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Treatment of Mild Traumatic Brain Injury using an Interdisciplinary Approach Presented by: Helen Mathison MA, CCC-SLP Nova McNally OTR/L Danielle Potokar.

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Presentation on theme: "Treatment of Mild Traumatic Brain Injury using an Interdisciplinary Approach Presented by: Helen Mathison MA, CCC-SLP Nova McNally OTR/L Danielle Potokar."— Presentation transcript:

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 GCS 15GCS 5 Metabolic brain dysfunction following traumatic brain injury GCS 15 Bergsneider, Hovda, 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 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

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