Introduction to Traumatic Brain Injury (TBI) July, 2011

1. Introduction toTraumatic Brain Injury (TBI)July, 2011 Cheryl L. Shigaki, Ph.D., ABPP & Thomas Martin, Psy.D., ABPP

2. Psychologists in US Health Care • Rehabilitation Psychology – focuses on adjustment to disability, maximizing function, full-participation in life activities. • Health Psychology – focuses on the intersection between behavior and health. • Neuropsychology – focuses on cognitive and behavioral sequelae from insults to the brain.

3. Rusk Rehabilitation CenterColumbia, Missouri 60 inpatient beds – serves post-acute: • Brain injury • Spinal Cord Injury • Stroke • Multi-trauma • Debility

4. TBI and Healthcare • The public and many health care professionals have limited and/or inaccurate understanding of TBI. • Overlap between TBI and psychiatric symptoms • Benefit and challenges of screening to identify history of TBI? • Benefit – Avoid misdiagnosis and promote care • “Have you ever had a head injury?” not effective

5. TBI in Rwanda • People with new brain injuries • Recognizing mild TBI • Helping victims and families adjust to moderate-severe TBI • People with previous TBI • Understanding personality and behavior change • Supporting chronic physical, cognitive and emotional effects

6. TBI and Healthcare • Typical rehabilitation approaches include: • Restorative strategies: Direct intervention to improve the problem • Compensatory strategies: Intervention focuses on adapting to the problem / working around it. • Psychological intervention: Address emotional reaction to loss and/or trauma; support motivation for active recovery. • Family caregiver support: Education about what to expect, how to manage problem behaviors and advocate for their loved one, and provide support for coping with stress and loss.

7. The Brain and TBI • The brain weighs about 1.4 kgs, with a consistency somewhere between butter and gelatin. • TBI causes brain damage in a number of ways. Damage can be caused by both primary and secondary injuries.

8. Overview of the Brain • CEREBRAL HEMISPHERES • Left hemisphere • Right hemisphere • FOUR LOBES OF THE BRAIN • Frontal lobe • Parietal lobe • Temporal lobe • Occipital lobe • BRAIN CELLS (NEURONS)

9. Lobes of the Brain

10. Structure of a Neuron (brain cell) Axon Dendrite Axon terminal Node Soma Schwann cell Myelin sheath Nucleus CC-BY-SA-3.0; Released under the GNU Free Documentation License.

11. The Corpus Callosum From Above Image from Gray’s Anatomy. In the public domain

12. Good Neuroanatomy Website Florida Institute for Neurologic Rehabilitation http:// www. finr. Net Note: App for iPhone now available!

13. Common Primary Injuries • Skull fractures • Contusions (bruising) • Intracranial hemorrhage (hematomas) • Diffuse axonal injury (DAI)

14. Contusions • Contusions are hemorrhagic lesions that typically form at the crests of gyri on the surface of the brain: • Coup contusions form at the site of cranial impact. • Contrecoup contusions form opposite the cranial impact and are typically more severe.

15. Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist. http://creativecommons.org/licenses/by/2.5/

16. The inside of the skull Is not smooth, it has sharp ridges

17. Hematomas • Classified by the location of bleeding; hematomas can damage the brain by exerting pressure on underlying brain structures • Epidural • Subdural • Subarachnoid

18. Hematomas Subdural • within the layers of brain covering • Due to vein bleeding which is slower than artery bleeding. • May not be discovered until days or weeks after the accident Epidural • Usually caused by tears in arteries, • Results in quick blood build up between the dura mater and the skull.

19. Hematomas Subdural hematoma as marked by the arrow with significant midline shift Epidural hematoma

20. Signs and Symptoms of Hematoma • Fluctuating levels of consciousness (or LOC) • Irritability • Seizures • Pain/Numbness • Headache • Dizziness • Hearing loss/ringing • Disorientation/amnesia • Weakness/lethargy • Nausea/vomiting • Loss of appetite • Personality changes • Difficulty speaking, slurred speech • Difficulty walking • Altered breathing • Blurred vision/abnormal eye movement

21. Diffuse Axonal Injury (DAI) • Widespread neuronal axon damage is frequently associated with “stretching” of the brain (motor vehicle accidents). • DAI is thought to contribute to LOC and prolonged coma. • The problem associated with “shaken baby syndrome”

22. Common Secondary Injuries • Ischemia – lack of blood/oxygen in area leading to cell death • Elevated intracranial pressure (swelling) & diminished blood flow • Neurochemical events – blood is toxic to brain tissue • Posttraumatic epilepsy • Cerebral infection

23. Elevated Intracranial Pressure (ICP) • The cranium is inflexible, increased pressure compresses brain tissue. • Edema • Hematoma • Sharp increases in intracranial pressure can contribute to cerebral ischemia and herniation. • Management of intracranial pressure and maintaining cerebral blood flow are primary concerns.

24. Edema (Swelling) • Cerebral edema results from disruption of the blood-brain barrier and impairment of vasomotor autoregulation with concomitant dilation of cerebral blood vessels. • Cerebral edema can lead to compression of the ventricular system, herniation, occlusion of intracranial vessels with secondary strokes, or increased intracranial pressure.

25. Elevated Intracranial Pressure (ICP) Types of brain herniation: Uncal 2) Central3) Cingulate 4) Transcalvarial 5) Upward 6) Tonsillar

26. TBI ASSESSment

27. Terminology: “Cognitive” • So far, we have been using the term “cognitive” to describe thinking styles in people with normal brain function • Based on social & personal context and habits we learn • Cognitive / Cognitive-Behavioral therapies are used to improve psychological wellbeing. Psychologists help patients explore and change thoughts and behaviors that are maladaptive

28. Terminology: “Cognitive” • Can also be used to describe thinking skills that are genetically/biologically driven and enhanced by opportunities for learning. • Neuropsychological research has attempted to define distinct aspects of “cognition” such as auditory & visual memory, attention, problem-solving, speed, etc. • Neuropsychological research also attempts to distinguish between normal and impaired cognition • Clinical Neuropsychologists test brain function following brain injury or disease (using tasks and questions) and make recommendations for living with impairment.

29. Assessment of Mild TBI • Domestic violence • Sports injuries • Work-related injuries • The effects of mild TBI can be cumulative • “Have you ever had a head injury?” is not an effective way to evaluate.

30. Assessment of Mild TBI • Acute Concussion Evaluation (ACE) • Heads Up: Brain Injury in Your Practice (CDC) http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html • Interview and assessment of risk factors • Symptom checklist • Diagnostic codes (ICD) • Sample follow-up plans/recommendations • Versions for return to work, school & sports

31. Assessment of Moderate-Severe TBI • Three pathways to assess severity of acute TBI: • Depth of coma • Duration of coma • The inability to continually register new experiences (Posttraumatic Amnesia or PTA)

32. Glasgow Coma Scale (GCS)

33. Glasgow Coma Scale (GCS) • Mild • Glasgow Coma Scale (GCS) score 13-15 • Loss of consciousness (LOC) < 20 Minutes • Posttraumatic amnesia (PTA) <24 hours • Moderate • GCS score 9 – 12 • LOC 20 - 36 hour • PTA 1 - 7 days • Severe • GCS score 3-8 • LOC > 36 hours • PTA > 7 days Note: A GCS score can be broken down, for example: GCS 12 = E4V3M5 Forms and training scripts can be found at: http://www.chems.alaska.gov/ems/documents/GCS_Activity_2003.pdf

34. Rancho Los Amigos:Level of Cognitive Functioning Scale • Helpful in assessing the patient in the first weeks or months following an injury. • Does not require cooperation from the patient • Rancho “levels” are based on observations of the patient’s response to external stimuli & provide a descriptive guideline of the various stages of brain injury. • Forms and descriptions can be found at: http://tbims.org/combi/lcfs/

35. Galveston Orientation & Amnesia Test (GOAT) • The GOAT can be used to track how much a person is recovering while in the hospital (no longer in a severe coma). • Requires patient cooperation. • Score is 100 MINUS error points. Score of 78 or more on three consecutive occasions/days indicates that patient is out of post-traumatic amnesia (PTA).

36. Galveston Orientation & Amnesia Test (GOAT) • What is your name? (2) • When were you born? (4) • Where do you live? (4) • Where are you now? (5) City, (5) Hospital • On what date were you admitted to this hospital? (5) • How did you get here? (5) • What is the first event you can remember after the injury? (5) • Can you describe in detail the first event you recall after the injury? (5)

37. Galveston Orientation & Amnesia Test (GOAT) • Can you describe the last event you recall before the accident? (5) • Can you describe in detail the first event you can recall before the injury? (5) • What time is it now? (-1 for each 30 min incorrect, up to -5) • What day of the week is it? (-1 for each day incorrect, -3) • What day of the month is it? (-1 for each day incorrect, -5) • What is the month? (-5 for each month incorrect, -15) • What is the year? (-10 for each year incorrect, -30) Levin, H.S., O'Donnell, V.M., & Grossman, R.G. (1975). The Galveston orientation and amnesia test: A practical scale to assess cognition after head injury.  Journal of Nervous and Mental Diseases, 167, 675-684.

38. TBI Outcomes

39. Consequences of TBI • The brain controls every aspect of our being and a traumatic brain injury has the capability of impacting any aspect of a person’s physical, cognitive, or psychological functioning. • In-depth evaluation of these skills is the domain of Neuropsychologists.

40. Impact of Mild TBI • Mild TBI is typically associated with modest and temporary changes in functioning, while severe TBI is associated with enduring changes and sometimes mortality. • Reductions in attention and information processing speed and efficiency are the most frequent cognitive consequences following mild TBI.

41. Physical Functioning: Mod-Severe TBI • Arm/leg weakness & paralysis • Compromised speech and swallowing ability • Dizziness & dyscoordination • Diminished sense of smell and taste • Hearing (e.g., tinnitus) and visual disturbance (e.g., diplopia) • Sleep disturbance and fatigue • Chronic headaches and pain • Sexual dysfunction

42. Cognitive Impact: Mod–Severe TBI • Although severe TBI can impact any aspect of cognition, the high incidence of orbitofrontal (front of the brain, around eye sockets) and anterior temporal lobe (tips of the temporal lobes) contusions often produces a constellation of symptoms that includes:

43. Cognitive Impact: Mod–Severe TBI • Slow speed of cognitive processing (functional) • Slowed behavioral responding (functional) • Attention deficits • Impaired learning & memory (need more exposures) • Behavioral symptoms: • impulsivity • Perseveration • initiation deficits • planning and organization

44. Cognitive Impact: Mod-Severe TBI • TBI does not typically compromise intelligence in mild-moderate cases. The Thinker – Musée Rodin, Paris

45. Speed of Processing • Speed of processing (reaction time) is very sensitive to any brain insult • Following a brain injury, it often takes longer to take information in and react to events • Reduced speed of processing can compromise other cognitive abilities • Degree of impairment may render the patient dysfunctional in daily activities.

46. Learning/Memory • Memory problems are the most common cognitive complaint following a TBI • Short term vs. long term memory • Verbal memory vs. visual memory • Explicit memory (e.g., experiences, facts, events) vs. implicit (e.g., skills, habits) memory • Research suggests deficit is in learning

47. Attention • Attention is on a continuum and task specific: • Simple Attention: Ability to register and attend to (e.g., focus on a noise) • Focused Attention: Ability to focus on important information while ignoring irrelevant information • Sustained Attention: Ability to focus for extended period • Divided Attention: Shift attention between tasks (e.g., cook & talk on the phone)

48. Executive Functions • Executive Functions – Skills necessary for complex goal-directed behavior and adaptation to changes • Planning and organization ability • Problem-solving ability • Ability to initiate and sustain action and anticipate consequences • Ability to benefit from feedback and adjust behavior

49. Personality Changes • Impulsivity • Grandiosity • Apathy / lack of initiative • Impaired ability to evaluate risk and need for safety measures (meta-awareness, metacognition) • They don’t know what they don’t know

50. Personality changes • Impulsivity • Grandiosity • Apathy / lack of initiative • Inability to be empathic / self-focused • Impaired ability to evaluate risk; judge one’s physical, cognitive and emotional functioning • Thinking about thinking - They don’t know what they don’t know