Patricia S. Benfield , MHDL, CRT, CBIS-CI, CCAA North Carolina Biofeedback Society’s

1. Mild Traumatic Brain Injury (mTBI)– A Silent Epidemic – Applications for Clinical Practice Patricia S. Benfield, MHDL, CRT, CBIS-CI, CCAA North Carolina Biofeedback Society’s 2012 Conference Greensboro, NC November 2-4, 2012

2. Outline • Brain development • Overview of TBI-definitions & epidemiology • Mechanics of brain trauma • Review study results • Implications for treatment • Better assessments & making referrals

3. Traumatic brain injury is the most misunderstood, misdiagnosed, underfunded public health problem our nation faces.” Susan Connors, President Brain Injury Association of America

4. With more than 100 billion neurons and billions of other specialized cells, the human brain is a marvel of nature. It is the organ that makes people unique.

5. Brain Development

6. Brain Development

7. Neuronal Networks • Neurons • form networks • Networks • hold data • redesign often • some are “carved in stone” • some are fleeting and weak

8. Synapse “Grand Central Communication” • Allows a neuron to pass electric or chemical signal • Pre-synaptic neuron releases a neurotransmitter to bind to receptor neuron. • The signal is passed • Neurotransmitter is uptaken

9. Glial Cells

10. Glial Cells A glial cell (green) grows among network of cortical neurons (in red). Studies using these cultured cells have led to discoveries on how growth factors can prevent neuronal death.

11. Glial Cells – Structural Support

12. Glial Cells – Brain’s Supervisors

13. Pax6 - Master Regulator of Brain Development

14. Neurogenesis & Pruning

15. Making Connections

16. Making Connections

17. Making Connections

18. Making Connections

19. MacLean’s Model-Triune Brain Reptilian-------survival Limbic--------emotions Neo-Cortex---thinking

20. Triune Brain-Reptilian • Oldest part • Survival or “Fight or Flight” • Acts without thinking • Threats, real or perceived, causes “downshifting to occur

21. Triune Brain-Limbic • Home of emotions • Has visual memory • Threat to our well-being will cause “downshifting” • Long-term memory

22. Triune Brain-Limbic System Hypothalmus controls ANS Cingulate Gyrus is conduit of messages Amygdala makes associations across stimulus modalities Hippocampus transitions information from short to long term memory Basal Ganglia plans & coordinates motor movements & posture

23. Triune Brain-Cortex • Thinking & new learning • Processes 1,000s of bits of information/minute • Must be free from threat for new learning or will downshift into its more primitive parts

24. Maslow’s Needs Basic needs must be met in order to reach the highest order of development

25. Brain Injury

26. Causes of BI

27. Risk by Age and Gender

28. Occurrence of Brain Injury • 1.7 million treated & released* • 75% of those are mTBI • 235,000 hospitalized • 50,000 die • 80,000 experience long-term effects • 5.3 million Americans (2% of population) live with a disability *most current update from CDC Image from www.biausa.org

29. Brain Injury Congenital brain injury Pre-birth During birth Acquired Brain Injury After birth process Traumatic Brain Injury (external physical force) Non-traumatic Brain Injury Closed Head Injury Open Head Injury Savage, 1991

30. Acquired Brain Injury (ABI) …is an injury to the brain that has occurred after birth and is not related to congenital defect or degenerative disease. Causes of ABI include (but are not limited to) hypoxia, illness, infection, stroke, substance abuse, toxic exposure, trauma, and tumor. …may cause temporary or permanent impairment in such areas as cognitive, emotional, metabolic, motor, perceptual motor and/or sensory brain function.  The Brain Injury Network

31. What is TBI? As of February 6, 2011, BIAA adopts a new definition TBI is defined as an alteration in brain function, or other evidence of brain pathology, caused by an external force.

32. 2 Types of TBI Two major types: • Penetrating brain injuries • Closed head injuries

33. Type of TBI-Penetrating • Foreign object enters brain (e.g. bullet) • Damage occurs along path of injury • Symptoms vary according to part of brain that is damaged

34. Penetrating Wounds 41 yr old man Attacked from behind Full recovery after removal No infection Left hospital 1 week after removal Epileptic medication and some memory problems • 33 year old man • 12 nails in head/brain from nail gun • Nails were not visible on initial exam • X-rays revealed the nails • Survived and released to psychiatry.

35. Type of TBI-Closed Head Injury • Results from blow to the head (e.g. car accident or assault) • Causes two type of brain injuries: • Primary • Secondary

36. 2 Types of Closed Head Injury • Primary • Direct trauma to brain and vascular structures • Examples: contusions, hemorrhages, and other direct mechanical injury to brain contents (brain, CSF, blood). • Secondary • Ongoing pathophysiologic processes continue to injure brain for weeks after TBI • Primary focus in TBI management is to identify and limit or stop secondary injury mechanisms

37. Primary Closed Head Injury • Skull fracture: breaking of the bony skull • Contusions/bruises: often occur right under the location of impact or at points where the force of the blow has driven the brain against the bony ridges inside the skull • Hematomas/blood clots: occur between the skull and the brain or inside the brain itself • Lacerations: Tearing of the frontal (front) and temporal (on the side) lobes or blood vessels of the brain ---(the force of the blow causes the brain to rotate across the hard ridges of the skull, causing the tears) • Nerve damage (diffuse axonal injury): Arises from a cutting, or shearing, force from the blow that damages nerve cells in the brain's connecting nerve fibers (www.asha.org)

38. Primary Closed Head Injury Coup Contrecoup Rotational forces

39. Secondary Closed Head Injury Evolves over time (after trauma has occurred) • brain swelling (edema) • increased pressure inside of the skull (intracranial pressure) • epilepsy • intracranial infection • fever • hematoma (for more info visit: www.asha.org)

40. TBI – Signature Injury of War • Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) • Most service related TBI caused by blast injuries • 66% of service personnel in Iraq are exposed to or injured by a blast injury

41. Blast Wound Mechanics - Primary • Primary Blast Injury An explosion generates a blast wave traveling faster than sound and creating a surge of high pressure immediately followed by a vacuum. Studies show that the blast wave shoots through armor and soldiers' skulls and brains, even if it doesn't draw blood. While the exact mechanisms by which it damages the brain's cells and circuits are still being studied, the blast wave's pressure has been shown to compress the torso, impacting blood vessels, which then send damaging energy pulses into the brain.

42. Blast Wound Mechanics- Secondary • Secondary Blast Injury Shrapnel and debris propelled by the blast can strike a soldier's head, causing either a closed-head injury through blunt force or a penetrating head injury that damages brain tissue.

43. Blast Wound Mechanics-Tertiary • Tertiary Blast Injury Results from individuals being thrown by the blast wind. Any body part may be affected. Causing • fracture and traumatic amputation • Closed and open brain injury

44. Blast Wound Mechanics-Quarternary • Quarternary Blast Injury All explosion-related injuries, illnesses, or diseases not due to primary, secondary, or tertiary mechanisms. Includes exacerbation or complications of existing conditions. Any body part may be affected. Includes • Burns (flash, partial, and full thickness) • Crush injuries • Closed and open brain injury • Asthma, COPD, or other breathing problems from dust, smoke, or toxic fumes • Angina • Hyperglycemia, hypertension

45. Review of Explosive-Related Injuries • AUDITORY: TM rupture, ossicular disruption, cochlear damage, foreign body • EYE, ORBIT, FACE: Perforated globe, foreign body, air embolism, fractures • RESPIRATORY: Blast lung, hemothorax, pneumothorax, pulmonary contusion and hemorrhage, A-V fistulas (source of air embolism), airway epithelial damage, aspiration pneumonitis, sepsis • DIGESTIVE: Bowel perforation, hemorrhage, ruptured liver or spleen, sepsis, mesenteric ischemia from air embolism • CIRCULATORY: Cardiac contusion, myocardial infarction from air embolism, shock, vasovagal hypotension, peripheral vascular injury, air embolism-induced injury • CNS INJURY: Concussion, closed and open brain injury, stroke, spinal cord injury, air embolism-induced injury • RENAL INJURY: Renal contusion, laceration, acute renal failure due to rhabdomyolysis, hypotension, and hypovolemia • CIRCULATORY: Traumatic amputation, fractures, crush injuries, compartment syndrome, burns, cuts, lacerations, acute arterial occlusion, air embolism-induced injury

46. Statistics on Service Related Injuries • 40% of service personnel returning from OIF & OEF show signs & symptoms of TBI due to a blast injury • The large majority (80%) of combat head injuries sustained in Operation Iraqi Freedom and Operation Enduring Freedom are mild concussions as opposed to severe, debilitating TBI. National Institute of Neurological Disorders and Stroke. (http://www.americasheroesatwork.gov)

47. More on Occurrences of BI • Traumatic brain injuries are among the top injuries of soldiers serving in Iraq and Afghanistan, with military estimates of over 200,000 affected soldiers. Most of these injuries result in concussions, but repeated injuries can result in permanent neurological problems. • While a concussion means that the brain swells and heals, those unseen breaks in the fiber pathways can cause problems later in life. Current diagnostic equipment only permits doctors to see swelling or bleeding.

48. Mild Traumatic Brain Injury (mTBI) …defined as a loss or alteration of consciousness <30 minutes, post-traumatic amnesia < 24 hours, focal neurologic deficits that may or may not be transient, and/or Glasgow Coma Score (GCS) of 13-15. …by definition, typically involves symptoms of brain damage but no sign of damage based on a neurological exam Controversy over whether primary blast injuries damage the brain. Animal models suggest they do.

49. Mild TBI • In most cases of mTBI, the patient returns to their previous level of function within 3-6 months. • 15% of patients may go on to develop chronic post-concussive symptoms.

50. Chronic Post Concussive Symptoms These symptoms can be grouped into 3 categories • Somatic (headache, tinnitus, vertigo, insomnia, etc.) • Cognitive (memory, attention/concentration difficulties, etc. ) • Emotional/behavioral (irritability, depression, anxiety, behavioral dyscontrol)