Traumatic Brain Injury – Traumatic Brain Injury – Evaluation and Evaluation and Treatment Treatment ConsiderationsConsiderations

Brian A. Boatwright, Psy.D.Brian A. Boatwright, Psy.D.

NeuropsychologistNeuropsychologist

Director of the Neurologic Director of the Neurologic Rehabilitation InstituteRehabilitation Institute

EpidemiologyEpidemiology

National Estimates – 1.7 million National Estimates – 1.7 million individuals sustain a head injury individuals sustain a head injury each year.each year.

52,000 die.52,000 die. 275,000 are hospitalized.275,000 are hospitalized. 1.365 million are treated and 1.365 million are treated and

released.released.

TBI accounts for a third of all TBI accounts for a third of all injury related deaths in the U.S.A.injury related deaths in the U.S.A.

Approximately 75% of brain Approximately 75% of brain injuries are mild (concussion).injuries are mild (concussion).

Number of those sustaining injury Number of those sustaining injury but do not seek treatment is but do not seek treatment is unknown.unknown.

Peak occurrences: Ages 0-4; 15-Peak occurrences: Ages 0-4; 15-19; and >65.19; and >65.

Those >75 have highest rates of Those >75 have highest rates of TBI related hospitalization and TBI related hospitalization and death.death.

Males>FemalesMales>Females Males ages 0-4 have highest rates Males ages 0-4 have highest rates

of brain injury E.D. visits.of brain injury E.D. visits.

Direct and indirect medical costs Direct and indirect medical costs of brain injury – $76.5 billion of brain injury – $76.5 billion (2000 CDC data).(2000 CDC data).

Causes-Motor Vehicle Crashes Causes-Motor Vehicle Crashes and Falls.and Falls.

Data from Centers for Disease Control and Prevention, 2012Data from Centers for Disease Control and Prevention, 2012

Primary Mechanisms Primary Mechanisms of Injuryof Injury ImpactImpact

– Contusion at point of impactContusion at point of impact

– Skull Fracture with focal injurySkull Fracture with focal injury

ContusionContusion

A contusion is a bruise (bleeding) A contusion is a bruise (bleeding) on the brain.on the brain.

A contusion can be the result of a A contusion can be the result of a direct impact to the head.direct impact to the head.

The behavioral effect depends on The behavioral effect depends on the size and location of the bleed.the size and location of the bleed.

Coup and CountrecoupCoup and Countrecoup

Head impacted at site of contact Head impacted at site of contact with object (causing contusion).with object (causing contusion).

Brain is forced into opposite side Brain is forced into opposite side of skull (causing contusion).of skull (causing contusion).

Diffuse Axonal InjuryDiffuse Axonal Injury

A result of shaking or strong rotation A result of shaking or strong rotation of the head or by rotational forces (e.g. of the head or by rotational forces (e.g. automobile accident).automobile accident).

The stationary brain lags behind the The stationary brain lags behind the movement of the skull causing brain movement of the skull causing brain structures to tear.structures to tear.

Individual presents a variety of Individual presents a variety of functional impairments depending on functional impairments depending on where the shearing (tears) occurred.where the shearing (tears) occurred.

Secondary Secondary Mechanisms of InjuryMechanisms of Injury EdemaEdema Disruption of CSF absorptionDisruption of CSF absorption HypoxiaHypoxia IschemiaIschemia

Damage Documented Damage Documented in Survivorsin Survivors Brain swelling by CT Brain swelling by CT 17-44%17-44% Focal Lesions by CT Focal Lesions by CT 23-46%23-46% Frontal MRI abnormalities 40%Frontal MRI abnormalities 40% Multifocal damage not detected Multifocal damage not detected

by routine clinical studiesby routine clinical studies

Brain Damage SurvivalBrain Damage Survival

More people survive diseases, More people survive diseases, accidents, and other medical accidents, and other medical conditions affecting the CNS.conditions affecting the CNS.

Consequently, more people live Consequently, more people live with chronic neurological conditions with chronic neurological conditions and associated impairments, and associated impairments, including cognitive disabilities and including cognitive disabilities and affective/behavioral disturbance.affective/behavioral disturbance.

Traumatic Brain InjuryTraumatic Brain Injury

Brain injury deaths declined from Brain injury deaths declined from 24.6 per 100,000 in 1979 to 19.3 24.6 per 100,000 in 1979 to 19.3 per 100,000 in 1992, in the per 100,000 in 1992, in the United States (Sosin, Sniezek, & United States (Sosin, Sniezek, & Waxweiler, 1995)Waxweiler, 1995)

Reliable estimates regarding survivors Reliable estimates regarding survivors with cognitive disability are not with cognitive disability are not availableavailable

One study in the Netherlands indicated One study in the Netherlands indicated that of all hospital admissions, 67% of that of all hospital admissions, 67% of brain injury survivors had long-term brain injury survivors had long-term cognitive and behavioral problemscognitive and behavioral problems

CDC-Estimates 3.17 million Americans CDC-Estimates 3.17 million Americans currently require ADL assistancecurrently require ADL assistance

Neuropsychological Neuropsychological DomainsDomains Acquired KnowledgeAcquired Knowledge Attention & MemoryAttention & Memory LanguageLanguage Visual Spatial Visual Spatial Motor & Sensory PerceptualMotor & Sensory Perceptual Reasoning & Problem SolvingReasoning & Problem Solving

Executive FunctionsExecutive Functions– PlanningPlanning– Processing SpeedProcessing Speed– Cognitive FlexibilityCognitive Flexibility

PersonalityPersonality Social CognitionSocial Cognition Motivation / Response BiasMotivation / Response Bias

TBI and TBI and NeuropsychologyNeuropsychology Performance IQ loss is generally greater than Performance IQ loss is generally greater than

Verbal IQ loss.Verbal IQ loss. Younger the child the greater the IQ loss.Younger the child the greater the IQ loss. Deficits may be seen in any number of Deficits may be seen in any number of

domains, dependent on lesion location.domains, dependent on lesion location. Memory is the most prominently effected Memory is the most prominently effected

neuropsychological function but will also see neuropsychological function but will also see marked impairment in executive functioning.marked impairment in executive functioning.

Greatest improvement seen shortly post-Greatest improvement seen shortly post-injury but may be two years and beyond.injury but may be two years and beyond.

IQ DistributionsIQ Distributions

0

160

Normal

THI-VIQ

THI-PIQ

Dennis 1985100

Basic Neuroanatomy Basic Neuroanatomy and Functional and Functional LocalizationLocalization Frontal LobesFrontal Lobes

– AttentionAttention– PlanningPlanning– SequencingSequencing– OrganizationOrganization– Mental FlexibilityMental Flexibility– Problem SolvingProblem Solving– Impulse ControlImpulse Control– Aspects of Memory (Executive Memory)Aspects of Memory (Executive Memory)

Temporal Lobes (Hippocampus, Temporal Lobes (Hippocampus, Amygdala, Basal Ganglia)Amygdala, Basal Ganglia)– Sound recognition and processingSound recognition and processing– Comprehension and production of Comprehension and production of

speechspeech– Aspects of memoryAspects of memory

Parietal LobesParietal Lobes– Integration of sensory information Integration of sensory information

from the bodyfrom the body– Contains primary sensory cortexContains primary sensory cortex– ProprioceptionProprioception– Spatial FunctioningSpatial Functioning– VisuoconstructionVisuoconstruction– Aspects of memoryAspects of memory

Occipital LobeOccipital Lobe– Primary Visual CortexPrimary Visual Cortex

CerebellumCerebellum– BalanceBalance– MovementMovement– CoordinationCoordination– Some aspects of attention/executive Some aspects of attention/executive

functioning, frontal connectionsfunctioning, frontal connections

Emotional and Emotional and Behavioral Changes Behavioral Changes Secondary to TBISecondary to TBI Emotional/Behavioral sequelae may Emotional/Behavioral sequelae may

occur in the absence of neurological and occur in the absence of neurological and neuropsychological findings.neuropsychological findings.

No specific psychiatric disorder is typical.No specific psychiatric disorder is typical. 90% of severe and about half of 90% of severe and about half of

moderate TBI patients have behavioral moderate TBI patients have behavioral and social problems.and social problems.

Hyperactive, mood, anxiety, and anger Hyperactive, mood, anxiety, and anger control problems all may occur.control problems all may occur.

Neuropsychological Neuropsychological Assessment of TBIAssessment of TBI EffortEffort Ability (Premorbid estimates and Ability (Premorbid estimates and

current)current) AchievementAchievement Sensory Motor/Visuospatial/ConstructionSensory Motor/Visuospatial/Construction Memory (Verbal and Visual)Memory (Verbal and Visual) Executive FunctioningExecutive Functioning Affect/PersonalityAffect/Personality

Treatment ModalitiesTreatment Modalities

Physical TherapyPhysical Therapy Occupational TherapyOccupational Therapy Speech TherapySpeech Therapy Neuropsychology Neuropsychology Cognitive RehabilitationCognitive Rehabilitation PsychotherapyPsychotherapy

Psychotherapy: Psychotherapy: Treatment Treatment ConsiderationsConsiderations Previously, psychotherapy thought to Previously, psychotherapy thought to

be less important due to TBI patient be less important due to TBI patient deficits (e.g. anosognosia, poor deficits (e.g. anosognosia, poor insight, memory problems, perceptual insight, memory problems, perceptual disturbance, language impairment). disturbance, language impairment).

With improved therapies in other With improved therapies in other modalities and compensatory modalities and compensatory strategies, psychotherapy currently strategies, psychotherapy currently viewed as very beneficial.viewed as very beneficial.

Therapy IssuesTherapy Issues

Consider neurocognitive strengths and Consider neurocognitive strengths and weaknesses when formulating approach to weaknesses when formulating approach to patient and treatment planningpatient and treatment planning

Impairments in concentration, memory, Impairments in concentration, memory, general ability to sustain focus and effort general ability to sustain focus and effort throughout sessionsthroughout sessions

Strengths-Maximizing intact abilities (e.g. Strengths-Maximizing intact abilities (e.g. verbal or visual memory)verbal or visual memory)

When in doubt, spell it outWhen in doubt, spell it out Contracting for treatmentContracting for treatment

Therapeutic relationship, may take Therapeutic relationship, may take time, exercise patience.time, exercise patience.

Cicerone and Prigatano-therapeutic Cicerone and Prigatano-therapeutic relationship is important when working relationship is important when working with problems of self-awareness.with problems of self-awareness.

Prigatano and Klonoff-therapeutic Prigatano and Klonoff-therapeutic alliance with patient and family alliance with patient and family predictive of client productivity as far predictive of client productivity as far out as 11 years.out as 11 years.

Presenting ProblemsPresenting Problems

Behavioral dyscontrol (e.g. anger, Behavioral dyscontrol (e.g. anger, irritability, impulsivity, self-awareness)irritability, impulsivity, self-awareness)

DepressionDepression Mania Mania Alcohol Abuse and DependenceAlcohol Abuse and Dependence Anxiety Disorders (PTSD, Social phobia, Anxiety Disorders (PTSD, Social phobia,

GAD, Panic Disorder)GAD, Panic Disorder) Personality ChangesPersonality Changes Recalling what happenedRecalling what happened

New role (Social, family, educational, New role (Social, family, educational, etc.)etc.)

EmploymentEmployment SleepSleep AppetiteAppetite LibidoLibido MedicationsMedications Family SupportFamily Support

Final NotesFinal Notes

Psychotherapy beneficial for Psychotherapy beneficial for helping patient and family adjust.helping patient and family adjust.

Collaborate with other providers Collaborate with other providers (e.g. ST, OT, Neuropsychologist, (e.g. ST, OT, Neuropsychologist, Physicians/Psychiatrist, PCP)Physicians/Psychiatrist, PCP)

ReferencesReferences

American Psychological Association (2011). Rehab for American Psychological Association (2011). Rehab for the brain after traumatic injuries, five questions and the brain after traumatic injuries, five questions and answers about traumatic brain injury.answers about traumatic brain injury.

Burg, J.S., Williams, R., Burright, R.G., & Donovick, P.J. Burg, J.S., Williams, R., Burright, R.G., & Donovick, P.J. (2000). Psychiatric treatment outcome following (2000). Psychiatric treatment outcome following traumatic brain injury. traumatic brain injury. Brain Injury, 14, Brain Injury, 14, 513-533.513-533.

Coetzer, R. (2007). Psychotherapy following traumatic Coetzer, R. (2007). Psychotherapy following traumatic brain injury: Integrating theory and practice. brain injury: Integrating theory and practice. Journal of Journal of Head Trauma Rehabilitation, 22, Head Trauma Rehabilitation, 22, 39-47.39-47.

Jorge R. & Robinson, R.G. (2003). Mood disorders Jorge R. & Robinson, R.G. (2003). Mood disorders following traumatic brain injury. following traumatic brain injury. International Review International Review of Psychiatry, 15, of Psychiatry, 15, 317-327.317-327.

References, cont.References, cont.

Schoonover, C. (2010). Schoonover, C. (2010). Portraits of the mind. Portraits of the mind. New York, NY:New York, NY: Abrams.Abrams.

Senathi-Raja, D., Ponsford, J., & Schonberger, M. (2010). Senathi-Raja, D., Ponsford, J., & Schonberger, M. (2010). Impact of age on long-term cognitive function after Impact of age on long-term cognitive function after traumatic brain injury. traumatic brain injury. Neuropsychology, 24, Neuropsychology, 24, 336-344. 336-344.

Sherer, M., Evans, C.C., Leverenze, J., Stouter, J., Irby Jr, Sherer, M., Evans, C.C., Leverenze, J., Stouter, J., Irby Jr, J.W., Lee, J.E., & Yablon, S.A. (2007). Therapeutic alliance in J.W., Lee, J.E., & Yablon, S.A. (2007). Therapeutic alliance in post-acute brain injury rehabilitation: Predictors of strength post-acute brain injury rehabilitation: Predictors of strength of alliance and impact of allegiance on outcome. of alliance and impact of allegiance on outcome. Brain Brain Injury, 21, Injury, 21, 663-672.663-672.

Sosin, D.M., Sniezek, J.E., & Waxweiler, R.J. (1995). Trends Sosin, D.M., Sniezek, J.E., & Waxweiler, R.J. (1995). Trends in death associated with traumatic brain injury, 1979 in death associated with traumatic brain injury, 1979 through 1992. through 1992. Journal of the American Medical Association, Journal of the American Medical Association, 273, 273, 1778-1780.1778-1780.

ResourcesResources

www.traumaticbraininjury.net www.braininjury.com www.traumaticbraininjury.com www.pbs.org/wnet/brain/3d www.g2conline.org www.cdc.gov/traumaticbraininjury/