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 Physical Exam 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 Re-diagnosis Co-diagnosis
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 Therapy Our 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

51. Main SLP Goal Areas Time and Energy Management
Awareness Training & TBI Education
Attention & Memory Compensation Techniques
Organizational Skills
Word Retrieval & Pragmatic Language Skills
Return to Work/Study Skills

52. Time and Energy Management
Client keeps daily log
Energy level, pain level, cognitive “success,” mood
SLP reviews log with client
Summarizes trends/progress
Helps client become own expert at compensating successfully

53. Awareness Training Train client to be own expert
Client gives own assessment of performance
SLP gives assessment, comparison of discrepancies, feedback
Continuous education helps generalization of strategies

54. Memory Compensation Increased Active Attention Increased Organization
Use of External Aids
Increased Awareness/Self-testing
Rehearsal
Elaboration
Association

55. Organizational Skills
Set Location for Important Items
Increased Use of Writing
More Methodical Approach
Successful Use of Planners, Alarms, Smartphones and Other External Aids

56. Return to Work Simulate work tasks
Plan and discuss recommended accommodations
Possibly educate employer &/or peers
Overlap treatment with RTW to provide feedback & problem solving

57. Return to School Achievement Testing Teach or Review Study Skills
Teach Organizational Skills
Focus on Awareness (e.g. need for strategies, rest)
Provide Guidance about Choosing Classes (Amount/Type)

58. Common Emotional Changes post mild TBI
Increased irritability (“short fuse”)
Crying (more often, without being able to control it at times)
Sadness
Anxious, nervous or feeling “edgy”
Increased worry thoughts
Overwhelmed
Hopeless about future
Wishing you had died in the accident
Feeling you are a burden to your family

59. Typical areas of focus in psychological work with TBI patients:
Adjusting to life changes because of TBI
Improving Sleep
Relaxation strategies
Improving Mood
Decreasing Anxiety
Improving Relationships
Identity and other Existential Issues

60. Common Diagnoses Adjustment Disorders With Depression With Anxiety
Anxiety Disorders
Anxiety NOS
Post-traumatic Stress Disorder (PTSD)
Generalized Anxiety Disorder (GAD)
Mood Disorders
Depression NOS
Major Depressive Disorder
Substance Use Disorders (LESS COMMON)

61. Therapeutic Approaches
Cognitive-Behavioral Therapy (CBT)
Acceptance and Commitment Therapy (ACT)
Interpersonal Process Therapy (IPT)

62. General Objectives for Therapy
Educate patients on the interaction between thoughts, feelings, and behaviors
Assist patients in heightening their awareness of symptoms (post-concussive and mental health) in vivo
Assist patient in learning ways to react to their symptoms in ways that lead to better outcomes
Provide patients with tools to catch, check and cope with negative self-statements that contribute to downward spiral of depression and anxiety

63. General Objectives for Therapy
Assist patient in reconciling multiple views of self (“old me” vs. “new me”)
Assist patient in processing the losses that arise from sustaining a TBI
Assist patient in articulating values and assisting patient work towards those values

64. Challenges when working with TBI patients in Psychotherapy
Stigma of “psychological help” can deter people from seeking or completing treatment
Attention and memory deficits can lengthen treatment
Visual challenges can impact ability to complete homework assignments
Heightened emotionality can lead to avoidance of therapy or homework