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Traumatic Brain Injury (TBI) in the Military - Cognitive Rehabilitation

Traumatic Brain Injury (TBI) in the Military - Cognitive Rehabilitation. The views expressed in this presentation are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government. Cognitive Rehabilitation.

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Traumatic Brain Injury (TBI) in the Military - Cognitive Rehabilitation

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  1. Traumatic Brain Injury (TBI) in the Military - Cognitive Rehabilitation The views expressed in this presentation are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  2. Cognitive Rehabilitation Other terms for Cognitive Rehabilitation Speech Pathology Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and Defense and Veterans Brain Injury Center consensus conference • Neurorehabilitation • Neuropsychological rehabilitation • Cognitive remediation • Cognitive retraining

  3. Cog Rehab Goal To provide guidance regarding cognitive rehabilitation of chronic post-concussive symptoms in service members and veterans receiving treatment within military medical settings VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  4. Recommendation If SM has three months or more post concussive injury and persistent cognitive symptoms 1. Assessment 2. Interventions 3. Outcome measures 4. Program implementation. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009. http://www.dcoe.health.mil/ForHealthPros/Resources.aspx

  5. Assessment: Part 1 – Initial Evaluation Purpose To determine if the individual has a history of mild traumatic brain injury (mTBI) (also known as concussion) with persistent cognitive symptoms or signs of cognitive impairment and to determine if any co-morbidities exist that may affect cognitive function VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  6. Initial Evaluation • Performed by a TBI-experienced provider. • Referral can be made by any provider. • Reasons for referral: cognitive symptoms observed by the provider or reported by the patient, family, or leadership. • SM displays evidence of cognitive dysfunction in daily social or occupational functioning. • Any suspicion of mild TBI with persistent cognitive symptoms warrants further cognitive evaluation VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  7. Assessment: Part 2 – Comprehensive Cognitive Evaluation Purpose To determine: • Primary factor(s) contributing to symptom 2) Cognitive deficits 3) Need for cognitive rehabilitation 4) Type of rehabilitation needed 5) Short- and Long-term goals. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  8. Comprehensive Cognitive Evaluation • Performed by an interdisciplinary team: neuropsychologist, occupational therapist, speech-language pathologist. • Includes a comprehensive neurological evaluation performed by a neurologist or physician • Includes a review of the medical records, education level, GT score, etc. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  9. Intervention • Based on a holistic approach and include individual as well as group therapies • Target attention, memory, executive functioning and social pragmatics VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  10. Outcome Measures To advance the published science • Administrative performance metrics • Pre- and post-assessment differences • Pre- and post-functional differences • Moderating variables • Discharge criteria • Consumer satisfaction • Aggregate program outcome data VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  11. Program Implementation • Assessment prior to treatment • Identification of individualized cognitive rehabilitation goals that target symptom reduction through restoration and compensation functional improvements/gains, and a therapeutic alliance • Development of an interdisciplinary individualized treatment plan • Periodic cognitive reassessment and review of goals • Development of a well defined discharge plan VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  12. Potential Team Members Audiologist Case manager Neurologist Neuropsychologist Occupational therapist Ophthalmologist Physical therapist Primary Care Manager Psychiatrist Speech-Language Pathologist Cognitive Rehabilitation for Military Personnel with Mild Traumatic Brain Injury and Chronic Post-Concussional Disorder: Results of April 2009 Consensus Conference. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  13. Comorbidity of Symptoms PTSD or Acute Stress Reaction Mild TBI or Post Concussive Syndrome Stress symptoms Emotional numbing Avoidance Intrusive symptoms Insomnia Impaired Memory Poor concentration Depression Anxiety Irritability Headache Dizziness Fatigue Noise/Light intolerance VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009. Post-Traumatic Stress Disorder and TBI in Returning Service Members & Veterans, Collins, 2009.

  14. Cognitive Symptoms VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  15. Memory Key Elements of Functional Memory for Those with Brain Injury: Linking Neuroscience to Clinical Practice, Burns, 2010. Key Elements of Functional Memory for Those with Brain Injury: Linking Neuroscience to Clinical Practice, Burns, 2010.

  16. Executive Functions Intervention for Executive Functions after Traumatic Brain Injury: A Systematic Review, Meta-Analysis and Clinical Recommendations, Kennedy et al, 2008. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  17. Attention Evaluation of Attention Process Training and Brain Injury Education in Persons with Acquired Brain Injury, Sohlberg et al, 2000. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  18. Speed of Processing Archives of Clinical Neuropsychology, Tombaugh et al, 2007. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  19. Communication VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009. Evidence-Based Cognitive Rehabilitation: Recommendations for Clinical Practice, Cicerone et al, 2000.

  20. Memory Aids External Aids Internal Aids Repetition Creating rhymes Making associations First-letter cues Chunking Mnemonics Visualization Categorization Active observation • Alarms • Timers • Notebooks • Datebooks • Calendars • Answering machines • Electronic organizers • Tape recorders • Watches with beepers • Medication dispensers • Highlighters • Journals • Computers Evidence-Based Practice for the Use of External Aids as a Memory Compensation Technique, Sohlberg et al, 2007. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  21. mTBI Cognitive-Communication Group • Offer support through group discussion, counseling, and therapeutic activities designed to maximize compensatory and facilitative strategies. • Invite guest speakers on topics of interest (e.g., sleep, nutrition, executive functions, meditation/relaxation, coping strategies, transition to school/work, community resources) and involve interdisciplinary care. • Group activities: focus on memory, critical thinking, problem solving, attention, organization, planning community outings. • Members include SB TBI group via VTC – offer peer support. • Provides supportive context and unit cohesion in the military culture. Cognitive Rehabilitation for Military Personnel with Mild Traumatic Brain Injury and Chronic Post-Concussional Disorder: Results of April 2009 Consensus Conference, Helmick et al, 2010. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  22. mTBI Cognitive-Communication Group VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  23. mTBI Cognitive-Communication Group VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

  24. TBI Resources • Brainline (DVBIC-sponsored): www.brainline.org • Brain Injury Association of America: www.biausa.org • Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury: www.dcoe.health.mil • Defense and Veterans Brain Injury Center: www.dvbic.org • CDC’s National Center for Injury Prevention and Control: www.cdc.gov/ncipc/tbi/TBI.htm • National Institute of Neurological Disorders and Stroke (NINDS) Traumatic Brain Injury Information Page: www.ninds.nih.gov/disorders/tbi/tbi.htm • Traumatic Brain Injury National Resource Center: www.nrc.pmr.vcu.edu VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

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