Treatment of Mild Traumatic Brain Injury using an Interdisciplinary Approach

1. Treatment of Mild Traumatic Brain Injury using an Interdisciplinary Approach Presented by: • Helen Mathison MA, CCC-SLP • Nova McNally OTR/L • Danielle Potokar PhD, LP • Sarah Rockswold M.D. • James Thomson PhD, LP

2. Traumatic Brain Injury: Magnitude of Problem • Occurs every 15 seconds in the U.S. • Death occurs every 5 minutes • Permanent disability occurs every 5 minutes

3. Traumatic Brain Injury: Magnitude of Problem • 1.7 million brain injuries per year • 1.0 million emergency department visits • 500,000 hospitalizations • 50,000 deaths • Direct & indirect costs of $60 billion

4. TBI Statistics • Major issue is premature death and disability • TBI is a disease of the young • 84% of the 1.7 million TBIs are sustained by people age 64 or less • Prevalence of long term disability due to TBI in the U.S. is over 3 million people

5. TBI: Definition • A traumatically induced physiological disruption of brain function manifested by: • Loss of consciousness • Amnesia – retrograde and/or anterograde • Confusion • Delayed verbal or motor responses

6. TBI: Mechanism • The head being struck • The head striking an object • The brain undergoing an acceleration-deceleration movement without direct trauma to the head

7. Mild Brain Injury • GCS score = 14 to 15 • Post-traumatic amnesia < 24h • Mild brain injury = negative CT scan • Mild complicated brain injury = positive CT scan

8. Epidemiology • Mild TBI constitute vast majority of brain injuries within the U.S. • Incidence of 1.2 million cases of mild TBI in the United States yearly • Account for 290,000 hospital admissions per year

9. Concussion Concussion = mild or moderate traumatic brain injury

10. Pathophysiology • May be metabolic rather than structural in nature • Traditional neurodiagnostic techniques not sensitive • PET scan, fMRI, Diffuse Tensor Imaging

11. Metabolic brain dysfunction following traumatic brain injury GCS 15 GCS 5 GCS 15 Bergsneider, Hovda, et.al. J Neurotrauma 2000

12. Why is follow-up important? • Symptoms will resolve within 2 weeks in 85% of patients with mild TBI • If the symptoms do not resolve, a chronic post concussive syndrome can develop which can cause significant occupational, social, and personal problems

13. Why is follow-up important? • Prevention of multiple TBIs is vital • Repetitive mild TBI results in more persistent cognitive impairments and physical symptoms • Ongoing symptoms need to be recognized more readily

14. Postconcussion Syndrome • Cognitive • Attention and concentration difficulties, memory impairment, efficiency • Affective • Irritability, depression, anxiety • Somatic • Headache, dizziness, insomnia, fatigue, sensory disturbances

15. Evaluation • History is key • What are the problems? • Cognition • Headache • Musculoskeletal complaints • Dizziness • Sleep • Psychosocial

16. Evaluation • History • What is their occupation? • What are their hobbies? • What is their living situation? • Physical Exam • Cognitive screen • Balance and coordination

17. Management • Interdisciplinary approach is key! • All physical, cognitive, and emotional disturbances must be identified and addressed for good recovery

18. Management • Based on history, social situation, and physical examination • Neuropsychological testing • SLP, PT, OT • Clinical Psychology • Therapeutic Recreation • Vestibular clinic • Medications

19. Management • Rest of absolute nature • Symptoms aggravated by exertion, both physical and cognitive • Time away from school or work • Discontinue fitness activities, aerobic activities and exertional activities of daily living

20. Management • As symptoms improve with treatment, patients can slowly be returned to their activities, i.e. school, work, sports

21. Conclusion • Mild/moderate TBI patients’ needs have traditionally been underserved • “Since CT scan normal, patient must be normal” • On the contrary, mild TBI is a challenging diagnosis • Individualized management utilizing an interdisciplinary team is essential

22. Case Report #1 • 19 y/o male who fell after syncope • + LOC • Seen at outside hospital in Denver • CT of brain: (-) • GCS score not recorded

23. Case Report #1 • PmHx: 6 previous TBIs, ADHD, Bipolar disorder, dyslexia, htn • Meds: Trazadone, metroprolol • Social Hx: Sophomore at U of Denver • Sent home from ED with primary care follow-up

24. Case Report #2 • 29 y/o male who fell 25 feet at work • - LOC • Admitted to HCMC • CT of brain: (cerebral contusionn, frontal sinus fracture) • GCS score 15 at admission

25. Case Report #2 • PmHx: mild TBI as infant • Meds: none • Social Hx: welder, workmans comp case • Seen in outpatient TBI clinic approx 1 month after hospital discharge

26. Neuropsychological Evaluation • Chart Review • Interview • Testing • Feedback • Education • Diagnosis • Recommendations

27. Chart Review • Medical History • Academic Reports • Psychology/Psychiatry Reports • Neuropsychology Evaluations • Legal Reports

28. Diagnostic Interview • Current Information • Symptom Review • Concurrent Issues • Current Activities • Coping Strategies • Goals and Plans

29. Diagnostic Interview • Social History • Childhood • Academic Achievement • Occupational History • Leisure Activities

30. Neuropsychological Testing • Cognitive Domains • Perception • Memory • Learning • Reasoning • Executive Abilities • Language • Achievement • Motor Coordination

31. Neuropsychological Testing • Behavior Observations • Affect • Appearance • Motivation • Rapport • Engagement • Attention • Organization • Frustration Tolerance • Personality

32. Feedback and Clarification • Review Results • Answer Questions • Clarify Diagnostic Issues

33. Education • Brain Structure and Function • Review of CT and MRI Data • Shearing Effects • Implications of Symptoms and Results • Natural History of TBI • Expectations for Recovery

34. Diagnosis • Extent of Brain Injury • Rate of Recovery • Prospects • Problems • Re-diagnosis • Co-diagnosis • No diagnosis • Malingering

35. Recommendations • Cognitive Rehabilitation (SLP/OT) • PT • Psychotherapy • Psychiatry • Feedback to MD or MDs

36. Recommendations • Driving • Work • School • Change in Supervision • Return to Normal Life

37. Follow-up • Continued Involvement with Team • Return for Re-evaluation • Return for Education • Later Contacts • New Problems • Re-entry to Hospital • Seeking Community Contacts • Support and Reassurance

38. Case Report • Neuropsychological Results

39. Occupational TherapyOur Role within the TBI clinic Assess: functional visual processing -ability to participate in daily activities including work, school, driving, and home management

40. Occupational Therapy and Visual Processing • Changes in visual processing are a common complaint after a head injury. • 20/20 vision does not equal good visual processing. • OT will perform a specialized visual processing screen to look for deficits. • A comprehensive eye examination, performed by a neuro-ophthalmologist, is needed to properly diagnose these deficits.

41. Common Complaints • Headaches • Double vision +/or blurry vision • Vertigo/dizziness • Nausea • Inability to focus (visual attention which will impact concentration)

42. Common Complaints • Movement of print when reading • Difficulty visually tracking • Photophobia • Visual overstimulation (feeling overwhelmed in a busy environment like a grocery store or riding in a car.)

43. How These Symptoms Can Impact Every Day Life • Blurred vision when looking from near to far or far to near as needed for driving or taking notes in class • Headaches, eye strain, pulling sensation around the eyes • Reading problems, movement of the print while reading, skipping lines or re-reading lines

44. Functional Impact continued • Avoidance of reading and other close work • Fatigue and sleepiness • Loss of comprehension over time, decreased short term memory, no retention of new information • Difficulty with ADL’s that require sustained close work/attention

45. Occupational Therapy Intervention • Treatment will focus on retraining the visual processing system with specially designed exercises and activities. • Symptom and energy management • Client and family education • Teaching compensatory strategies as needed • Pre-drive screen • Assist with the transition back to work or school • Monitor return to exercise/physical activity

46. Challenges of OT Treatment • Client awareness and insight into their deficits • Compliance with home exercises and energy management strategies • Under reporting of symptoms » Direct communication with the interdisciplinary team for quality continuum of care.

47. Speech Pathology’s Role • Assessment of Cognitive-Linguistic Abilities • Intervention • Direct Treatment • Awareness Training • Compensation Training • Adjustment to Cognitive Changes • Return to Work / School

48. Speech Pathology Assessment • In depth interview • Diagnostic interview • Post concussive symptom questionnaire • Formal cognitive-linguistic assessment • Observe behaviors & symptoms • Observe strategy use • Informal evaluation of multi-processing abilities

49. Challenges of SLP Assessment • Most formalized tests are often not sensitive enough with mTBI • Informal evaluation of multi-processing abilities in distracting environments essential • In depth interview & direction observation also essential

50. Effective Treatment • Awareness training is a key element • Goals must relate to complex activities in life and work • Regular interdisciplinary communication is needed