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Transcript
Mild Traumatic Brain Injury
9th Annual Fall Nursing
Symposium-9/17/2008
Robert G. Kohn D.O.
Neurology, Psychiatry, Neuropsychiatry
815 344 7951
www.drrobertkohn.com
Goals
• 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
Overview
• 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 ).
–www.biail.org fact sheet page 1
Mild TBI
• A concussion or event that may leave a
person dazed or cause a brief loss of
consciousness
• 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
transient
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
hospitalizations,
emergency department
visits, and deaths between
1995-2001
• As a cumulative result of
TBI, an estimated 5.3
million Americans are
living with a permanent
disability
1
Deaths
4%
Hospitaliz
ations
17%
ED visits
79%
TBI Incidence by Severity in U.S.
Population15
• Mild TBI- 131
cases/100,000 people
(397,700)
• Moderate TBI- 15
cases/100,000 people
9%
9%
Mild
Moderate
Severe
(45,540)
• Severe TBI- 14
cases/100,000 people
(42,500)
• Mortality rates:
– severe TBI 33%
– moderate TBI 2.5%
82%
Incidence by External Cause in
1
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
LTD
• 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
Prevalence
(OEF/OIF)
• 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
related)
• 56% have moderate to severe TBI
• 44% have mild TBI (MTBI)
– 10–20% of combat veterans meet
the criteria for MTBI on postdeployment screening
44%
56%
Mild
Mod/Severe
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
Cortex
Thalamus
Striatum
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
involved.
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
abuse
– Consider PTSD and substance screening
forms
Collaborative History
• Obtain records from other professionals if
available; ie hospital emergency room
• Legal status; ie litigation pending or
implemented
• If child or young adult get school report
cards
• Assure time to obtain collaborative history
from significant others in patient’s life
5 Regions of Impairment to
evaluate-SCABS
• 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; www.cmrr.uic.edu
• Event Related Potentials-EEG based pattern of
visual, auditory or cognitive processing
QEEG Temporal lobe slowing +3sd
Visual relaxation
Autumn
Winter
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
Medications
• 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
Summary
• MTBI has many faces of impairment
• The evaluation process requires a broad
framework of knowledge and resource
allocation
• 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.
HAPPY FAMILY