Download Introduction to Traumatic Brain Injury

INTRODUCTION TO
TRAUMATIC BRAIN INJURY (TBI)
JULY, 2011
Cheryl L. Shigaki, Ph.D., ABPP
& Thomas Martin, Psy.D., ABPP
Psychologists in US Health Care
Rehabilitation Psychology – focuses on
adjustment to disability, maximizing
function, full-participation in life activities.
 Health Psychology – focuses on the
intersection between behavior and health.
 Neuropsychology – focuses on cognitive
and behavioral sequelae from insults to
the brain.

Rusk Rehabilitation Center
Columbia, Missouri
60 inpatient beds –
serves post-acute:
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Brain injury
Spinal Cord Injury
Stroke
Multi-trauma
Debility
TBI and Healthcare
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The public and many health care professionals have
limited and/or inaccurate understanding of TBI.
Overlap between TBI and psychiatric symptoms
Benefit and challenges of screening to identify history
of TBI?
 Benefit – Avoid misdiagnosis and promote care
 “Have you ever had a head injury?” not effective
TBI in Rwanda
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People with new brain injuries
 Recognizing
mild TBI
 Helping victims and families adjust to moderate-severe
TBI

People with previous TBI
 Understanding
personality and behavior change
 Supporting chronic physical, cognitive and emotional
effects
TBI and Healthcare

Typical rehabilitation approaches include:
Restorative strategies: Direct intervention to improve the
problem
 Compensatory strategies: Intervention focuses on adapting
to the problem / working around it.
 Psychological intervention: Address emotional reaction to
loss and/or trauma; support motivation for active recovery.
 Family caregiver support: Education about what to expect,
how to manage problem behaviors and advocate for their
loved one, and provide support for coping with stress and
loss.

The Brain and TBI
The brain weighs about 1.4 kgs, with a
consistency somewhere between butter
and gelatin.
 TBI causes brain damage in a number
of ways. Damage can be caused by
both primary and secondary injuries.

Overview of the Brain

CEREBRAL HEMISPHERES
 Left
hemisphere
 Right hemisphere

FOUR LOBES OF THE BRAIN
 Frontal
lobe
 Parietal lobe
 Temporal lobe
 Occipital lobe

BRAIN CELLS (NEURONS)
Lobes of the Brain
Structure of a Neuron (brain cell)
Axon
Dendrite
Axon terminal
Soma
Node
Schwann cell
Nucleus
Myelin sheath
CC-BY-SA-3.0; Released under the GNU Free Documentation License.
The Corpus Callosum From Above
Image from Gray’s Anatomy.
In the public domain
Good Neuroanatomy Website
Florida Institute for
Neurologic Rehabilitation
http:// www. finr. Net
Note: App for iPhone now
available!
Common Primary Injuries
Skull fractures
 Contusions (bruising)
 Intracranial hemorrhage (hematomas)
 Diffuse axonal injury (DAI)

Contusions

Contusions are hemorrhagic lesions that
typically form at the crests of gyri on
the surface of the brain:
contusions form at the site of cranial
impact.
 Contrecoup contusions form opposite the
cranial impact and are typically more
severe.
 Coup
Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist. http://creativecommons.org/licenses/by/2.5/
The inside of
the skull
Is not smooth,
it has sharp
ridges
Hematomas

Classified by the location of bleeding;
hematomas can damage the brain by exerting
pressure on underlying brain structures
 Epidural
 Subdural
 Subarachnoid
Hematomas
Subdural
 within the layers of
brain covering
 Due to vein bleeding
which is slower than
artery bleeding.
 May not be discovered
until days or weeks
after the accident
Epidural
 Usually caused by
tears in arteries,
 Results in quick blood
build up between the
dura mater and the
skull.
Hematomas
Subdural hematoma as marked by the
arrow with significant midline shift
Epidural hematoma
Signs and Symptoms of Hematoma
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Fluctuating levels of
consciousness (or LOC)
Irritability
Seizures
Pain/Numbness
Headache
Dizziness
Hearing loss/ringing
Disorientation/amnesia
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Weakness/lethargy
Nausea/vomiting
Loss of appetite
Personality changes
Difficulty speaking,
slurred speech
Difficulty walking
Altered breathing
Blurred vision/abnormal
eye movement
Diffuse Axonal Injury (DAI)
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Widespread neuronal axon damage is frequently
associated with “stretching” of the brain (motor
vehicle accidents).
DAI is thought to contribute to LOC and prolonged
coma.
The problem associated with “shaken baby
syndrome”
Common Secondary Injuries
Ischemia – lack of blood/oxygen in area
leading to cell death
 Elevated intracranial pressure (swelling) &
diminished blood flow
 Neurochemical events – blood is toxic to brain
tissue
 Posttraumatic epilepsy
 Cerebral infection
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Elevated Intracranial Pressure (ICP)
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The cranium is inflexible, increased pressure
compresses brain tissue.
 Edema
 Hematoma
Sharp increases in intracranial pressure can
contribute to cerebral ischemia and herniation.
 Management of intracranial pressure and
maintaining cerebral blood flow are primary
concerns.

Edema (Swelling)
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Cerebral edema results from disruption of the
blood-brain barrier and impairment of
vasomotor autoregulation with concomitant
dilation of cerebral blood vessels.
Cerebral edema can lead to compression of
the ventricular system, herniation, occlusion of
intracranial vessels with secondary strokes, or
increased intracranial pressure.
Elevated Intracranial Pressure (ICP)
Types of brain
herniation:
1) Uncal
2) Central
3) Cingulate
4) Transcalvarial
5) Upward
6) Tonsillar
TBI ASSESSMENT
Terminology: “Cognitive”

So far, we have been using the term “cognitive” to
describe thinking styles in people with normal brain
function
 Based
on social & personal context and habits we learn
 Cognitive / Cognitive-Behavioral therapies are used to
improve psychological wellbeing. Psychologists help
patients explore and change thoughts and behaviors
that are maladaptive
Terminology: “Cognitive”

Can also be used to describe thinking skills that are
genetically/biologically driven and enhanced by
opportunities for learning.
 Neuropsychological
research has attempted to define
distinct aspects of “cognition” such as auditory & visual
memory, attention, problem-solving, speed, etc.
 Neuropsychological research also attempts to
distinguish between normal and impaired cognition
 Clinical Neuropsychologists test brain function following
brain injury or disease (using tasks and questions) and
make recommendations for living with impairment.
Assessment of Mild TBI
Domestic violence
 Sports injuries
 Work-related injuries
 The effects of mild TBI can be cumulative
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“Have you ever had a head injury?” is not an
effective way to evaluate.
Assessment of Mild TBI
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Acute Concussion Evaluation (ACE)
Heads Up: Brain Injury in Your Practice (CDC)
http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html
 Interview
and assessment of risk factors
 Symptom checklist
 Diagnostic codes (ICD)
 Sample follow-up plans/recommendations
 Versions
for return to work, school & sports
Assessment of Moderate-Severe TBI
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Three pathways to assess severity of acute TBI:
 Depth of coma
 Duration of coma
 The inability to continually register new
experiences (Posttraumatic Amnesia or PTA)
Glasgow Coma Scale (GCS)
Glasgow Coma Scale (GCS)
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Mild
 Glasgow Coma Scale (GCS) score 13-15
 Loss of consciousness (LOC) < 20 Minutes
 Posttraumatic amnesia (PTA) <24 hours
Moderate
Note: A GCS score can be broken down,
 GCS score 9 – 12
for example: GCS 12 = E4V3M5
 LOC 20 - 36 hour
 PTA 1 - 7 days
Forms and training scripts can be found at:
Severe
http://www.chems.alaska.gov/ems/docum
 GCS score 3-8
ents/GCS_Activity_2003.pdf
 LOC > 36 hours
 PTA > 7 days
Rancho Los Amigos:
Level of Cognitive Functioning Scale
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Helpful in assessing the patient in the first weeks or
months following an injury.
Does not require cooperation from the patient
Rancho “levels” are based on observations of the
patient’s response to external stimuli & provide a
descriptive guideline of the various stages of brain
injury.
Forms and descriptions can be found at:
http://tbims.org/combi/lcfs/
Galveston Orientation & Amnesia Test
(GOAT)
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The GOAT can be used to track how
much a person is recovering while in
the hospital (no longer in a severe
coma).
Requires patient cooperation.
Score is 100 MINUS error points.
Score of 78 or more on three
consecutive occasions/days indicates
that patient is out of post-traumatic
amnesia (PTA).
Galveston Orientation & Amnesia Test
(GOAT)
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What is your name? (2)
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When were you born? (4)
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Where do you live? (4)
Where are you now? (5) City, (5) Hospital
On what date were you admitted to this hospital? (5)
How did you get here? (5)
What is the first event you can remember after the injury? (5)
Can you describe in detail the first event you recall after the
injury? (5)
Galveston Orientation & Amnesia Test
(GOAT)
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Can you describe the last event you recall before the accident? (5)
Can you describe in detail the first event you can recall before the
injury? (5)
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What time is it now? (-1 for each 30 min incorrect, up to -5)
What day of the week is it? (-1 for each day incorrect, -3)
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What day of the month is it? (-1 for each day incorrect, -5)
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What is the month? (-5 for each month incorrect, -15)
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What is the year? (-10 for each year incorrect, -30)
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Levin, H.S., O'Donnell, V.M., & Grossman, R.G. (1975). The Galveston orientation and amnesia test: A practical
scale to assess cognition after head injury. Journal of Nervous and Mental Diseases, 167, 675-684.
TBI OUTCOMES
Consequences of TBI
The brain controls every aspect of our being
and a traumatic brain injury has the capability
of impacting any aspect of a person’s physical,
cognitive, or psychological functioning.
 In-depth evaluation of these skills is the domain
of Neuropsychologists.

Impact of Mild TBI
Mild TBI is typically associated with modest and
temporary changes in functioning, while severe
TBI is associated with enduring changes and
sometimes mortality.
 Reductions in attention and information
processing speed and efficiency are the most
frequent cognitive consequences following mild
TBI.
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Physical Functioning: Mod-Severe TBI
Arm/leg weakness & paralysis
 Compromised speech and swallowing ability
 Dizziness & dyscoordination
 Diminished sense of smell and taste
 Hearing (e.g., tinnitus) and visual disturbance
(e.g., diplopia)
 Sleep disturbance and fatigue
 Chronic headaches and pain
 Sexual dysfunction

Cognitive Impact: Mod–Severe TBI
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Although severe TBI can
impact any aspect of
cognition, the high incidence
of orbitofrontal (front of the
brain, around eye sockets) and
anterior temporal lobe (tips
of the temporal lobes)
contusions often produces a
constellation of symptoms that
includes:
Cognitive Impact: Mod–Severe TBI
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Slow speed of cognitive processing (functional)
Slowed behavioral responding (functional)
Attention deficits
Impaired learning & memory (need more exposures)
Behavioral symptoms:
 impulsivity
 Perseveration
 initiation deficits
 planning and organization
Cognitive Impact: Mod-Severe TBI

The Thinker – Musée Rodin, Paris
TBI does not typically
compromise intelligence in
mild-moderate cases.
Speed of Processing
Speed of processing (reaction time) is very
sensitive to any brain insult
 Following a brain injury, it often takes longer to
take information in and react to events
 Reduced speed of processing can compromise
other cognitive abilities
 Degree of impairment may render the patient
dysfunctional in daily activities.
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Learning/Memory
Memory problems are the most common
cognitive complaint following a TBI
 Short term vs. long term memory
 Verbal memory vs. visual memory
 Explicit memory (e.g., experiences, facts,
events) vs. implicit (e.g., skills, habits) memory
 Research suggests deficit is in learning
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Attention
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Attention is on a continuum and task specific:
 Simple Attention: Ability to register and attend to
(e.g., focus on a noise)
 Focused Attention: Ability to focus on important
information while ignoring irrelevant information
 Sustained Attention: Ability to focus for extended
period
 Divided Attention: Shift attention between tasks
(e.g., cook & talk on the phone)
Executive Functions
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Executive Functions – Skills necessary for
complex goal-directed behavior and
adaptation to changes
 Planning
and organization ability
 Problem-solving ability
 Ability to initiate and sustain action and anticipate
consequences
 Ability to benefit from feedback and adjust
behavior
Personality Changes
 Impulsivity
 Grandiosity
 Apathy
/ lack of initiative
 Impaired ability to evaluate risk and need
for safety measures (meta-awareness,
metacognition)
 They don’t know what they don’t know
Personality changes
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Impulsivity
Grandiosity
Apathy / lack of initiative
Inability to be empathic / self-focused
Impaired ability to evaluate risk; judge one’s
physical, cognitive and emotional functioning
 Thinking
about thinking - They don’t know what they
don’t know
Psychiatric/Behavioral Impact
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Altered mood, behavior,
and personality are common
following TBI; even mild TBI
has been associated with
significant affective
disturbance.
Reactive, “organic” or both?
Psychiatric/Behavioral Impact
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Rates of psychiatric disorders following TBI:
 Major
depression (44%)
 Substance abuse/dependence (22%)
 Post-traumatic stress disorder (14%)
 Panic disorder (9%)
 Generalized anxiety disorder (9%),
 Obsessive compulsive disorder (6%)
 Bipolar disorder (4%)
 Schizophrenia (0.7%)
van Reekum et al., (2000)
Psychiatric/Behavioral Impact
Diminished tolerance for frustration
 Decreased social skills
 Adjustment disorders and emotional lability
 Aggressive behavior (verbal and physical),
particularly when overwhelmed
 Increased rates of alcohol and substance
abuse and risk of suicide
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Psychiatric/Behavioral Impact
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Symptom overlap between TBI
and PTSD:
Memory / attention
 Sensory changes (sensitivity)
 Depression/poor emotional control
 Headache, fatigue, other physical or
sensory problems
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Co-occurrence can make
diagnosis difficult
TBI and Post-traumatic Stress
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Self-report study (N>3000)
4
Groups
 Multi-trauma,
with no TBI
 Multi-trauma, with TBI (mild, mod, severe)
 Telephone
survey, 12 months post-injury
 Asked about cognition and PTSD symptoms
Zatzick, Rivara, Jurkovich et al. Arch Gen Psychiatry. 2010;61:1291-1300
TBI and Post-traumatic Stress
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More severe TBI was related to diminished signs
and symptoms of PTSD
 Due
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to impaired consolidation of traumatic memories
Those with facial injuries and spinal cord injuries
(SCI) showed increased risk for PTSD symptoms
At all levels of TBI, those with PTSD symptoms
reported the greatest levels of impairment
 Cognition,
activities
physical health, and functioning in everyday
TBI and Post-traumatic Stress
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In studies where cognition was tested
Individuals exposed to combat, rape
and childhood abuse have
demonstrated difficulty with verbal
learning.*
Adults with chronic PTSD were found
to have volume and activity
differences in the brain
(hippocampus)*
*Bremner JD. The Relationship between cognitive and brain changes in
Posttraumatic stress disorder. Ann NY Acad Sci 2006;1071: 80-86
.
Working with individuals who have TBI
and their families
Outcomes Following TBI
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Severity of injury is the best predictor of outcome
Age also noted to be a independent predictor
Other factors that contribute to outcome include:
prior history of TBI, history of substance abuse, PTSD,
vocational history, and adequacy of social
relationships
Larger brain volume and higher educational level
are known to exert a positive influence
Genetic factors also play a role.
General Cautions for Healthcare
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TBI can impact sensory functioning (e.g., diplopia and
altered vision, ringing in ears, and decreased balance)
TBI can contribute to the development of medical
disorders such as sleep disturbance and substance
abuse issues.
Communication deficits can be a significant source of
frustration and disability.
General Cautions for Healthcare
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Many medical conditions can exacerbate TBI
symptoms including sleep disorder, infection, and
pain.
Use of alcohol or other substances may have a worse
effect or lead to worse consequences for individuals
with TBI.
Individuals with a history of TBI are at increased risk
for future TBI. Cumulative effect of multiple
concussions.
Recommendations for Working with
Individuals with TBI
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Allow adequate time to process information and respond
Appreciate that the injured brain is easily overwhelmed
by multiple stimuli (noise, lights, activity)
Maintain a supportive setting that utilizes structure and
avoids dramatic changes in routine
Potential for behavioral problems increases when the
individual is physically, cognitively or emotionally
stressed (e.g., fatigue, pain) and with experience of
expressive language dysfunction
Recommendations for Working with
Individuals with TBI
Provide information in multiple modalities in a
concrete and brief manner with limited
distraction.
 Focus on one task at a time / limit multitasking.
 Memory for visual and verbal information may
be individual strength.
 Diminished initiation can easily be mistaken for
depression, apathy or resistance.

Recommendations for Working with
Individuals with TBI
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Receptive Language Deficits
 Speak
slowly, using short phrases and sentences
 Use gestures with your speech; use visual cues
 Repeat your message in different ways
 Do not rush-allow time for response, alleviating pressure
to speak and allowing time to process information
 Use an alternate communication system when
appropriate (i.e., pictures)
 Include the individual in conversation, but don’t overload
them with information
General Recommendations

For Expressive Language Deficits
 Ask
one-part yes/no questions
 Acknowledge and discuss the frustration the person might
be having when communication attempts are made
 Allow adequate time for the individual to speak
 Involve the individual in decision making whenever
possible, practicing expressive reasoning and review of
steps one might make to achieve a desired outcome
 Continue normal daily routines and encourage use of
learned strategies (e.g., over-articulation and increased
volume)
Cheryl L. Shigaki, Ph.D., ABPP
Associate Professor
University of Missouri
Department of Health Psychology
Dc116.88
One Hospital Drive
Columbia, MO 65212 USA
[email protected]