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Diagnosis and Treatment of Traumatic Brain Injury

Diagnosis and Treatment of Traumatic Brain Injury. Angela Colantonio, PhD, OT Reg. (Ont.) Carolyn Lemsky, PhD, C. Psych. Catherine Wiseman Hakes, PhD Candidate, Reg. CASLPO. Diagnosis & Treatment of Traumatic Brain Injury. March is National Brain Injury Awareness Month

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Diagnosis and Treatment of Traumatic Brain Injury

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  1. Diagnosis and Treatment of Traumatic Brain Injury Angela Colantonio, PhD, OT Reg. (Ont.) Carolyn Lemsky, PhD, C. Psych. Catherine Wiseman Hakes, PhD Candidate, Reg. CASLPO

  2. Diagnosis & Treatment of Traumatic Brain Injury • March is National Brain Injury Awareness Month • Traumatic Brain Injury (TBI) is a serious public health problem • TBI: It’s not just an injury

  3. Presenters • Saunderson Family Chair in Acquired Brain Injury (ABI) Research, Professor at University of Toronto • Leads an internationally recognized program of research on ABI Angela Colantonio, PhD, OTCarolyn Lemsky, PhD,Catherine Wiseman-Hakes, Reg. C. Psych. M.Sc. Reg. CASLPO • Clinical Director at Community Head Injury Resource Services of Toronto • Director of the Substance Use and Brain Injury (SUBI) Bridging Project • Registered Speech Pathologist and a doctoral candidate, University of Toronto • Specializes in the assessment and treatment of children & adults with cognitive communication impairments secondary to TBI

  4. Goals of theSession • Prevalence and history of TBI among the homeless population • Clinical manifestations of TBI • Screening tools for TBI • Treating TBI and co-morbidities (e.g., substance abuse) • Communicating with someone with TBI

  5. ABI in the Population Intervention Studies Providers Knowledge Transfer Consumers / Caregivers Students, Trainees,Visiting scholars Gender Issues Aging with TBI • Collaborative links: • Local • Provincial • National • International Improvement in Quality of Life in Adults with ABI

  6. Acquired Brain Injury • TRAUMATIC • Open • Closed NON-TRAUMATIC • Anoxia • Aneurysms • Brain Tumors • Encephalitis • Meningitis • Metabolic Encephalopathy • Stroke with Cognitive Disabilities

  7. Brain Injury is a leading cause of death and disability worldwide.Injuries to the brain are among the most likely to result in death and permanent disability International Brain Injury Association Brain Injury is the leading cause of death and disability worldwide.Injuries to the brain are among the most likely to result in death and permanent disability International Brain Injury Association

  8. Extent of TBI TBI is more common than breast cancer, spinal cord injury, HIV/AIDS and multiple sclerosis combined Estimated prevalence, 2% of population

  9. Definition of TBI An alteration in brain function, or other evidence of brain pathology, caused by an external force…” Brain Injury Association of America

  10. The effect of TBI on the health of the homeless(Hwang, Colantonio et al, 2008) • Have you ever had an injury to the head which knocked you out or at least left you dazed, confused, or disoriented? Yes: 53% (of 904 participants)

  11. TBI in the Homeless Population Age at Time of First TBI (Any Severity): Mean (SD): 18 years (13 Years) • 70% prior to first episode of homelessness

  12. Persons with a history of TBI compared to persons without a history had significantly higher levels of: • Seizures • Mental health problems • Alcohol problems • Drug abuse problems The risk of these conditions increased significantly with severity of injury

  13. Diagnosis • History of TBI • Length of unconsciousness, post traumatic amnesia • Physical examination • Imaging: CT, MRI • Neuropsychology

  14. Measuring Severity/Level of Consciousness Glasgow Coma Scale: • Eye Opening (1-4) • Best Motor Response (1-6) • Verbal Response (1-5) Scoring: • Mild 13-15 • Moderate 9-12 • Severe <12

  15. American Congress of Rehabilitation Medicine definition of mTBI A traumatically induced physiological disruption of brain function, as manifested by at least one of the following: • Any loss of consciousness; • Any loss of memory for events immediately before or after the accident; • Any alteration in mental state at the time of the accident (e.g. feeling dazed, disoriented, or confused); and • Focal neurological deficit(s) that may or may not be transient; but where the severity of the injury does not exceed the following: • Loss of consciousness of approximately 30 min or less; • After 30 minutes, an initial Glasgow Coma Scale (GCS) of 13-15; and • Posttraumatic amnesia (PTA) not greater than 24 hrs. • Katy, et al. (1993)

  16. Consequences of TBI Cognition:concentration, memory, judgment, communication, sleep. Movement abilities:strength, coordination, balance, fatigue. Sensation:tactile sensation, vision, hearing, headaches. Emotion:instability, impulsivity, mood. Community integration:impacts family, work, economic/ social wellbeing

  17. Clinical Sequelae Highly variable presentation depending on area of the brain affected TBI survivors described like “snowflakes” e.g., frontal lobe damage can affect social behaviour Occipital lobe damage may affect vision

  18. Women and TBI Impact on reproductive health, women with TBI vs. women without TBI: • 68% of women 5-10 years post TBI reported their cycles were irregular after injury • 46% experienced amenorrhea • No significant differences in conception but more post partum difficulties • Significantly more mental health issues • Colantonio et al., 2010

  19. SCREENING TOOLS Survey Questions to Identify Traumatic Brain Injuries

  20. Background of Surveys to Identify TBI Many surveys exist. Some examples are: • Ohio State University TBI Identification Method • Brain Injury Screening Questionnaire • HELPS Brain Injury Screening Tool

  21. Bogner J, Corrigan JD. (2009). Reliability and predictive validity of the Ohio State University TBI identification method with prisoners. J Head Trauma Rehabil, 24:279-291. Corrigan JD, Bogner J. (2007). Initial reliability and validity of the Ohio State University TBI identification method. J Head Trauma Rehabil, 22:318-329. Ohio State University TBI Identification Method (OSU TBI-ID) Inter-rater reliability and predictive validity have both proved acceptable when tested in a substance abuse population: • IR (r=0.849-0.951) • Intra-class correlation coefficient all above 0.80, with 6/7 above 0.90

  22. Definition of Brain Injury in Context of the Survey • Self-identification of an injury to the head (Questions 1-5) PLUS • An Affirmative Answer to one of 6-8 • Confirmation of head injury and loss of consciousness or episode of blacking out

  23. Neuropsychological Evaluation Typically involves many hours of testing Repeatable Battery for Assessment of Cognition (RBANS) is a short test

  24. Treatment Referral for further evaluation and treatment Multidisciplinary rehabilitation Wide range of treatments with emerging evidence Follow up for disability support services/payments

  25. CMHA Kelowna and Brain Trust Canada partnership: ABI Outreach Services • Aims to secure residential settlement • ABI Outreach Worker provides the knowledge required to maintain a productive lifestyle, including budgeting, dealing with mental health problems, drug addiction and other physical issues. • ABI Tenant Support Worker assists in providing access to non-emergency medical support, basic needs such as nutritious food, and support with coping skills, personal health practices, etc.

  26. Research Based Theatre • Based on focus groups with consumers, family members and health care providers • Translated key elements on experience of TBI and experiences with providers • AFTER THE CRASH www.ruckusensemble.com

  27. Carolyn Lemsky, PhD, C. Psych. Models of ABI Intervention

  28. Overview Models of community-based care for ABI Cognitive compensation (adapting substance use/mental health interventions) Principles for working with people living with acquired brain injury

  29. Integration of substance use and mental health intervention in the continuum of Rehabilitation care Time of Injury mild moderate Severe

  30. Supporting people with ABI in the community

  31. Whatever it Takes • No two people with brain injury are alike • Skills are more likely to generalize when taught in the environment where they will be used. • Environments are easier to change than people. • Community integration should be holistic. • Life is a place-and-train venture. Willer and Corrigan (1994)

  32. …Cont’d 6. Natural supports last longer than professionals. 7. Interventions must not do more harm than good. 8. Service delivery systems present many of the barriers to community integration 9. Respect for the individual is paramount. 10. Needs of the individuals last a lifetime, so should their resources.

  33. Case Example Tom’s goal: Get a job Problems Observed: • Poor hygiene • Limited compensation for memory impairment • Socially inappropriate behaviour

  34. Learn and then Place… Get a Job

  35. Place and Learn Keep Job Maintain Change

  36. Good morning, Tom. Your shower is getting warm…

  37. Hey Tom, Good morning, your shower is getting warm…

  38. “In the absence of meaningful, chosen life activities, all interventions are doomed to failure” Ylvisaker, 1998

  39. Restorative Compensatory Environmental Behavioural

  40. Restorative Therapy activities designed to promote return of function: • Attention training • Aphasia therapies

  41. Compensatory Learning a way to get around the existing impairment: • Memory books, notes, alarms • Meta-cognitive strategies (planning) • Routines

  42. Environmental • Reminder signs • Locks • Staff member provides a cue • Routine that is driven by others in the environment

  43. Behavioural Using behavioural strategies to train a skill: • Modeling • Rehearsal • Chaining • Errorless learning

  44. Program Modifications • Smaller sessions • Simplified materials • Flexible programming (breaks/shortened sessions) • Integrating rehabilitation workers into treatment

  45. Why some clients don’t compensate • Lack of awareness • Feeling that compensating means ‘giving up’ on progress • Stigma and shame • Impaired cognition

  46. What does the literature say about treatment of substance abuse after ABI?

  47. Simplified Program Model Brain injury Mild Severe CHIRS - Based Psycho-educational Case Management Community Based Psycho-educational Approach Mild Substance Abuse CAMH – Based CHIRS Support CHIRS –Based CAMH support Harm reduction Intensive Case Management Severe Adapted from Corrigan (2004)

  48. From the literature…ABI-Specific Treatment Models Common Characteristics: Engagement in meaningful activity (incompatible with substance use and addresses mood/behaviour) Skills training Treatment may begin before insight/readiness to change

  49. Case Management Models Access to substance abuse services/mental Health Services ABI consultation Explain Neuro-cognitive Impairment Adapt treatment plans Trouble-shoot Assist with access to other support services

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