ie litigation pending or implemented • If child or young adult get school report cards • Assure time to obtain collaborative history from significant others in patient’s life

29. 5 Regions of Impairment to evaluate-SCABS • Sleep- fatigue, insomnia, restfullness, emergent OSA • Cognition-short term memory, attention states, processing speed, mental stamina, distractability, focus • Affective-observed mood changes, vegetative symptoms of depression, anxiety, fears, anger,suicidality • Behavior-disinhibition leading to property or physical destruction, aggression, agitation, safety status • Somatic-pain symptoms, headache, dizziness, balance difficulties,etc

30. Office Evaluation • MSE -include digit span, WLG, categorical naming, read, writing, math, drawing,etc • Physical attention to pain • Neurologicalattention to general versus focal deficits; test for smell and taste, balance and coordination, weakness and power, vision and pupil reaction, deep tendon reflexes, sensory gradients with vibration, position, graphesthesia,etc • Attention testing; CPT- IVA, Quotient tests against ADHD data set, personality w NEO5 factor inventory- CANOE

31. Additional Testing • EEG- awake and asleep study for post traumatic epilepsy • QEEG- spectral analysis of brain wave frequency distribution; localized slowing, etc • SPECT-nuclear medicine test for regional or focal hypoperfusion • 3T MRI- done at centers using higher resolution than 1.5 T evalute white matter tracts and cortex • fMRI- functional testing; ie language based protocol evaluate networks activated or delayed; www.cmrr.uic.edu • Event Related Potentials-EEG based pattern of visual, auditory or cognitive processing

33. QEEG Temporal lobe slowing +3sd

34. Visual relaxation

35. Autumn

36. Winter

37. Summer Imagination

38. Approach to Treatment- An Integrated Model • Define the Problem-Biological, Psychological, Social Perspectives • Patient focus- fears? Loss? Anger? Transient. • System view- family acknowledgement or disbelief?, partner intimacy loss?, employment risk or continuity? • Search for Meaning the event holds • Legal issues to recover costs or seek financial gain • Religious beliefs to sustain recovery • Hidden expectations from parents, siblings, family, partner • Temperment profile and capacity to process injury

39. Time Framework • Initial evaluation- • prepare patient before hand for paperwork, records, define initial expectations. Arrive earlier to complete. • Access willingness and resources; what is the capacity of the patient to particpate? Are injury deficits limiting information flow or emotional capacity? • Provide written list of the next steps in the evaluation; where to go, testing orders, contacts. • Provide timely follow up to assure compliance and answer questions from the patient. Do this before the next visit or reschedule follow up.

40. Treatment Plan • Build a treatment team • Family, care giver role reversals • Case management • Referral resources for cognitive evaluation and rehabilitation ( neuropsychology ), for individual and marital therapy, for physical therapy • Medications, Alternative Therapies • Osteopathic, Chiropractic, Accupuncure, Nutritional

41. Treatment Plan • Target specific measureable results: • Overview of SCABS • Sleep- consider sleep study or risk of etoh or sedative-hypnotic rx from other source for self medication • Cognition- consider Neuropsychology evaluation, Cognitive rehabilitation, Medication, • Affect- consider medication, individual therapy or marital therapy referral. • Behavior- discuss risks and benefit of medications • Somatic- discuss importance of pain specialist and risk of narcotic diversion-dependence to self medicate mood

42. Medications • Medication can improve: • Attention- stimulants used for ADHD tx such as ritalin, Concerta, Focalin, Adderall, etc • Working memory-Amantadine, Aricept, Exelon ( patch ), Reminyl • Mood stability- Depakote, other AED’s • Self control-impulsivity-atypical antipsychotics such as Abilify, Seroquel, Risperidal,etc • Pain

43. Non medication treatment • EEG Neurofeedback- brain wave reinforcement programs • Osteopathic and Chiropractic- help muscloskeletal components of pain and redirect somatic forces of imbalance • Massage- help soft tissue injuries • Accupuncture- help pain • Physical Therapy- help pain, confidence

44. Time is fleeting

45. Summary • MTBI has many faces of impairment • The evaluation process requires a broad framework of knowledge and resource allocation • Significant recovery is the RULE not the Exception but the time frame and expectations vary • An ounce of Prevention is worth a pound of cure….

46. Thank you.