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Mild Traumatic Brain Injury
9th Annual Fall Nursing
Robert G. Kohn D.O.
Neurology, Psychiatry, Neuropsychiatry
815 344 7951
• 1. Familiarize the audience with the scope
of mTBI
• 2. Explain relevant brain anatomy and
function impacted by TBI
• 3. Provide a guideline for initial evaluation
and ongoing treatment with practical
resourses available in the community
• Part I-Mild TBI, Epidemiology, Brain
anatomy and function
• Part II- Evaluation Process of TBI
• Part III- Approach to Treatment; An
Integrated Bio-Psycho-Social Model
SPECT normal vs TBI
Normal 3-D Surface Image
Traumatic Brain Injury
Traumatic Brain Injury- TBI
• …with or without skull fracture is an insult
to the brain caused by external physical
force that may produce a diminished or
altered state of consciousness.
– Acquired Brain injury- not hereditary or present at
birth or degenerative condition that may be due to a
stroke, toxic ( alcohol, cocaine, etc ), anoxic-hypoxic (
cardiac, sepsis, metabolic, etc ).
– fact sheet page 1
Mild TBI
• A concussion or event that may leave a
person dazed or cause a brief loss of
• Any period of LOC of < 30 minutes and a GCS of 13-15
• Any loss of memory for events immediately before or
after an accident with PTA <24 hours
• Any alteration in mental state ( dazed, confused,
disoriented ) at the time of the accident
• Focal neurological deficits that may or may not be
Post Concussion Syndrome
• May follow from the injury that includes a
spectrum of deficits
– Headache
– Dizziness
– Dysequilibrium
– Mild mental slowing
– Fatigue
Epidemiology of TBI
Prevalence in total US Population
• 1.4 million people sustain
a TBI each year
• Distribution of Average
incidence of
emergency department
visits, and deaths between
• As a cumulative result of
TBI, an estimated 5.3
million Americans are
living with a permanent
ED visits
TBI Incidence by Severity in U.S.
• Mild TBI- 131
cases/100,000 people
• Moderate TBI- 15
cases/100,000 people
• Severe TBI- 14
cases/100,000 people
• Mortality rates:
– severe TBI 33%
– moderate TBI 2.5%
Incidence by External Cause in
total US Population
Some Statistics about brain injury
• 1.5 million Americans sustain TBI annually
• 80,000 Americans experience LTDisability
• 5.3 million Americans-2% pop have TBI
• MVA cause 44%, Falls 26%,Assualts and
Firearms 17%, sports and recreation13%
• 50,000 children TBI from bicycle
• 200,000 children hospitalized and 30,000
are permanent TBI injuries
U.S. Military Incidence and
• Head/neck injuries: 15-20% of all
battle injuries2,3
• Up to 28% of all war fighters4
• Defense and Veterans Brain Injury
Center (DVBIC) at Walter Reed
Army Medical Center among
OIF/OEF veterans5– 30% had traumatic brain injury
(greater percentage meeting TBI
criteria when injury was blast
• 56% have moderate to severe TBI
• 44% have mild TBI (MTBI)
– 10–20% of combat veterans meet
the criteria for MTBI on postdeployment screening
How does TBI happen- mechanism
Bicycle fall head injury
Helmet Protection Bicycle
TBI proposed mechanisms
• Shearing forces from rapid accelerationdeceleration disrupt molecular bonds that hold
white matter fibers together
• Decrease in rCBF
• Decrease in Glucose availability to neurons
• Cytotoxicity from Glutamate release
• Thalamus injury alters pacemaker generation
fails to gate cortical-subcortical firing patterns
White matter disruption-axonal
shearing & Thalamus injury
Brain Anatomy and FunctionLobes-F,P,T,O,Cb
Cortex lobes and function
– Frontal lobe-central executive, emotional
executive; planning, decision making, time
management, organziation, motivation,drive
and reward systems for behavior, taste, smell
– Temporal lobe-”what systems” for attention
and language, brain dictionary, “memory” for
declarative and emotional recordshippocampus and amygdala
Cortex lobes-function
– Parietal lobe-sensory-motor cortex for
visual-spatial processing, “ where”
attention system and “ How “ systems
for motor planning- praxis and language
– Occipital lobe- primary, secondary and
tertiary visual processing- faces, color,
shapes, movement, etc
Cortex, Subcortex and brainstem
• Cerebellum- balance and coordination of trunk,
limbs, eye movements,” time keeper” for data
sequencing- cognitive dysmetria.
• Basal Ganglia
• Cingulate lobe
• Insula
• Thalamus
• Brainstem- origination of NE, 5HT,DA projection
pathways, sleep circuits, etc
Brain regions
Brain Stem
Spinal Cord
Limbic System properties
• Mental content; linking mental content to
autonomic, hormonal, immunological
states; coordination of affiliative behaviors
related to social cohesion
• Channeling emotion; drives to
extrapersonal events
• Includes perception of taste, smell, taste
Cortical-Subcortical Loops:
Thalamo-Cortical-Striatal Anatomy
Japanese Cherry Blossoms
Evaluation Process of TBI
• Patient Narrative- observe, listen and
ensure an open minded, patient centered
space for each person to report their story
• Obtain Pre and Post Injury report of
functionality from patient and family,
partner, children, etc
• Broad framework of observation from
patient report of symptoms to systems
Assist information gathering
• Provide rating forms for patient and family
before patient is seen
• Include
– TBI patient and care giver rating form
– MINI- NIMH form assessment screen for
Depression, Panic, Anxiety and Substance
– Consider PTSD and substance screening
Collaborative History
• Obtain records from other professionals if
available; ie hospital emergency room
• Legal status; ie litigation pending or
• If child or young adult get school report
• Assure time to obtain collaborative history
from significant others in patient’s life
5 Regions of Impairment to
• Sleep- fatigue, insomnia, restfullness, emergent OSA
• Cognition-short term memory, attention states,
processing speed, mental stamina, distractability, focus
• Affective-observed mood changes, vegetative
symptoms of depression, anxiety, fears, anger,suicidality
• Behavior-disinhibition leading to property or physical
destruction, aggression, agitation, safety status
• Somatic-pain symptoms, headache, dizziness,
balance difficulties,etc
Office Evaluation
• MSE -include digit span, WLG, categorical naming, read, writing,
math, drawing,etc
• Physical attention to pain
• Neurological attention to general versus focal deficits; test for
smell and taste, balance and coordination, weakness and power,
vision and pupil reaction, deep tendon reflexes, sensory gradients
with vibration, position, graphesthesia,etc
• Attention testing; CPT- IVA, Quotient tests
against ADHD data set, personality w NEO5
factor inventory- CANOE
Additional Testing
• EEG- awake and asleep study for post traumatic epilepsy
• QEEG- spectral analysis of brain wave frequency distribution;
localized slowing, etc
• SPECT-nuclear medicine test for regional or focal hypoperfusion
• 3T MRI- done at centers using higher resolution than 1.5 T
evalute white matter tracts and cortex
• fMRI- functional testing; ie language based protocol evaluate
networks activated or delayed;
• Event Related Potentials-EEG based pattern of
visual, auditory or cognitive processing
QEEG Temporal lobe slowing +3sd
Visual relaxation
Summer Imagination
Approach to Treatment- An
Integrated Model
• Define the Problem-Biological, Psychological,
Social Perspectives
• Patient focus- fears? Loss? Anger? Transient.
• System view- family acknowledgement or disbelief?, partner
intimacy loss?, employment risk or continuity?
• Search for Meaning the event holds
Legal issues to recover costs or seek financial gain
Religious beliefs to sustain recovery
Hidden expectations from parents, siblings, family, partner
Temperment profile and capacity to process injury
Time Framework
• Initial evaluation• prepare patient before hand for paperwork, records,
define initial expectations. Arrive earlier to complete.
• Access willingness and resources; what is the capacity
of the patient to particpate? Are injury deficits limiting
information flow or emotional capacity?
• Provide written list of the next steps in the evaluation;
where to go, testing orders, contacts.
• Provide timely follow up to assure compliance and
answer questions from the patient. Do this before the
next visit or reschedule follow up.
Treatment Plan
• Build a treatment team
• Family, care giver role reversals
• Case management
• Referral resources for cognitive evaluation and
rehabilitation ( neuropsychology ), for individual and
marital therapy, for physical therapy
• Medications, Alternative Therapies
– Osteopathic, Chiropractic, Accupuncure, Nutritional
Treatment Plan
• Target specific measureable results:
• Overview of SCABS
• Sleep- consider sleep study or risk of etoh or sedativehypnotic rx from other source for self medication
• Cognition- consider Neuropsychology evaluation,
Cognitive rehabilitation, Medication,
• Affect- consider medication, individual therapy or marital
therapy referral.
• Behavior- discuss risks and benefit of medications
• Somatic- discuss importance of pain specialist and risk
of narcotic diversion-dependence to self medicate mood
• Medication can improve:
– Attention- stimulants used for ADHD tx such
as ritalin, Concerta, Focalin, Adderall, etc
– Working memory-Amantadine, Aricept,
Exelon ( patch ), Reminyl
– Mood stability- Depakote, other AED’s
– Self control-impulsivity-atypical antipsychotics
such as Abilify, Seroquel, Risperidal,etc
– Pain
Non medication treatment
• EEG Neurofeedback- brain wave
reinforcement programs
• Osteopathic and Chiropractic- help
muscloskeletal components of pain and
redirect somatic forces of imbalance
• Massage- help soft tissue injuries
• Accupuncture- help pain
• Physical Therapy- help pain, confidence
Time is fleeting
• MTBI has many faces of impairment
• The evaluation process requires a broad
framework of knowledge and resource
• Significant recovery is the RULE not the
Exception but the time frame and
expectations vary
• An ounce of Prevention is worth a pound
of cure….
Thank you.