Download Module 1 - Brain Injury Research Center

Assisting Patients with
Traumatic Brain Injury:
A Brief Guide for
Primary Care Physicians
Margaret A. Struchen, Ph.D.1,2
Lynne C. Davis, Ph.D.1,2
Stephen R. McCauley, Ph.D.1
Department of Physical Medicine and Rehabilitation, Baylor
College of Medicine, Houston, TX
2 Brain Injury Research Center, TIRR Memorial Hermann,
Houston, TX
1
Module 1
General Information on
Traumatic Brain Injury
© Baylor College of Medicine, 2009
Definition

A TBI occurs when an outside mechanical force is
applied to the head and affects brain functioning.
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The physical force can consist of a blow to the head
(such as from an assault, a fall, or when an individual
strikes his/her head during a motor vehicle accident) or
a rapid acceleration-deceleration event (like a motor
vehicle accident).
It is possible for the brain to become injured even if the
head has not directly struck or been struck by another
object.
The brain can become injured whether or not the skull is
fractured.
© Baylor College of Medicine, 2009
Causes of Injury
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The most common causes of TBI:
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Falls (28%)
Motor vehicle-traffic crashes (20%)
Being struck by or against an object (19%)
Assaults (11%).1
Blasts are a leading cause of TBI for active
duty military personnel in war zones.2
Overview:
Pathology/Pathophysiology of TBI
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Primary brain injury secondary to trauma:
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Cerebral contusions
Lacerations
Hemorrhage (sometimes considered secondary)
Diffuse axonal injury
Secondary injury to brain tissue:
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Intracranial hypertension
Brain shift and herniation
Biochemical processes
Swelling
Cerebral ischemia
© Baylor College of Medicine, 2009
Overview:
Pathology/Pathophysiology of TBI
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Cerebral contusions: typically in tips/bases of
frontal lobes and tips/bases/lateral surfaces of
temporal lobes.
Lacerations: less frequent but associated with
penetrating TBI
Hemorrhage: may be epidural, subdural,
subarachnoid, intraparenchymal, and/or
intraventricular.
Diffuse axonal injury (DAI): occurs due to
widespread shearing and stretching of axons and
myelin sheaths in white matter. DAI is best
correlate with prolonged coma after TBI.3
© Baylor College of Medicine, 2009
Overview:
Pathology/Pathophysiology of TBI
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Intracranial hypertension: most common cause of
death from TBI from those surviving initial injury
due to brainstem herniation compromising vital
functions.4 Compression effects and/or ischemic
injury secondary to intracranial hypertension can
cause further impairment for those who survive.
Brain shift: Pressure effects from bleeds, edema
can cause mass effect or brain shift leading to
additional damage to brain tissue.
Biochemical processes: that occur as part of the
body’s response to injury can cause additional
cell death and therefore, poorer functional
outcome.
© Baylor College of Medicine, 2009
Overview:
Pathology/Pathophysiology of TBI
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Brain swelling: can occur due to increased
cerebral blood volume or cerebral edema.
Swelling may be localized adjacent to contusions,
diffuse within a cerebral hemisphere, or diffuse
throughout both hemispheres.
Cerebral ischemia: can occur even without
increased intracranial pressure and may relate to
vascular disruption and vasospasm.
Most acute hospital care is focused on limiting or
eliminating secondary injury to the brain by:
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Keeping open airway
Providing appropriate seizure control
Relieving intracranial hypertension
Aggressively treating intracranial hematomas
© Baylor College of Medicine, 2009
Grading of Injury Severity
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Level of severity can be related to many
variables, including the amount of force involved
and the speed at which the head or object was
moving at the time of injury.
Injury severity classification labels refer to the
initial injury, not to the eventual outcome (i.e., a
person with a severe injury may have a good
outcome, a person with a mild injury may have a
poor outcome).
Typically, initial injuries with greater severity are
associated with poorer outcomes.
Injury severity classification assist with initial
triaging.
© Baylor College of Medicine, 2009
Grading of Injury Severity
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Duration of Loss of Consciousness:
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In acute hospital settings, tracked hourly/daily often
with GCS score (detailed below).
Longer duration of LOC, more severe the injury.
Glasgow Coma Scale5 score:
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Scale to assess responsiveness widely used.
Evaluates eye opening (score 1-4), motor responses (16), and verbal responses (1-5).
Total scores range from 3-15 and are sum of 3
subcomponent scores.
3-8 Severe; 9-12 Moderate; 13-15 Mild injury severity
Scale values available in website supplementary
materials.
© Baylor College of Medicine, 2009
Grading of Injury Severity
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Duration of Post-traumatic Confusion:
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After TBI, common for persons to be confused
or disoriented for a period of time after injury.
The ability to remember information during
this time is affected. In general, the longer the
period of post-traumatic confusion, the more
severe the injury.
© Baylor College of Medicine, 2009
Common Sequelae following Mild TBI
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Every brain injury is different, with heterogeneity
of sequelae being a hallmark of TBI.
Most common sequelae of a mild TBI (in order of
frequency) include:
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Headache
Fatigue
Dizziness
Irritability
Other fairly common sequelae after mild TBI
include:
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Sensitivity to light/noise; attention/concentration
problems; memory problems; slowed information
processing; depression; and less often blurred/double
vision.
© Baylor College of Medicine, 2009
Sequelae after Moderate to Severe TBI
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All of the following problems may be seen after TBI,
although some are more common than others.
Somatosensory:
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Motor:
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Hemiparesis, spasticity; slowed performance; poor
coordination; dysarthria
Cognitive:
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Headaches, fatigue, dizziness, blurred vision, visual field cuts,
sensitivity to light/noise, anosmia, aguesia
Attention/concentration problems; memory problems; slowed
information processing; visuospatial difficulties; executive
functioning impairments
Emotional/Behavioral:
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Decreased initiation; impaired self-awareness; impulsivity;
inappropriate or embarrassing behaviors; depression;
irritability/anger; emotional lability; anxiety
© Baylor College of Medicine, 2009
Sequelae of TBI
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Every brain injury is different.
Experiences vary due to factors such as:
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Severity of injury
Localization of injury to brain
Mechanism of injury
Other factors:
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Pre-injury functioning
Use of compensatory strategies
Material supports (e.g. financial resources, access to
transportation)
Social supports (e.g., family members, friends)
Awareness of patient’s ongoing symptoms
important to your clinical interactions and
treatment.
© Baylor College of Medicine, 2009
Typical Course of Recovery after Mild TBI
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Majority with mild TBI experience symptoms in
initial weeks and months after injury.
“Postconcussion syndrome” often termed to
describe symptoms experienced after mild TBI.
Most will feel close to “normal” within the first
three months after a single, uncomplicated mild
TBI.
Different people have different rates of recovery.
Recovery can be slower for:
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Persons with one or more previous brain injury.
Older-age adults.
© Baylor College of Medicine, 2009
Course of Recovery after Mild TBI
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Symptoms usually worse acutely.
Sometimes patients may not notice problems until they
attempt to resume normal daily activities (e.g., discovering
concentration problems after return to work).
Symptoms tend to get better over time for most people.
Small subset of individuals with mild TBI experience
continuing problems.
Presence of persisting symptoms likely due to multiple
factors, such as:
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Biomechanics of injury
Personal characteristics of injury person (and brain)
Severity of injury
Symptom presentation
Reactions to symptoms
Availability of material/social resources to address issues after
injury.
© Baylor College of Medicine, 2009
Typical Course
of Recovery after more Severe Injury
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Recovery course longer than for mild TBI.
Most rapid improvements in functioning occur in
first six months.
Continued improvement between six months and
one year after injury, although not as rapid or
dramatic as in first six-month period.
Between 1-2 years post-injury, recovery may
differ with some showing continued slow and
gradual improvement while others plateau.
Those with more severe injury show little change
2 or more years post-injury, although possible to
see functional changes with implementation of
compensatory strategies.
© Baylor College of Medicine, 2009
Typical Course
of Recovery after more Severe Injury
Patients with moderate to severe injuries
are more likely to have longer-lasting
sequelae post-injury.
 Likelihood increases with severity of injury
and degree of initial impairments related
to such injury.
 Longer durations of coma and/or posttraumatic confusion associated with more
severe impairments post-injury.
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© Baylor College of Medicine, 2009
References
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1. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic Brain Injury in
the United States: Emergency Department Visits, Hospitalizations, and
Deaths 2006. Atlanta, GA: Centers for Disease Control and Prevention,
National Center for Injury Prevention and Control.
2. Defense and Veterans Brain Injury Center (DVBIC). [unpublished].
Washington (DC): U.S. Department of Defense; 2005.
3. Gennarelli TA, Thibault LE, Adams JH, Graham DI, Thompson CJ,
Marcincin RP. Diffuse axonal injury and traumatic coma in the primate.
Ann Neurol 1982; 12(6): 564-74.
4. Becker DP, Miller JD, Ward JD, Greenberg RP, Young HF, Sakalas R. The
outcome from severe head injury with early diagnosis and intensive
management. J Neurosurg 1977; 47:491-502.
5. Teasdale G, Jennett B. Assessment of coma and impaired
consciousness. A practical scale. Lancet 1974; 2: 81-84.
© Baylor College of Medicine, 2009
Module 2
Clarifying Diagnosis and
Utilization of the
Neuropsychological Report
© Baylor College of Medicine, 2009
Clarifying Diagnosis
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General practitioners may not be aware that a
new patient has experienced a traumatic brain
injury.
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Patient may present to you for other medical reason.
Patient may not spontaneously report history of TBI.
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Not reported because presenting symptom complaint
unrelated to TBI.
Not reported because patient unaware of importance of
injury to your care.
Not reported due to patient’s cognitive deficits which may
interfere with accurate self-reporting of medical history
information.
Important as part of your initial patient history to
inquire as to history of significant head injury to
ascertain presence of TBI.
© Baylor College of Medicine, 2009
Clarifying Diagnosis
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Questions to include:
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Ever had injury to head?
If so, accompanied by loss of consciousness (LOC),
confusion, or memory disturbance?
Obtain details of any hospital treatment,
neuroimaging studies, brain-injury related
surgeries, and rehabilitation services.
If patient has had head injury but no LOC,
confusion, or memory problems, it is unlikely that
a TBI has occurred. If head injury is accompanied
by these problems, it is likely that a TBI has
occurred. Query to determine severity of injury.
© Baylor College of Medicine, 2009
Clarifying Diagnosis
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Patients with cognitive problems may have
difficulty answering these questions or providing
an accurate history.
Keep in mind that persons with TBI may have few
obvious physical problems, yet have significant
cognitive, emotional, or behavioral difficulties.
When encountering patients with severe cognitive
impairments, obtaining permission from the
patient to talk with other family members may be
critical to your management of the patient’s care.
© Baylor College of Medicine, 2009
Clarifying Diagnosis
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Obtaining medical records is important to understanding
history of your patient with TBI.
Variables to look for:
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Date and severity of injury
Physical, cognitive, emotional, and behavioral changes related
to injury
Therapies received
Assistive devices used to help with daily functioning
Social and material resources
Functional limitations
Recommendations
Attend to the various dates when information was gathered,
as information that was gathered early in recovery may not
accurately reflect current functioning.
The closer in time that data collected in relation to your
visit, the more accurate findings will be towards depicting
your patient’s status.
© Baylor College of Medicine, 2009
The Neuropsychological (NP) Report
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A good source of information about the patient’s physical,
cognitive, emotional, and behavioral status in the NP
report.
NP evaluation uses the following types of measures to
assess the domains of interest:
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Interview
Observation
Behavioral measures
Patients often referred for NP evaluation if have or
suspected to have neurological disorder or dysfunction.
Patients with moderate to severe TBI often will have had NP
evaluation, although those with limited healthcare
resources may not have had such an assessment.
Few with mild TBI will have had such an evaluation,
especially for those who were not hospitalized as a result of
the injury.
© Baylor College of Medicine, 2009
The Neuropsychological (NP) Report:
Why can it be helpful?
Describes areas of cognitive weakness and
strength, which may help determine what
modifications to your treatment approach
may be needed in caring for your patient.
 Describes emotional functioning which
may assist with consideration of
medication management and/or referral to
a psychologist or psychiatrist.
 NP report will provide recommendations
which may be helpful in determining what
might be your patient’s current needs.

© Baylor College of Medicine, 2009
The Neuropsychological (NP) Report:
Areas Typically Evaluated
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Orientation
Attention
Memory
Language
Visuospatial
Functioning
Processing Speed
Problem-Solving
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Conceptual Reasoning
Self-awareness
Emotional
Functioning:
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Depression
Anxiety
Anger/irritability
© Baylor College of Medicine, 2009
The Neuropsychological (NP) Report:
When should you refer your patient?
If your patient never had a NP assessment
and he or she is experiencing cognitive
problems as indicated by self-report,
family report, or clinical observation.
 If the patient had a NP evaluation, but
findings are outdated and you need an
update on current patient functioning.

© Baylor College of Medicine, 2009
The Neuropsychological (NP) Report:
Maximizing Utility
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Be sure to provide your medical records on the
patient to the neuropsychologist.
Be clear in communicating you referral
question(s).
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Specific questions will yield more fruitful information
than a non-specific referral.
Be sure to include all questions you wish to be
addressed.
Be sure to specify the time by which you need to
receive the evaluation results, especially if critical
clinical decisions are pending receipt of the
results.
Contact the neuropsychologist to talk over report
if you have any questions.
© Baylor College of Medicine, 2009
Module 3
Common Comorbid
Emotional and Behavioral
Disorders for
Persons with TBI
© Baylor College of Medicine, 2009
Emotional/Behavioral Disorders
commonly associated with TBI
Postconcussion syndrome
 Depression
 Post-traumatic stress disorder
 Anger, agitation, aggression
 Problems with behavioral regulation
 Impaired self-awareness
 Sexual dysfunction
 Alcohol and substance abuse issues

© Baylor College of Medicine, 2009
Postconcussion syndrome (PCS)
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Set of symptoms occurring in loose cluster
following mild (sometimes moderate) TBI:
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Headache
Dizziness
Irritability
Difficulty concentrating
Impairment of memory
Insomnia
Reduced tolerance for stress, emotional
excitement, and alcohol
© Baylor College of Medicine, 2009
Postconcussion syndrome (PCS)
Estimated 80-100% of patients with
uncomplicated mild TBI experience at
least one PCS symptom in first month
post-injury.1
 Symptoms often accompanied with
feelings of depression, anxiety, fear of
permanent brain damage.
 Most recover completely within 1-3
months after injury, but minority (roughly
10-20%) experience more persistent
symptoms.2

© Baylor College of Medicine, 2009
Postconcussion syndrome (PCS)
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Although secondary gain
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often a concern, studies have found that a large
percentage of those with persisting PCS
symptoms have no such incentive – so do not
automatically assume that secondary gain is the
root cause of your patient’s symptoms.3-4
Chronic symptom presentation in patients with an
initial uncomplicated mild TBI is likely
multifactorial (physical, psychological and environmental).
Careful identification of factors and referral to
those experienced in these issues (e.g., physiatrists,
neuropsychologists, and the like) will be important to the
management of these patients.

(e.g., participation in litigation
or receiving insurance or other compensation after injury) is
© Baylor College of Medicine, 2009
Depression
Depression is the most common affective
disturbance after TBI and incidence rates
far exceed those of community base
rates.5-12
 Depression after TBI can exacerbate TBIrelated cognitive impairments (e.g.,
attention, memory, etc.).8, 13-16
 Depression also contributes to functional
impairment and quality of life for those
with TBI.17-18

© Baylor College of Medicine, 2009
Depression
Diagnosis of depression post-TBI can be
complicated as sequelae of TBI can lead to
overdiagnosis or underdiagnosis.
 Changes in sleep, libido, fatigue,
concentration, and memory may be direct
result of injury and not a symptom of
depression but overlap can lead to
overdiagnosis.19
 Poor self-awareness after TBI can lead to
underreporting of symptoms contributing
to underdiagnosis.20-21

© Baylor College of Medicine, 2009
Depression
Carefully assess your patient’s symptoms
to determine if depression is present.
 Use of the Centers for Epidemiologic
Studies Depression Scale (CES-D)22 as a
good screening instrument for detecting
depression (available as a downloadable
file on our website).

© Baylor College of Medicine, 2009
Depression
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Assessment of suicidality in patients with TBI is important
as regular part of your evaluation of mood in these
patients. Persons with TBI and depression are at greater
risk for suicide relative to those with depression and no
history of TBI.23-25
Strongest predictors of suicide attempts in patients with
TBI are:
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Young age
Male gender
Increased feelings of hostility/aggression23
Substance use25
Patients who are post-TBI with co-morbid diagnoses of
mood disorder and substance abuse were at 21 times
higher odds of suicide attempts than persons without TBI.26
© Baylor College of Medicine, 2009
Post-traumatic stress disorder (PTSD)
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Diagnosis of PTSD in patients with TBI is
controversial since concern over whether patients
with no memory of circumstances around the
traumatic event could develop features and meet
criteria for PTSD (frequent re-experiencing of
event unlikely to occur).
Discussion of these is beyond scope of this
podcast, but convincing evidence that PTSD can
develop in patient with TBI severe enough to
result in period of amnesia surrounding traumatic
event.
© Baylor College of Medicine, 2009
Post-traumatic stress disorder (PTSD)
Prevalence rates vary from 12-24% in
those with mild TBI and 27% in those with
severe TBI.27-30
 One study found rate of PTSD in patients
with TBI to be 5.8 time the relative risk
observed in the general population.30
 Note: Generalized anxiety disorder is
possibly the most common type of anxiety
disorder diagnosed following TBI.31-32

© Baylor College of Medicine, 2009
Post-traumatic stress disorder (PTSD)
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Keep in mind that features of PTSD overlap with
postconcussion syndrome. Overlapping features
include:
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Feeling of anxiety
Disordered sleep
Concentration difficulties
Irritability/anger outbursts
Trouble recalling important details of traumatic event
Diminished interest or participation in significant
activities
Feelings of detachment from others
© Baylor College of Medicine, 2009
Post-traumatic stress disorder (PTSD)
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Good screening instrument to help detect PTSD following
TBI is the Posttraumatic Checklist-Civilian form (PCL-C),
available as a downloadable file from our website.
Post-TBI PTSD is sometimes associated with pre-injury
psychiatric history.33-34 Other factors associated with PTSD
include:
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Trauma severity
Poor social support networks
High number of life stressors34
Specific features of PTSD for patients with TBI include:
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PTSD more common in patients who deny loss of
consciousness.29
Women are over-represented among those with TBI and
PTSD.29, 35
Patients with TBI are less likely to report re-experiencing
phenomena.33,35
© Baylor College of Medicine, 2009
Anger, Agitation, and Aggression
People often report having a “shorter fuse”
after TBI.
 Increased irritability noted for persons
with all levels of injury severity.
 Violent behavior is rare, but can occur.
 More commonly, verbal and sometimes
physical outbursts occur.

© Baylor College of Medicine, 2009
Anger, Agitation, and Aggression
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During acute recovery from severe TBI, patients
may experience agitated behavior and as much
as 33% may exhibit aggression and/or agitation
at 6 months post-injury.36
A high percentage of patients with severe TBI
(anywhere from 31-71%) report increased
irritability, aggression, or agitated behavior over
the long term. Also occurs in those with mild and
moderate TBI, however.37
Pre-injury history of poor social functioning,
substance abuse, and presence of major
depression significantly correlated with
aggressive behavior in persons with TBI.38
© Baylor College of Medicine, 2009
Problems with Behavioral Regulation
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After TBI, poor behavioral regulation may
be present including:
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Impulsivity
Poor initiation
Inappropriate behavior
Personality changes
Emotional dysregulation
These behavioral issues can greatly affect
the ability to resume community activities
(work, school, independent living) and can
interfere with relationships.
© Baylor College of Medicine, 2009
Problems with Behavioral Regulation
Impulsivity, or the difficulty inhibiting
actions, can occur after TBI.
 Neural mechanisms that help us “stop and
think” prior to acting have been affected.

© Baylor College of Medicine, 2009
Problems with Behavioral Regulation
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Patients may experience impaired initiation after
TBI, having trouble getting started with things
even if expressing an interest in engaging in
activities.
Often misinterpreted as “laziness” or
“noncompliance” by family members or
caregivers, can be a significant source of stress.
However, initiation difficulties can occur as a
result of damage to neural systems involved in
activating motor sequences and are not a deficit
of motivation.
© Baylor College of Medicine, 2009
Problems with Behavioral Regulation
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Inappropriate behaviors may occur, often due to
disinhibition.
Examples include:
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Asking casual acquaintances or strangers overly
personal questions (e.g., about finances or sexual
issues).
Disclosing overly personal information to others.
Engaging in inappropriate activities (e.g., childlike
behaviors or sexual behaviors)
Such problems are often very stressful for family
members, friends, and caregivers.
© Baylor College of Medicine, 2009
Problems with Behavioral Regulation
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Personality and social skill changes can
occur, including:
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Impaired social perceptiveness
Poor self-monitoring
Verbosity
Perseveration on topic
Difficulty maintaining topic or idea
Inability to benefit from previous social
experiences
© Baylor College of Medicine, 2009
Problems with Behavioral Regulation
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For some with TBI, emotional regulation can be
affected.
Emotions may shift quickly from one extreme to
another.
Control of emotions may be difficult with patients
more easily crying or laughing in situations.
In some cases, emotional reactions may be
inappropriate to the context (e.g., laughing when
someone is hurt or dies) due to difficulty
controlling the emotional display.
© Baylor College of Medicine, 2009
Impaired Self-Awareness (ISA)
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Major challenge to healthcare professionals and
family members is impaired self-awareness.
As direct result of TBI, some individuals have
difficulty seeing themselves and their abilities and
behaviors accurately.
Nearly 45% of those with moderate to severe TBI
may experience a significant degree of ISA.39
Problems with ISA are associated with:
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Poor treatment compliance
Longer rehabilitation stays
Increased caregiver distress
Poorer vocational outcomes40
© Baylor College of Medicine, 2009
Impaired Self-Awareness (ISA)
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ISA is different than denial.
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Denial: person is aware at some level that
problem exists but uses defense mechanisms
to deny the problem
ISA: person does not realize that a problem is
present or is unaware of how problems might
impact their ability to perform daily tasks.
© Baylor College of Medicine, 2009
Impaired Self-Awareness (ISA)
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ISA may pose challenges to physicians as patient may
not fully understand the reasons for a referral or may
not be able to provide accurate history regarding
symptom and presenting problem.
ISA often noted more with more general questions (do
you have problems with memory?), rather than
specific ones (can you remember to go to scheduled
appointments?).21
ISA also more pronounced with nonphysical
functioning (cognitive and affective issues) than with
physical functioning.21
You may need to use more specific questions to elicit
information and/or may need assistance of a family
member or close other to help provide clinical history.
© Baylor College of Medicine, 2009
Impaired Self-Awareness (ISA)
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Presence of ISA may vary from person to person and
over time after injury.
Patients may or may not be able to report presence of
symptom, report how such symptoms affect
functioning, or anticipate when such symptoms are
likely to affect functioning in future situations.
For many with ISA, improvements are noted over time.
However, post-acute brain injury rehabilitation
programs may be helpful for increasing awareness.
Consultation with physiatrist or neuropsychologist may
be helpful, particularly if awareness problems are
interfering with your ability to treat your patient or are
contributing to family distress.
© Baylor College of Medicine, 2009
Sexual Dysfunction
Problems with sexual functioning and/or
intimacy issues are not uncommon among
persons with TBI.
 Although typically not addressed during
medical appointments, including a
standard question or questions about
sexual functioning may be important
(especially if other factors such as
prescription medications or depression
may impact sexual functioning).

© Baylor College of Medicine, 2009
Sexual Dysfunction

More common problems after TBI include:41

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Much less commonly reported include:

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Diminished libido
Decreased frequency of intercourse
Difficulty achieving/maintaining erection
Difficulty reaching orgasm
Hypersexuality
Problem sexual behaviors (e.g. exhibitionism, public or
frequent masturbation, promiscuity, sexual
aggressiveness).
Sexual problems not limited to those with
moderate/severe TBI, but may occur in those
with mild TBI as well.42
© Baylor College of Medicine, 2009
Alcohol and Substance Use/Abuse
Likelihood of confronting issues related to
alcohol or other substance use is high.43-46
 May be a pre-injury issue and often
related to cause of injury.
 Can also be a post-injury issue.
 Alcohol and substance use/abuse
associated with poorer outcomes.47-50

© Baylor College of Medicine, 2009
Alcohol and Substance Use/Abuse


Pre-injury abuse in patients with TBI is
common.45, 51
Pre-injury history of alcohol abuse related to:





Higher mortality
Greater frequency of mass lesions
Poorer neuropsychological functioning acutely and at 1year follow-up
Poorer global outcome45, 52-53
If TBI occurred as result of alcohol intoxication,
patient has a 4-fold increased risk of sustaining a
second TBI.54
© Baylor College of Medicine, 2009
Alcohol and Substance Use/Abuse
Post-injury substance use also carries
significant morbidity after injury
(particularly for those with greater TBI
severity).
 Substance use may have greater effect on
cognition and judgment than may have
been the case prior to injury.
 Highly problematic for patients with poor
insight, reasoning, and judgment who
become even more impaired while
drinking or using illegal drugs.

© Baylor College of Medicine, 2009
Alcohol and Substance Use/Abuse
Although alcohol and substance use/abuse
often declines in the near-term following
TBI, longer-term follow-up studies suggest
that use (of alcohol in particular) increases
to pre-injury levels over time.
 Approximately 15-25% of persons with
TBI who were abstinent or light drinkers
prior to injury may become heavy drinkers
after injury.55

© Baylor College of Medicine, 2009
References
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1. Levin HS, Mattis S, Ruff RM, et al. Neurobehavioral outcome following minor head
injury: a three-center study. Journal of Neurosurgery. Feb 1987;66(2):234-243.
2. Ruff RM, Camenzuli L, Mueller J. Miserable minority: Emotional risk factors that
influence the outcome of a mild traumatic brain injury. Brain Injury. Aug 1996;10(8):551565.
3. McCauley SR, Boake C, Pedroza C, et al. Correlates of persistent postconcussional
disorder: DSM-IV criteria versus ICD-10. J Clin Exp Neuropsychol. Jul 25 2007:1-20.
4. Binder LM, Rohling ML. Money matters: a meta-analytic review of the effects of financial
incentives on recovery after closed-head injury. The American journal of psychiatry. Jan
1996;153(1):7-10.
5. Dikmen SS, Bombardier CH, Machamer JE, Fann JR, Temkin NR. Natural history of
depression in traumatic brain injury. Archives of Physical Medicine and Rehabilitation 2004;
85:1457-1464.
6. Fann J, Katon W, Uomoto J, Esselman P. Psychiatric disorders and functional disability in
outpatients with traumatic brain injury. American Journal of Psychology 1995; 152:14931499.
7. Federoff JP, Starkstein SE, Forrester AW, et al. Depression in patients with acute
traumatic brain injury. American Journal of Psychiatry 1992; 149:918-923.
8. Jorge RE, Robinson RG, Moser D. Tateno A, Crespo-Facorro B, Arndt S. Major depression
following traumatic brain injury. Archives of General Psychiatry 2004; 61:42-50.
© Baylor College of Medicine, 2009
References
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9. Kreutzer JS, Seel RT, Gourley E. The prevalence and symptom rates of depression after
traumatic brain injury: A comprehensive examination. Brain Injury 2001; 15:563-576.
10. Seel RT, Kreutzer JS. Depression assessment after traumatic brain injury: An
empirically-based classification method. Archives of Physical Medicine and Rehabilitation
2003; 84:1621-1628.
11. Seel RT, Kreutzer JS, Rosenthal M, Hammond FM, Corrigan JD, Black K. Depression after
traumatic brain injury: A National Institute on Disability and Rehabilitation Research model
systems multicenter investigation. Archives of Physical Medicine and Rehabilitation 2003;
84:177-184.
12. Underhill AT, Lobello SG, Stroud TP, Terry KS, Devivo MJ, Fine PR. Depression and life
satisfaction in patients with traumatic brain injury: A longitudinal study. Brain Injury 2003;
17:973-982.
13. Rappoport MJ, McCullagh S, Shammi P, Feinstein A. Cognitive impairment associated
with major depression following mild and moderate traumatic brain injury. J
Neuropsychiatry Clin Neurosci. Winter 2005;17(1):61-65.
14. Keiski MA, Shore DL, Hamilton JM. The role of depression in verbal memory following
traumatic brain injury. Clin Neuropsychol. Sep 2007;21(5):744-761.
15. Farrin L, Hull L, Unwin C, Wykes T, David A. Effects of depressed mood on objective and
subjective measures of attention. J Neuropsychiatry Clin Neurosci. Winter 2003;15(1):98104.
16. Chamelian L, Feinstein A. The effect of major depression on subjective and objective
cognitive deficits in mild to moderate traumatic brain injury. J Neuropsychiatry Clin
Neurosci. Winter 2006;18(1):33-38.
© Baylor College of Medicine, 2009
References
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17. Jorge RE, Robinson RG, Starkstein SE, Arndt SV. Influence of major depression on 1-year
outcome in patients with traumatic brain injury. J Neurosurg. Nov 1994;81(5):726-733.
18. McCleary C, Satz P, Forney D, et al. Depression after traumatic brain injury as a function of
Glasgow Outcome Score. J Clin Exp Neuropsychol. Apr 1998;20(2):270-279.
19. Robinson RG, Jorge RE. Mood disorders. In: Silver JM, McAllister TW, Yudofsky SC, eds.
Textbook of traumatic brain injury. Washington, D.C.: American Psychiatric Publishing, Inc. ;
2005:201-212.
20. Sherer M, Bergloff P, Boake C, High W, Jr., Levin E. The Awareness Questionnaire: factor
structure and internal consistency. Brain Inj. Jan 1998;12(1):63-68.
21. Sherer M, Boake C, Levin E, Silver BV, Ringholz G, High WM, Jr. Characteristics of impaired
awareness after traumatic brain injury. J Int Neuropsychol Soc. Jul 1998;4(4):380-387.
22. Bay E, Hagerty BM, Williams RA. Depressive symptomatology after mild-to-moderate
traumatic brain injury: a comparison of three measures. Arch Psychiatr Nurs. Feb 2007;21(1):211.
23. Oquendo MA, Friedman JH, Grunebaum MF, Burke A, Silver JM, Mann JJ. Suicidal behavior
and mild traumatic brain injury in major depression. J Nerv Ment Dis. Jun 2004;192(6):430434.
24. Silver JM, Kramer R, Greenwald S, Weissman M. The association between head injuries and
psychiatric disorders: findings from the New Haven NIMH Epidemiologic Catchment Area Study.
Brain Inj. Nov 2001;15(11):935-945.
© Baylor College of Medicine, 2009
References
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25. Teasdale TW, Engberg AW. Suicide after traumatic brain injury: a population study. J
Neurol Neurosurg Psychiatry. Oct 2001;71(4):436-440.
26. Simpson G, Tate R. Clinical features of suicide attempts after traumatic brain injury. J
Nerv Ment Dis. Oct 2005;193(10):680-685.
27. Bryant RA, Harvey AG. Relationship between acute stress disorder and posttraumatic
stress disorder following mild traumatic brain injury. Am J Psychiatry. May
1998;155(5):625-629.
28. Bryant RA, Marosszeky JE, Crooks J, Gurka JA. Posttraumatic stress disorder after
severe traumatic brain injury. Am J Psychiatry. Apr 2000;157(4):629-631.
29. Levin HS, Brown SA, Song JX, et al. Depression and posttraumatic stress disorder at
three months after mild to moderate traumatic brain injury. J Clin Exp Neuropsychol. Dec
2001;23(6):754-769.
30. van Reekum R, Bolago I, Finlayson MA, Garner S, Links PS. Psychiatric disorders after
traumatic brain injury. Brain Inj. May 1996;10(5):319-327
31. Hiott DW, Labbate L. Anxiety disorders associated with traumatic brain injuries.
NeuroRehabilitation. 2002;17(4):345-355.
32. Rogers JM, Read CA. Psychiatric comorbidity following traumatic brain injury. Brain
Injury. 2007;21(13-14):1321-1333.
33. Ashman TA, Spielman LA, Hibbard MR, Silver JM, Chandna T, Gordon WA. Psychiatric
challenges in the first 6 years after traumatic brain injury: cross-sequential analyses of Axis
I disorders. Arch Phys Med Rehabil. Apr 2004;85(4 Suppl 2):S36-42.
© Baylor College of Medicine, 2009
References
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34. Ozer EJ, Best SR, Lipsey TL, Weiss DS. Predictors of posttraumatic stress disorder and
symptoms in adults: a meta-analysis. Psychol Bull. Jan 2003;129(1):52-73.
35. McMillan TM. Post-traumatic stress disorder following minor and severe closed head
injury: 10 single cases. Brain Inj. Oct 1996;10(10):749-758.
36. Levin HS, Grossman RG. Behavioral sequelae of closed head injury. A quantitative study.
Arch Neurol. Nov 1978;35(11):720-727.
37. Hibbard MR, Uysal S, Kepler K, Bogdany J, Silver J. Axis I psychopathology in individuals
with traumatic brain injury. J Head Trauma Rehabil. Aug 1998;13(4):24-39.
38.Tateno A, Jorge RE, Robinson RG. Clinical correlates of aggressive behavior after traumatic
brain injury. J Neuropsychiatry Clin Neurosci. Spring 2003;15(2):155-160.
39. Freeland J. Awareness of deficits: A complex interplay of neurological, personality, social
and rehabilitation factors. Magazine. 1996;4:32-34.
40. Sherer M. Rehabilitation of impaired awareness. In: High WM, Jr., Sander AM, Struchen
MA, Hart KA, eds. Rehabilitation for traumatic brain injury. New York: Oxford University
Press; 2005:31-46.
41. Kreutzer JS, Zasler ND. Psychosexual consequences of traumatic brain injury:
methodology and preliminary findings. Brain Inj. Apr-Jun 1989;3(2):177-186.
42. Kosteljanetz M, Jensen TS, Nørgård B, Lunde I, Jensen PB, Johnsen SG. Sexual and
hypothalamic dysfunction in the postconcussional syndrome. Acta Neurol Scand. Mar
1981;63(3):169-180.
© Baylor College of Medicine, 2009
References
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43. Sherer M, Bergloff P, High W, Jr., Nick TG. Contribution of functional ratings to prediction
of longterm employment outcome after traumatic brain injury. Brain Inj. Dec
1999;13(12):973-981.
44. Bogner JA, Corrigan JD, Mysiw WJ, Clinchot D, Fugate L. A comparison of substance
abuse and violence in the prediction of long-term rehabilitation outcomes after traumatic
brain injury. Arch Phys Med Rehabil. May 2001;82(5):571-577.
45. Corrigan JD. Substance abuse as a mediating factor in outcome from traumatic brain
injury. Arch Phys Med Rehabil. Apr 1995;76(4):302-309.
46. Corrigan JD, Bogner JA, Mysiw WJ, Clinchot D, Fugate L. Life satisfaction after traumatic
brain injury. J Head Trauma Rehabil. Dec 2001;16(6):543-555.
47. Kreutzer JS, Marwitz JH, Witol AD. Interrelationships between crime, substance abuse,
and aggressive behaviours among persons with traumatic brain injury. Brain Inj. Nov-Dec
1995;9(8):757-768.
48. Brooks N, Symington C, Beattie A, Campsie L, Bryden J, McKinlay W. Alcohol and other
predictors of cognitive recovery after severe head injury. Brain Inj. Jul-Sep 1989;3(3):235246.
49. Hall KM, Karzmark P, Stevens M, Englander J, O'Hare P, Wright J. Family stressors in
traumatic brain injury: a two-year follow-up. Arch Phys Med Rehabil. Aug 1994;75(8):876884.
50. Kreutzer JS, Wehman PH, Harris JA, Burns CT, Young HF. Substance abuse and crime
patterns among persons with traumatic brain injury referred for supported employment.
Brain Inj. Apr-Jun 1991;5(2):177-187.
© Baylor College of Medicine, 2009
References
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
51.Corrigan JD, Bogner J, Lamb-Hart G. Problematic substance use identified in the TBI Model
Systems national database: The Center for Outcome Measurement in Brain Injury. Center for
Outcome Measurement in Brain Injury (COMBI) website:
http://tbims.org/combi/subst/index/html. 2003. Accessed March 20, 2008.
52. Dikmen SS, Donovan DM, Loberg T, Machamer JE, Temkin NR. Alcohol use and its effects
on neuropsychological outcome in head injury. Neuropsychology. 1993;7(3):296-305.
53. Ruff RM, Marshall LF, Klauber MR, et al. Alcohol abuse and neurological outcome of the
severely head injured. Journal of Head Trauma Rehabilitation. 1990;5(3):21-31.
54. Winqvist S, Luukinen H, Jokelainen J, Lehtilahti M, Nayha S, Hillbom M. Recurrent
traumatic brain injury is predicted by the index injury occurring under the influence of
alcohol. Brain Inj. Sep 2008;22(10):780-785.
55. Corrigan JD, Rust E, Lamb-Hart GL. The nature and extent of substance abuse problems
among persons with traumatic brain injuries. J Head Trauma Rehabil. 1995;11(5):58-69.
© Baylor College of Medicine, 2009
Module 4
Modifying Clinical Practice
and Suggestions Regarding
Resources
© Baylor College of Medicine, 2009
Modifications to Clinical Practice
Patients with TBI may experience sensory,
motor, cognitive, behavioral, and
emotional difficulties that can impact the
ability to provide accurate history and to
comply with treatment.
 This section provides selected examples of
tips to assist you in working with patients
with TBI.

© Baylor College of Medicine, 2009
Modifications to Clinical Practice

Patient with learning/memory problems:

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
Provide all important information in writing.
Repeat important information many times.
Ask patient to repeat back important information.
Depending on severity of the impairment, consultation
with family or close others may be needed.
Patients should be encourage to write down important
information in an organized fashion (like a planner or
memory notebook).
Patients may need reminder calls the day before their
appointments, and in some cases, on the day of the
appointment as well.
© Baylor College of Medicine, 2009
Modifications to Clinical Practice

Patient with attention problems:




Conduct session in a quiet environment with
minimal distraction
Focus on one topic at a time
Ask patient to repeat back important
information
If patient is getting off-topic, provide
redirection and cueing to return to topic at
hand.
© Baylor College of Medicine, 2009
Modifications to Clinical Practice

Patients with slowed speed of processing:



Allow extra time for patient to process your
statements and to respond.
Present information at a slower rate of speed,
and focus on one issue at a time.
Encourage the patient to ask others to slow
down or repeat information as needed.
© Baylor College of Medicine, 2009
Modifications to Clinical Practice




You may wish to consider staff training for all
support staff to ensure that all patients are
treated with courtesy and flexibility.
Training should include all staff members who
might interact with patients, including
receptionists, administrative assistants, and
others.
Increasing staff knowledge about potential
difficulties that patients with TBI may experience
can prevent negative interactions from occurring.
Increased staff knowledge may also enhance the
clinical experience for both patients and staff
members.
© Baylor College of Medicine, 2009
Modifications to Clinical Practice

Examples of issues that can present challenges to
the staff/patient interaction:

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

Dysarthria: some patients with TBI may have slurred
speech, which can be misinterpreted as intoxication with
patients being misperceived as being “drunk.”
Increased staff awareness of this issue can prevent a
negative interaction from occurring.
In addition, such patients may require staff to pay close
attention to patients to understand information.
It may be necessary for staff to request that information
be written down to ensure that they are receiving the
correct interpretation of the patient’s communication.
© Baylor College of Medicine, 2009
Modifications to Clinical Practice




Slowed speed of processing/response: Patients
may take longer to respond to questions or to
get their ideas out.
Encourage staff to be patient and wait for the
patient to complete the statement.
Bypassing the patient by speaking only to
family can be upsetting to the patient with TBI.
If clarification of the patient’s statement is
needed, staff can then ask the patient or
family to clarify.
© Baylor College of Medicine, 2009
Modifications to Clinical Practice





Memory problems: Patients with such
problems are likely to have difficulty
remembering appointments. To facilitate
attendance, staff should be encouraged to:
Provide appointment date/time in writing.
Call patient with reminder the day before
appointment.
Consider calling on day of appointment for
reminder.
Provide any additional instructions needed for
appointment in writing.
© Baylor College of Medicine, 2009
Modifications to Clinical Practice
Take time to let staff members know if
there are any modifications that you
would recommend in interacting with
specific patients to facilitate a good clinical
experience.
 Encourage staff to use courtesy with all
patients and to come to you if they are
having any particular challenge in
interacting with a specific patient.

© Baylor College of Medicine, 2009
Resources - Referrals

Your patient with TBI may benefit from referral to
specialized healthcare providers and/or TBIrelated resources. Here are some resources that
you may find helpful in working with your patient
with TBI:

Physiatrist: physician specializing in rehabilitation of
neurological conditions like TBI, stroke, and spinal cord
injury. Such physicians also treat musculoskeletal
injuries, pain syndromes, and sports injuries. Other
physician specialists who may be helpful for your patient
with TBI include: behavioral neurologists,
neurorehabilitation specialists, and neuropsychiatrists/
© Baylor College of Medicine, 2009
Resources - Referrals




Neuropsychologists: clinical psychologists with advanced
training in brain-behavior relationships. They specialize
in the assessment of cognitive functioning and may
provide specification of your patient’s cognitive strengths
and weaknesses, along with recommendations for
interventions and referrals.
Speech language pathologists: specialize in assessment,
diagnosis, and treatment of language and cognitive
communication disorders. They also evaluate and treat
swallowing problems.
Occupational therapists: work with patients to maximize
performance of activities of daily living (e.g., dressing,
grooming, bathing, feeding, etc.)
Physical therapists: work with patients to improve their
ability to move and function within their environment
and to restore fitness and health.
© Baylor College of Medicine, 2009
Resources - Referrals


Clinical and counseling psychologists: provide
psychotherapy to patients with TBI and their
family members.
Rehabilitation counselors: specialize in working
with patients with disabilities, providing
personal and vocational counseling,
coordination of vocational training and job
placement services.
© Baylor College of Medicine, 2009
Resources - Referrals

Your patient with TBI and his or her family may
also benefit from referral to state and nationallyrun resources that may provide information and
assistance. Examples include:



Brain Injury Association of America: leading organization
servicing and advocating for persons with TBI and their
families. A network of 40 state affiliates and hundreds of
local chapters provide information, education, and
support.
North American Brain Injury Society: organization
composed of professionals involved in care of those with
brain injury. Provides educational programs and
scientific updates to all those interested.
Vocational Services: Each state agency provides funding
to assist patients in searching for employment, obtaining
job training, and providing support for services to
facilitate return to work.
© Baylor College of Medicine, 2009