Traumatic Brain Injury Independent Study Course Released: April 2010 Sponsored By:

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Traumatic Brain Injury
Independent Study Course Released: April 2010
Sponsored By:
Department of Veterans Affairs
Employee Education System
This is a Veterans Health Administration System-Wide Training Program sponsored by
the Veterans Affairs Employee Education System and the Office of Public Health and
Environmental Hazards, Department of Veterans Affairs. It is produced by the Employee
Education System.
Table of Contents
Introductory Material
Independent Study Outline ..................................................................... ii
Program Implementation and VA Application Procedures ........................... iii
The estimated study time for this program is 5 hours ............................... iii
Program Development ......................................................................... iv
Content Materials
1
A Conceptual Framework for TBI Assessment and Management ........... 1
2
Epidemiology and the Nature of Traumatic Brain Injuries ...................... 5
3
VA Care and Rehabilitation for TBI and Polytrauma ............................ 21
4
Initial Assessment and Management of TBI ...................................... 31
5
Post-Acute/Chronic Sequelae: Medical and Physical Problems ............ 47
6
Assessment and Management of Cognitive Problems ........................ 57
7
Emotional and Behavioral Sequelae and Treatment ............................ 67
8
TBI in the Elderly and Aging with TBI ................................................ 80
9
The Impact of TBI on the Family System ........................................... 86
10 Community Integration and Extended Care: Services and Resources .... 96
11 References ................................................................................ 104
Appendices
A
AMA and ANCC Continuing Education Credits ................................. 124
B
Polytrauma System of Care Referral Regions and Facility Designation . 126
C
Recovering From Mild Brain Injury: A Guide For Patients ...................130
D
Interdisciplinary TBI Specialists for Possible Consultation .................. 140
E
Pharmacotheray and Associated Treatments for Physical/Somatic Symptoms following TBI ............................................................... 144
F
Pharmacotherapy in Concussion/mTB – List of Selected First line Agents ......................................................................... 148
G
Driving Issues after TBI ............................................................... 150
H
Disclosure[s] ............................................................................. 158
CME Test ........................................................................................ 160
Traumatic Brain Injury
i
Independent Study Outline
This independent study presents an overview of Traumatic Brain Injury (TBI)
issues that Primary Care practitioners may encounter when providing care to
Veterans and active duty military personnel.
Purpose
This independent study module is a part of the Veterans Health Initiative (VHI).
This VHI is a comprehensive program of continuing education designed to
improve recognition and treatment of health problems related to traumatic
brain injury.
Background
After completing this independent study, participants will be able to:
Objectives
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Identify the epidemiology and the nature of TBI;
Describe concussion management and treatment of mild TBI;
List the rehabilitation process for a Veteran with TBI;
Identify medical and physical problems of Veterans with TBI;
Identify cognitive problems for Veterans with TBI;
Recognize emotional and behavioral problems for Veterans with TBI;
Explain TBI in the Elderly and Aging with TBI;
List the issues and impact on the TBI survivor and their family;
Describe the issues related to driving for a TBI survivor; and
Describe the VA TBI System of Care
As a result of this program, clinicians will have a broader base of knowledge
with which to provide effective care to patients with TBI and a better under­
standing of patients who experience this condition. Drug treatments and
dosages provided in this study guide should be double-checked prior to pre­
scribing therapy.
Outcome
This independent study is primarily designed for Department of Veterans
Affairs clinicians and interested VA staff. Other health care providers, espe­
cially those working in Veterans and military health care facilities in the U.S.,
also are encouraged to complete this study module.
Target Audience
ii
Traumatic Brain Injury
Program Implementation and VA
Application Procedures
The estimated study time for this program is 5 hours.
To receive CME credit for this course:
1. Read the independent study materials in this booklet.
2. Complete the CME test questions (located at the back of this booklet)
by placing answers on the Independent Study Registration /Answer/
Evaluation Scantron Form (two-sided), which is located at the back of the
independent study booklet. A passing score of 70% or higher on the CME
test is required to receive credit. For more information on CME credits,
please see the AMA and ANCC Continuing Education Credits section
located in Appendix A.
3. Complete the program evaluation using the Scantron form.
4. Submit the completed Independent Study Registration /Answer/Evalua­
tion Scantron Form to:
Employee Education Resource Center
ATTN: Evaluation Processing Center (EPC)
Medical Forum Suite, 500
950 North 22nd Street
Birmingham, AL 35203-5300
Note: Scantron forms cannot be photocopied. For additional copies of
this independent study module, please contact your facility education
contact person.
If you have attained a passing score of 70% or higher, a certificate will be
mailed to you approximately 6-8 weeks after your test has been graded. The
test may be retaken.
If you have questions or special needs concerning this independent study,
please contact:
Constance L. Singleton, National Project Manager
(205) 731-1812 ext 317
Email to [email protected]
Traumatic Brain Injury
iii
Program Development:
Editors
Sherry Dyche Ceperich, Ph.D.
Rodney D. Vanderploeg, Ph.D., ABPP-CN
Psychologist
Clinical Neuropsychologist
Polytrauma Rehabilitation Center
Polytrauma/TBI
Hunter Holmes McGuire VAMC
Rehabilitation Program
Richmond, VA
Psychology Service
James A. Haley Veteran’s Hospital
David X Cifu, M.D.
Tampa, FL
National Director, PM&R VHA
Assoc. Professor
Chief, PM&R Service
Univ. of South Florida
Hunter Holmes McGuire VAMC
Depts. of Psychiatry and Psychology
Richmond, VA
Professor and Chairman,
Micaela Cornis-Pop, Ph.D.
Virginia Commonwealth University
Speech Pathologist
Dept. of PM&R
VACO Rehabilitation Services
Hunter Holmes McGuire VAMC
Micaela Cornis-Pop, Ph.D.
Richmond, VA
Speech Pathologist
Assistant Professor
VACO Rehabilitation Services
Virginia Commonwealth University
Hunter Holmes McGuire VAMC
Dept. of PM&R
Richmond, VA
Assistant Professor
Authors
Virginia Commonwealth University
Sharon M. Benedict, Ph.D.
Dept. of PM&R
Rehabilitation Psychologist
VACO Rehabilitation Services
Henry L. Lew, MD, PhD
Hunter Holmes McGuire VAMC
DVBIC National Consultant for PM&R
Richmond, VA
Professor, Department of PM&R
Virginia Commonwealth University
Heather G. Belanger, Ph.D., ABPP-CN
Clinical Neuropsychologist
Kimberly Meyer, MSN, CNRN, ACNP-BC
Polytrauma/TBI
Neuroscience Clinician
Rehabilitation Program
Defense and Veterans Brain Injury Center
Psychology Service
Washington, DC
James A. Haley Veteran’s Hospital
Tampa, FL
Assistant Professor
Univ. of South Florida
Dept. of Psychology
iv
Traumatic Brain Injury
Program Development:
Shane McNamee, M.D.
Barbara Sigford, M.D., Ph.D., Retired
Medical Director, Polytrauma
VACO Rehabilitation Services
Hunter Holmes McGuire VAMC
Director, Physical Medicine and
Richmond, VA
Rehabilitation Services
Assistant Professor
Washington, DC
Virginia Commonwealth University
Dept. of PM&R
Gretchen Stephens, MPA, OTR/L
VACO Rehabilitation Services
Nicholas J. Pastorek, Ph.D., ABPP-CN
PM&R Services Program Office
Clinical Neuropsychologist
National TBI and Polytrauma Program
Polytrauma Network Site
Coordinator
Rehabilitation Care Line
Hunter Holmes McGuire VAMC
Michael E. DeBakey VA Medical Center
Richmond, VA
Houston, TX
Jeffrey Teraoka, M.D.
Michelle Peterson, DPT, NCS
Chief, PM&R Service
Physical Therapist
VA Palo Alto Health Care System
Minneapolis Polytrauma Rehabilitation
Clinical Associate Professor, Affiliated,
Center
Dept. of Orthopedics
Minneapolis VA Medical Center
Stanford University School of Medicine
Palo Alto, CA
Joel Scholten, M.D.
VACO Rehabilitation Services
Rodney D. Vanderploeg, Ph.D., ABPP-CN
Director of Special Projects, Physical
Clinical Neuropsychologist
Medicine and Rehabilitation Services
Polytrauma/TBI
Associate Chief of Staff, Rehab Services
Rehabilitation Program
Washington DC VA Medical Center
Psychology Service
Washington, DC
James A. Haley Veteran’s Hospital
Tampa, FL
Karen A. Schwab, Ph.D.
Assoc. Professor
Chief of Epidemiology and Statistics
Univ. of South Florida
Defense and Veterans Brain Injury Center
Depts. of Psychiatry and Psychology
Assistant Professor of Neurology (Adjunct)
Uniformed Services University of the
Health Sciences
Bethesda, Maryland
Traumatic Brain Injury
v
Program Development:
Marina Waisman, M.D.
David X Cifu, M.D.
Psychiatrist
National Director, PM&R VHA
Polytrauma/TBI Rehabilitation Program
Chief, PM&R Service
James A. Haley Veteran’s Hospital
Hunter Holmes McGuire VAMC
Tampa, FL
Richmond, VA
Professor and Chairman,
William C. Walker, M.D.
Virginia Commonwealth University
Professor & ViceChairman, Virginia
Dept. of PM&R
Commonwealth Univeristy, Dept. Physical
Medicine & Rehabilitation
Micaela Cornis-Pop, Ph.D.
Site Director of Defense & Veterans Brain
Speech Pathologist
Injury Center
VACO Rehabilitation Services
Hunter Holmes McGuire VAMC
Hunter Holmes McGuire VAMC
Richmond, VA
Richmond, VA
Assistant Professor
Outside Readers
Virginia Commonwealth University
Lori J. Golterman, Pharm.D.
Dept. of PM&R
Clinical Specialist
Pharmacy Benefits Management
Simone Hogan, MSW, LICSW
Department of Veterans Affairs
Polytrauma Social Work Case Manager
Washington, DC
Polytrauma Rehabilitation Center
PM&R Services
Christine Erickson, M.D.
Minneapolis VA Medical Center
Department of Veterans Affairs
Minneapolis, MN
VISN 12 OEF/OIF Primary Care Champion
Co-Medical Director GMC
Kimberly Meyer, MSN, CNRN, ACNP-BC
Edward Hines Jr. VA Hospital
Neuroscience Clinician
Hines, Illinois
Defense and Veterans Brain Injury Center
Washington, DC
Planning Committee
Sharon M. Benedict, Ph.D.
Joel Scholten, M.D.
Rehabilitation Psychologist
VACO Rehabilitation Services
VACO Rehabilitation Services
Director of Special Projects, Physical
Hunter Holmes McGuire VAMC
Medicine and Rehabilitation Services
Richmond, VA
Associate Chief of Staff, Rehab Services
Washington DC VA Medical Center
Washington, DC
vi
Traumatic Brain Injury
Program Development:
Barbara Sigford, M.D., Ph.D.
VACO Rehabilitation Services
Director, Physical Medicine and
Rehabilitation Services
Washington, DC
Gretchen Stephens, MPA, OTR/L
VACO Rehabilitation Services
PM&R Services Program Office
National TBI and Polytrauma Program
Coordinator
Hunter Holmes McGuire VAMC
Richmond, VA
Rodney D. Vanderploeg, Ph.D., ABPP-CN
Clinical Neuropsychologist
Polytrauma/TBI Rehabilitation Program
Psychology Service
James A. Haley Veteran’s Hospital
Tampa, FL
Assoc. Professor
Univ. of South Florida
Depts. of Psychiatry and Psychology
Haley Steele, Ph.D.
Employee Education Services
E-Learning Producer
North Little Rock, AR
Traumatic Brain Injury
vii
CHAPTER 1:
A Conceptual Framework for TBI
Assessment and Management
Learning Objectives
• Describe the importance of having a conceptual framework for managing patients with TBI
• State important questions to address in the initial assessment of an individual with TBI
Introduction
Over the last several years, traumatic brain injury (TBI) has been thrust into
the forefront of the consciousness of the medical community and the general
public. This is in large part due to recent combat operations and subsequent
recognition of this potentially “silent injury.” Fortunately, TBI has been studied
for decades in the academic medical world. This foundation of knowledge
guides current diagnostics and interventions.
TBI produces a complex constellation of medical consequences including physi­
cal, emotional, behavioral and cognitive deficits. The impact is heterogeneous
given the varied types of injury (closed, penetrating, blast), severity, comorbid
conditions, and premorbid characteristics. Furthermore, when assessing and
supporting recovery, the practitioner must consider the profound impact psy­
chosocial factors have on recovery.
The practitioner managing patients in the federal or private sector must
acknowledge the impact of comorbidities that affect successful community
re-entry. In particular, the combat experience may contribute to significant and
sustained exposure to both physical and psychological trauma. In turn, these
experiences can evolve into puzzling comorbidities which blur the diagnostic
picture and care plan. The effects of the psychological burden and somatic dys­
function share similar symptom constellations as TBI, which complicates the
diagnostic process. Establishing a proper diagnosis is important and can help
drive clinical management, though this may not always be a clear-cut option.
When complexities exist, referrals should be made to mental health and TBI
rehabilitation resources.
Traumatic Brain Injury
1
Appropriate outcomes and recovery expectations must be integrated early into
management strategies. Conceptually, TBI is not a disorder with a hallmark
symptom complex. Rather, it is a set of impairments that ultimately affect suc­
cessful community re-entry. Management strategies of the impairments should
be holistic in nature and driven by patient centered goals.
Framework for Developing a Management Plan
Developing a management plan for patients with a historical diagnosis of
TBI can be a challenging endeavor. The complex of cognitive, behavioral and
physical symptoms is non-specific to TBI. It is shared with numerous other
disorders and many symptoms are prevalent in the general population. Fur­
thermore, when seeking care, these individuals tend to be in distress and to
possess poor health literacy.
Numerous factors must be considered when an individual with TBI - related con­
cerns presents to a health care provider. The amount of prior treatment and
services received varies significantly. Understanding the patient’s treatment
history will provide valuable information regarding potential first treatment
steps. Given the heterogeneity of TBI, it is helpful to establish a conceptual
and historical framework for each patient who presents for medical evaluation.
Answering the following questions during the assessment process helps to
determine patient needs and to formulate management strategies:
01. What brings the patient to seek services at this time?
The reasons the patient gives for seeking services can provide important
information regarding the primary factors at play as well as the most
appropriate treatments and/or referrals. For example, if the patient is
five months post-injury and seeking services for the first time, it becomes
critical to understand why the patient is presenting now versus two
weeks ago, or two weeks after the injury.
02. What was the medical severity of the initial injury?
Establishing the severity level of the TBI (i.e., severity of the original injury)
is a key initial step in evaluating impairments and charting a treatment
course. The severity of TBI closely prognosticates the outcome over time
and the nature of long term sequelae. For example, the issues encoun­
tered with postconcussive syndrome (headaches, balance and working
memory deficits) are markedly different from those due to severe TBI
(spasticity, hemiplegia, behavioral disinhibition). There is also growing
evidence that multiple injuries may negatively affect prognosis. Determin­
ing the severity of TBI and recovery patterns is discussed in detail in
Chapters 2 and 4.
03. What has been the course of recovery from the event?
As a general rule, patients with TBI gradually improve and stabilize over
time. A scalloping or stepped recovery course or an acute change in the
patient’s well being should raise red flags. Specifically, this may indicate
2
Traumatic Brain Injury
a secondary medical complication specific to TBI (e.g., seizures) or a
behavioral change (e.g., depression). An improving course followed by a
generalized decline in cognitive and behavioral health is rarely attributable
solely to TBI. In particular, anxiety and pain disorders produce unstable
patterns of recovery. If these confounders are apparent, multidisciplinary
care and referral to specialty services is recommended (see Chapters
5, 6, & 7).
04. What services and interventions have been utilized?
The interventions and services received vary greatly among those with
a diagnosis of TBI. A detailed history of types and effectiveness of thera­
peutic and pharmacologic interventions greatly increases the efficiency
of care delivery along the continuum of care. The history of previous
interventions undoubtedly leads to more appropriate diagnosis and man­
agement plans.
05. What is the severity and duration of the symptom complex?
After consultation with TBI clinics, patients with isolated or mild symp­
toms can generally be effectively managed in primary care settings.
When TBI severity and symptom duration increase, practitioners should
rely more on specialty services for both diagnostics and care coordina­
tion. It is also important to note that these factors undoubtedly affect
prognosis for recovery (see Chapters 5, 6 & 7).
06. What is the global impact of the patient’s current symptoms?
The assessment of the severity of the patient’s current impairments
should not be limited to a review of systems and reporting of symptoms.
They should include assessment of any personality or mood changes, new
onset of interpersonal difficulties, and the impact of injury on academic,
vocational, and social aspects of current functioning (see Chapter 4).
07. Is there a root cause to the current impairment?
Though not always present, establishing the primary driving force behind
the impairment can significantly affect recovery. As an example, severe
post combat anxiety can present primarily as cognitive and somatic dys­
function. Without aggressive and timely management of this root cause,
recovery is highly unlikely (see Chapter 4).
08. What is the patient’s readiness to change?
Assessing the patient’s readiness to change can assist in establishing
effective use of support and consultation services. Application of services
that are incongruous with the patient’s perceived needs may result in less
effective outcomes. Similarly, missing “windows” of readiness can nega­
tively affect outcomes. Establishing a therapeutic alliance with the patients
provides the optimum environment to encourage readiness to change.
Traumatic Brain Injury
3
09. Are there comorbidities that add to the complexity of the
presentation?
The TBI diagnosis is often historical based on medical record review or
patient self-report. The diagnosis may be supported by non-specific symp­
toms or made complicated by psychosocial challenges. Other diagnoses
have similar presentations to TBI. In particular, post traumatic anxiety
disorders and pain syndromes can mimic postconcussive syndromes. It
is important to note that “all that is cognitive or behavioral dysfunction is
not TBI.” When faced with these confounding factors, referral to consul­
tant services is highly recommended (see Chapters 6 & 7).
10. How should disability compensation and status affect care?
Individuals with a history of TBI often receive a rating and compensation
for “disability”. The concept of “disability” can be perceived as both a
financial and psychological disincentive to recovery. It is very important
to stress that despite a determination of disability, most patients with
TBI can improve with appropriate management. It is incumbent upon the
practitioner to dispel the myth of “disability” and to attempt to motivate
their patients toward wellness.
4
Traumatic Brain Injury
CHAPTER 2:
Epidemiology and the Nature of
Traumatic Brain Injuries
Learning Objectives
• Define traumatic brain injury
• State why traumatic brain injury is a significant health problem
• List three common causes of traumatic brain injury
• Describe four indices for classifying severity of brain injury
• Describe the main types of physiological changes in the brain resulting from trauma
• Describe the course of recovery following traumatic brain injury
Traumatic Brain Injury Definition
The Department of Defense and the Department of Veterans Affairs (May
2007), by consensus, have defined traumatic brain injury (TBI) as any traumat­
ically induced structural injury and/or physiological disruption of brain function
as a result of an external force that is indicated by new onset or worsening of
at least one of the following clinical signs, immediately following the event:
1. Any period of loss of or a decreased level of consciousness;
2. Any loss of memory for events immediately before or after the injury;
3. Any alteration in mental state at the time of the injury (e.g., confusion, disorientation, slowed thinking);
4. Neurological deficits (e.g., weakness, balance disturbance, praxis, pare­
sis/plegia, change in vision, other sensory alterations, aphasia.) that may
or may not be transient;
5. Intracranial lesion.
External forces. Forces causing brain injury include the head being struck by
an object, the head striking an object, the brain undergoing an acceleration/
deceleration movement without direct external trauma to the head, a foreign
body penetrating the brain, forces generated from events such as a blast or
explosion, or other force yet to be defined.
Open Versus Closed TBI. A TBI resulting from something passing through
the skull into brain, such as a bullet or fragments from an explosion, is called a
penetrating or open head injury. A TBI that results from either an object hitting
the head or from the head hitting something forcefully, such as the dashboard
of a car, is referred to as a nonpenetrating or closed head injury.
Traumatic Brain Injury
5
The above criteria define the historical event of a TBI. If a person meets these
criteria, they should be diagnosed as having sustained a TBI.
TBI Sequelae. Sequelae of TBI may resolve quickly, within minutes to hours
after the event, or may persist longer. Some sequelae of TBI, particularly after
moderate or severe injury may be permanent. Most signs and symptoms will
manifest immediately following the event, but following more severe injury,
other symptoms or complications may be delayed from hours to days (e.g.,
subdural or epidural hematoma) or even many months (e.g., seizures, hydro­
cephalus, spasticity, etc.). Signs and symptoms may occur alone or in varying
combinations and may result in significant functional impairments. New or
worsening signs and symptoms appearing after TBI should only be attributed
to the TBI if not better explained by pre-existing conditions or other medical,
neurological, or psychological causes. Symptoms generally fall into one or
more of the three following categories:
1. Physical: headache, nausea, vomiting, dizziness, blurred vision, sleep
disturbance, weakness, paresis/plegia, sensory loss, spasticity, aphasia,
dysphagia, apraxia, balance disorders, disorders of coordination, and
seizure disorder.
2. Cognitive: difficulties or impairments in attention, concentration, new
learning, memory, speed of mental processing, planning, reasoning, judg­
ment, executive control, self-awareness, language, and abstract thinking.
3. Emotional/Behavioral: depression, anxiety, agitation, irritability, impulsiv­
ity, and aggression.
Points to Remember
• Traumatic Brain Injury (TBI) is a historical diagnosis
• Sequelae of TBI may resolve quickly, but some impairments may be
permanent
• Delayed onset of symptoms or worsening of symptoms over time is
uncommon following TBI
Epidemiology of TBI
TBI is a leading cause of death and disability in the United States. One and
a half million Americans incur a traumatic brain injury (TBI) each year (CDC,
2007) and approximately 5.3 million individuals have enduring disabilities as a
direct result of a TBI (CDC, 2007). These figures likely underestimate the true
incidence as military injuries and those with mild injuries may not seek healthcare. Direct costs for hospital care, extended care, and other medical care
and services, coupled with indirect costs such as lost productivity were esti­
mated at $60 billion annually in 2000 (CDC 2007; Finkelstein et al., 2006).
These figures do not include the physical, emotional, and social costs to the
injured person and their family from TBI - related disability. For fiscal year 2009,
there were 1,313 Veterans who received VA inpatient hospital care for TBI.
6
Traumatic Brain Injury
From April 2007 through fiscal year 2009, 66,023 Veterans were identified
as possibly having a TBI through outpatient screening of individuals presenting
to the VA for health care following deployment in Operation Enduring Freedom
or Operation Iraqi Freedom. Of those identified through screening, 24,559
were confirmed to have sustained a TBI.
Mortality
Research studies indicate an annual mortality of 50,000 from TBI-related
causes (IOM, 2008, Table 3.6). Australian studies found mortality rates of
65% in patients with an admission GCS of 3 decreasing to 10-15% in those
with a GCS of 7-13. Older age at time of injury also contributes significantly
to mortality. Teasdale et al. (1979) found mortality rates of 39% in a young
adult population (21-30 years) versus 95% in patients > 80 years of age who
sustained a severe TBI.
Causes of TBI
In the civilian sector the most common means of sustaining a TBI is through
falls. Data from the CDC indicate falls account for 28% of all reported TBIs
(see Figure 1). Following falls are motor vehicle-related incidents (20%). These
include all incidents involving motor vehicles, bicycles, pedestrians, and recre
ational vehicles. Firearm use is the leading cause of death related to TBI (CDC,
1999). Blasts in combination with other mechanisms are a leading cause of
TBI for active duty military personnel in war zones (DVBIC, 2005).
Figure 1. Most Common Causes of TBI (from http://www.cdc.gov/ncipc/factsheets/tbi.htm)
Traumatic Brain Injury
7
Who sustains a TBI?
Civilians
Males outnumber females by at least 2:1 in frequency of TBIs (Langlois,
Rutland-Brown, & Thomas, 2004). Individuals between the ages of 0 to 4
and those 15 to 19 are at high risk for TBI, as are the elderly (see Figure 2).
Adults aged 75 and older have the highest rates of TBI-related hospitalization
and death (CDC, 2007; Langlois et al., 2004).
Figure2. TBI and Age (from http://www.cdc.gov/ncipc/images/figure10.gif) Traumatic brain injury rates by age group and cause of injury – Arizona, Colorado, Minnesota, Mis­
souri, New York, Oklahoma, and South Carolina, 1994 Individuals who abuse substances are at increased risk for TBI. Prevalence
for alcohol intoxication at the time of injury is about 37 to 51% (Parry-Jones,
Vaughan & Miles Cox, 2006). Other risk factors of TBI include lower socioeco­
nomic status and prior TBI (Annegers et al., 1980).
Military
TBI has been called a “signature injury” of Operation Enduring Freedom and
Operation Iraqi Freedom (OEF/OIF). Thirty-three percent of all patients with
combat-related injuries and 60% of the patients with blast-related injuries seen
at Walter Reed Army Medical Center have sustained a TBI (Okie, 2005). Mild
TBI or concussion is one of the most common forms of combat-related injury.
Based on self-report data, approximately 15% of troops engaged in active
combat in Afghanistan and Iraq may have suffered a mild TBI (Hoge et al.,
2008). Additionally, a recent study of the Navy-Marine Corps Combat Trauma
Registry revealed that battle-injured were more likely than those injured outside
of battle to have multiple TBIs (Galarneau et al., 2008).
8
Traumatic Brain Injury
Points to Remember
Primary Care providers in the VA and DOD healthcare settings are very
likely to encounter individuals who have sustained a TBI because:
• The majority of Veterans and individuals on active military duty are male
• Many active duty service members fall within the age ranges of greater risk
• Recent cohorts of active duty Service Members have undergone multiple deployments with increased exposure to blast or blast-related events.
• The risk of falls increases in the aging Veteran population
Severity of Brain Injury
Severity of TBI is determined at the time of injury. Though severity level has
prognostic value it does not necessarily predict the patient’s likelihood of
functional recovery. Severity of TBI is a continuum and the particular classifica­
tion used to designate a patient as having mild, moderate or severe injury is
somewhat arbitrary. The severity grades, i.e., mild, moderate, and severe, are
defined by using one of four indexes:
• Glasgow Coma Scale (GCS)
• length of coma (duration of unconsciousness)
• length of period of altered consciousness or mental status and
• length of posttraumatic amnesia (PTA).
Glasgow Coma Scale (GCS)
The GCS is a 15-point scale based upon ratings of the patient’s best eye open­
ing, motor, and verbal responses following an injury (see Table 1). Distribution
of hospitalized trauma patients diagnosed with TBI based on GCS severity has
generally been found to have a ratio of mild to moderate to severe of 8:1:1
(IOM, 2008). While the GCS is recognized as a reliable measurement tool, it is
influenced by factors unrelated to the TBI itself such as intoxication, intubation
and other injuries, and length of time between the injury and measurement.
The GCS is not particularly useful in the assessment of mild TBI/concussion.
Table 1. Glasgow Coma Scale (GCS)
Glasgow Coma Scale
Score
Motor Responses:
Obeys commands
6
Localizing responses to pain
5
Generalized withdrawal to pain
4
Flexor posturing to pain
3
Extensor posturing to pain
2
Traumatic Brain Injury
9
Glasgow Coma Scale
No motor response to pain
Score
1
Verbal Responses:
Oriented
5
Confused conversation
4
Inappropriate speech
3
Incomprehensible speech
2
No speech
1
Eye opening:
Spontaneous eye opening
4
Eye opening to speech
3
Eye opening to pain
2
No eye opening
1
Total (Add above 3 scores)
Range = 3-15
Coma
Coma or unconsciousness is the time a patient is non-responsive after injury.
The duration of coma is one parameter used to determine injury severity; the
longer the coma, the more severe the TBI. Although this may appear to be an
easy and objective measure, often patients are unaware of whether or not they
have had a period of unconsciousness (Levin et al., 1987). In addition, the
injury may have been unwitnessed or the patient may have regained conscious­
ness by the time of evaluation.
Alteration of Consciousness (AOC)
Following a TBI an individual may not be rendered unconscious but may none­
theless be confused, disoriented, feels mentally dazed, have difficulty mentally
tracking events, and may respond in a confused manner to questions. How­
ever, later when questioned about this period of altered consciousness they
can recall events from the accident forward to the present.
Posttraumatic amnesia (PTA)
PTA is the time interval from when the person regains consciousness until
he or she is able to consistently form memories for ongoing events (Whyte,
Rosenthal & Zuccarelli, 2000). During PTA, the individual is neither fully ori­
ented nor able to remember information after a period of distraction. PTA can
be influenced by medications that are given in routine trauma care (i.e., pain
meds). Retrospectively, PTA can be assessed by asking the patient about the
first event which they can remember following the injury, always distinguishing
10
Traumatic Brain Injury
between what the patient actually remembers and what they have been told
by family members. Asking family members how long it was before the patient
remembered events of a visit from one day to the next may help establish
the duration of PTA. In sports concussions it is not uncommon for an athlete
to have an alteration of consciousness (feeling dazed and having a confused
response to questions), but not have memory gaps. If this is the case, they
would have had an alteration of consciousness, but no period of PTA.
Table 2 presents the severity grades and defining criteria for these indices, as
well as neuroimaging findings. If different indices result in different classifica­
tions, the most severe classification is typically assigned.
Table 2. TBI Severity Indices
Severity Index
Mild TBI/Concussion
Moderate TBI
Severe TBI
Neuroimaging Find­
ings
Normal structural
imaging
Normal or abnormal
structural imaging
Normal or abnormal
structural imaging
Initial GCS
13-15
9-12
< 9
Loss of Conscious­
ness (LOC)
0-30 min
> 30 min and < 24
hours
> 24 hrs
Length of Alteration
of Consciousness
(AOC)
a moment up to 24
hours
AOC > 24 hours (use other criteria)
Length of Posttrau­
matic Amnesia (PTA)
0 – 1 day
> 1 and < 7 days
> 7 days
DoD/DVA consensus based classification of Closed TBI Severity
Approximately 75% of patients who sustain TBIs have had a mild TBI (CDC,
2003). In mild TBI, there is often no evidence of structural injury on clini­
cal neuroimaging. Mild TBI is believed to result when a traumatic force to
the brain triggers a pathologic neurochemical cascade, but is insufficient to
produce widespread neuronal dysfunction or the axonal disruption that char­
acterizes more severe brain injuries. The American Congress of Rehabilitation
Medicine’s (1993) formal definition of mild TBI is presented in Table 3.
Table 3. American Congress of Rehabilitation Medicine Criteria for Mild Traumatic Brain Injury
Diagnostic Criteria for Mild Traumatic Brain Injury
I. Traumatically induced physiologic disruption of brain function as indicated
by at least one of the following:
a. Any period of loss of consciousness
b. Any loss of memory for events immediately before or after the accident
c. Any alteration in mental state at the time of the accident
d. Focal neurologic deficits that may or may not be transient
Traumatic Brain Injury
11
Diagnostic Criteria for Mild Traumatic Brain Injury
II. Severity of the injury does not exceed:
a. Loss of consciousness of 30 min
b. GCS score of 13-15 after 30 min
c. Posttraumatic amnesia of 24 hr
Unlike moderate to severe TBI, diagnosis of mild TBI often cannot be corrobo­
rated with objective diagnostic tools. Furthermore, there is a lack of evidence
regarding the long-term impact of mild TBI on functioning. Issues of mild TBI
are discussed more fully in Chapter 4. The majority of patients with a mild
TBI make excellent neurobehavioral recovery (Belanger et al. 2005), but some
have persistent symptoms (Luis et al., 2003; Vanderploeg et al., 2007).
When neuroimaging findings or positive signs on an acute neurological exami­
nation are present, following what otherwise would be classified as a mild TBI,
the classification changes to “complicated mild TBI”. “Complicated mild TBIs”
have a 6-month outcome more similar to moderate TBI than to an uncompli­
cated mild TBI (Williams, Levin, & Eisenberg, 1990).
Points to Remember
• Brain injury severity is classified by signs and symptoms at the time of
the original injury
• The Glasgow Coma Scale (GCS), duration of coma, and length of post
traumatic amnesia (PTA) are common measures of severity of
brain injury
• The majority of brain injuries are mild
• A number of nontrauma-related factors (e.g., intoxication or medications) can complicate severity assessment
Cumulative Concussion (Mild TBI)
Most of the data regarding the impact of multiple concussions (multiple mild
TBIs) is derived from the sports literature which suggests a possible cumula­
tive effect from multiple concussions (Guskiewicz et al., 2003). With regard
to residual adverse effects, any threshold for frequency and severity of con­
cussions has yet to be established. However, there is concern that a second
concussion prior to complete recovery from the first may pose increased risk.
This is of particular concern in the military and Veteran population given their
exposure to multiple training and combat related events that can increase the
risk for sustaining a concussion.
Pathophysiology of Injury
TBI can result in both primary and secondary brain injury. Primary brain
injuries are classified as focal, diffuse, or mixed depending on the mechanism
of injury and the brain’s response. Focal damage, such as contusion or hema12
Traumatic Brain Injury
toma, can be appreciated by standard neuroimaging studies such as CT or
MRI. Focal lesions are usually the result of direct impact of the brain against
the cranium, most often from impact with the frontal, temporal or occipital
bones, but may also occur in penetrating injuries such as gunshot wounds.
Widespread disruption of neuronal circuitry or diffuse axonal injury (DAI) can
be difficult to detect on standard neuroimaging. It is possible to have both
types of injury (i.e., focal and diffuse) from a single traumatic event.
Primary Injuries
Focal Lesions
Focal lesions occur primarily in moderate to severe TBI, but should always
be a consideration in any head trauma. Focal lesions may include subdural
hematoma (SDH), epidural hematoma (EDH), subarachnoid hemorrhage (SAH),
intracerebral hemorrhage (ICH), and cortical contusion. Subdural hematomas
result when small bridging veins between the skull and the dura are torn result­
ing in bleeding into the subdural space. This can occur following motor vehicle
accidents, falls and other types of trauma. These patients may not always be
evaluated at the time of the injury or may not be evaluated for subsequent TBI
symptoms when they do receive acute intervention. Elderly individuals are at
particular risk for this type of injury following a fall and the primary care physi­
cian may be the first to see and evaluate these patients for their symptoms.
Epidural hematomas result from damage to dural veins and arteries and can
result in rapid deterioration and death if not treated promptly. Subarachnoid
hemorrhages result from damage to microvessels in the subarachnoid space
and are often associated with cerebral contusions. Intracerebral hemorrhage
results from brain laceration and typically occurs in the frontal and temporal
areas. Cortical contusions result from direct trauma to the brain parenchyma
from impact with boney prominences of the skull. Typical areas of contusions
are the frontal, orbital frontal, anterior temporal and lateral temporal areas.
Frontal Contusions
Subdural Hematoma
Traumatic SAH
Diffuse Axonal Injury (DAI)
DAI results from rotational acceleration-deceleration forces. DAI has been
observed in pathology studies following mild injuries (Blumbergs et al., 1994).
Historically it was thought that the disconnection of axons observed after TBI
resulted from the direct tearing and disruption of axons at the time of injury,
referred to as primary axotomy. However, it has been shown that primary
axotomy is rare, even in severe TBI (Maxwell, Povlishock, & Graham, 1997).
Rather, axonal disconnection seems to occur several hours after injury as a
Traumatic Brain Injury
13
result of events in the axonal membrane and cytoskeleton (Povlishock, Becker,
Cheng, & Vaughan, 1983). There may be changes in functional deficits over
time as a result of this ongoing process. These pathophysiological changes are
observed diffusely throughout the subcortical white matter, corpus callosum,
fornix, internal capsules, cerebellum and brain stem (Adams et al., 1989).
Secondary Injury
Following the initial injury to the brain, mechanisms of secondary injury includ­
ing cellular response and neurochemical and metabolic cascades are set
in motion. Contributing to secondary cellular injury are increased excitatory
amino acids such as glutamate, neurotoxic free radicals and oxidants, lipases,
arachadonic acid, and increased calcium (Graham, 1999; Meythaler, Peduzzi,
Eleftheriou, & Novack, 2001). Hypoventilation or elevated intracranial pressure
(ICP) can lead to secondary brain injury. Secondary ischemic insults can occur
in the form of focal cerebral infarcts or diffuse watershed brain injury from
circulatory failure. Secondary brain injury may also result from extracranial
causes including hypotension, hypoxia, hyperthermia all of which can exacer­
bate neurologic injuries.
Points to Remember
• Brain injuries can result in diffuse axonal injuries, focal lesions, or
both depending on the mechanism of injury and the brain’s response
• Diffuse axonal injury results from inertial (rotational accelerationdeceleration) forces and is thought to be a result of calcium influx and
subsequent cytoskeletal damage
• Focal injuries are typically due to a direct blow to the head or pen­
etrating head injury (e.g., GSW) and include subdural hematoma,
epidural hematoma, subarachnoid hemorrhage, intracerebral hemor­
rhage, and cortical contusion
TBI in the Military Context: Blast, Polytrauma, and
Psychiatric Comorbidities
Recent military conflicts have increased the likelihood of exposure to high
energy blasts and explosions. Currently in OEF/OIF upwards of 78% of combat
injuries are the result of explosive munitions (Owens et al., 2008). As a result
of this increasingly common mechanism of injury, more Service Members
wounded in war are returning with multiple complex injuries. Common injuries
in multiple combinations include open wounds, traumatic amputations, TBI,
spinal cord injuries, eye injuries, musculoskeletal injuries, and mental health
problems. The term “polytrauma” has been introduced to encompass injuries
to more than one physical region or organ system that result in physical,
cognitive, psychological, or psychosocial impairments and functional disability.
These injuries — sometimes called “blast injuries” — occur almost daily in Iraq
and Afghanistan as a result of rocket-propelled grenades, improvised explosive
devices, explosively formed projectiles, and land mines. Other sources of blast
injury during combat are from artillery, rocket and mortar shells, and aerial
14
Traumatic Brain Injury
bombs. Brain injury is common following blasts and can occur from multiple
mechanisms – possibly from direct exposure to the over-pressurization wave,
from the impact of blast-energized debris (both penetrating and non-penetrat­
ing), from the individual being physically thrown into environmental hazards or
from motor vehicle accidents triggered by the blast, and from inhalation of
gases and vapors or from anoxic injuries. Non-penetrating concussive injuries
may go undiagnosed and untreated as attention is focused on the more “vis­
ible” injuries.
The same combat exposure that causes TBI may also result in other comorbid­
ities. Common post-deployment issues, such as posttraumatic stress disorder
(PTSD), pain conditions, amputations, acute stress reactions, and substance
use/abuse also can result in numerous symptoms overlapping with TBI. Table
4 presents data from series of patients seen by Scott et al. (2006) illustrating
common sequelae of those with blast-related injuries.
Table 4. Common sequelae of those with blast-related injuries from Scott et al. (2006).
Table Commonly Overlooked Blast-Related Conditions in Patients With Polytrauma (N=50)*
Condition
No. (%)
Concussion
33 (66)
Soft-tissue damage
31 (62)
Posttraumatic stress disorder/acute stress reactions
26 (52)
Nerve damage
21 (42)
Acute or chronic pain
21 (42)
Hearing loss
14 (28)
Chronic infections (eg, sinus)
13 (26)
Vision changes
11 (20)
Lung injury
10 (20)
Vestibular problems
9 (18)
Undiscovered fragments
4 (8)
*From a consecutive sample of patients with blast-related injuries seen at the Polytrauma
Rehabilitation Center at the Veterans Affairs Medical Center in Tampa, Fla.
Mental health comorbidities are common in this patient population including
PTSD, depression, anxiety, and somatoform disorders. It is recognized that
the symptoms associated with PTSD may overlap with symptoms of mild TBI.
Disentangling the symptoms of brain injury and PTSD is challenging. PTSD has
an estimated prevalence of 13 to 17% in mild TBI (Hoge et al., 2004; 2007)
Traumatic Brain Injury
15
compared to 5% pre-deployment (Hoge et al., 2004). Hoge et al. (2008)
report that more than 40% of soldiers who had symptoms associated with
mild TBI with loss of consciousness also met criteria for PTSD. These mental
health conditions may account for symptom complaints and clinical presenta­
tion. Indeed, some studies have suggested that PTSD and depression may
account for most symptom complaints in the chronic phases after mild TBI
(Hoge et al., 2008; Chamelian & Feinstein, 2006), though this remains an
area of controversy.
Active duty Service Members returning from OEF/OIF are screened for TBI
and PTSD as part of the routine military Post-Deployment Health Assessment
(PDHA). The TBI screen consists of identifying any injury that resulted in an
alteration of consciousness with current symptomology. Patients with positive
TBI screens are evaluated with a clinical interview to determine the diagnosis
of TBI and appropriate referrals are provided. This screening process identifies
Service Members at risk for complications from undiagnosed TBI. For OEF/OIF
patients entering the VA healthcare system, similar screening occurs regard­
less of entry portal. The purpose of this screening is to identify those in need
of ongoing TBI-related services. VA TBI screening, evaluation and treatment
programs for this patient population are described in Chapter 3.
Points to Remember
• The term “polytrauma” has been introduced to encompass injuries to
more than one physical region or organ system and which result in
ongoing disability.
• Patients who screen positive for mild TBI may have mental health and
other physical comorbidities.
• Common post-deployment issues, such as PTSD, pain conditions,
acute stress reactions, depression, and substance use/abuse can
result in numerous symptoms overlapping with mild TBI sequelae.
16
Traumatic Brain Injury
Course of Recovery
For those with mild TBI/concussion, the majority recover fully in a short time
period (days to weeks). Once medically stabilized, those with more severe injury
show the most rapid improvement in the first six months after injury. However,
additional recovery can occur for up to 36 months or longer. Figure 3 illus­
trates hypothetical recovery paths of cognitive functioning following different
severities of TBI.
Figure 3: Hypothetical recovery paths of cognitive functioning.
Mild TBI Recovery
Individuals with mild TBI/concussion typically recover fully in a short time
period, particularly in terms of cognitive performance (Belanger et al., 2005;
Schretlen & Shapiro, 2003). Nevertheless, about 10-15% continue to report
distressing symptoms for months (Alves, Macciocchi, & Barth, 1993; Dik­
man, McLean, & Temkin, 1986; Powell, Collin & Sutton, 1996) or years post
injury (Vanderploeg et al., 2007; Hartlage et al., 2001; Deb et al., 1999).
Individuals with repeated mild TBI have an increased potential for persistent
symptoms.
Without appropriate interventions, patients who continue to exhibit symptoms
for more than 1-3 months are more likely to experience:
• Functional difficulties when trying to return to previous living patterns
• Depression and anxiety, which has an impact on the person’s capacity to function • A tendency to isolate and significantly limit themselves to the comfort of familiar surroundings and routines • Activity avoidance
• Estrangement from his/her spouse, children, family, and friends
Traumatic Brain Injury
17
• Suicidal ideations and attempts
• Problems with the law
• A tendency for re-injury
Moderate to Severe TBI Recovery
Persisting functional limitations are common in those with moderate to severe
TBI. At one year follow-up, self reported functional limitations were found in up
to 47% in hospitalized patients (Pickelsimer, Selassie, Gu, & Langlois, 2006).
In another study (Whiteneck et al., 2004) 24% of patients hospitalized with
moderate or severe TBI failed to return to work by one year follow-up. Similarly,
in a cohort of Vietnam Veterans with penetrating brain injuries, when followedup 15 years later, only 56% of those with TBI were employed compared with
82% of the uninjured controls (Schwab, Grafman, Salazar & Kraft, 1993). TBI
patients also have been found to have higher rates of depression than similar
controls (Fann et al., 2004; Jorge & Robinson, 2003; Vanderploeg, Curtiss,
Luis & Salazar, 2007).
Recovery from TBI is influenced by multiple factors. These include:
• Age
• Overall general health
• Premorbid functional status (Raymont et al., 2008)
• Psychiatric comorbidities
• Supportive environment (family, work, friends)
Severity of TBI
In the acute phase of recovery (initial several months) rehabilitation profession­
als frequently use the Rancho Los Amigos Level of Cognitive Function Scale
(Hagen, Malkmus, Durham, & Bowman, 1979) to characterize the level of
functioning and track the course of recovery. It is a descriptive instrument that
characterizes the level of cognitive and behavioral deficits after moderate to
severe TBI. Ratings range from Level I, indicative of no response (comatose),
to Level VIII, indicative of a person whose behavior is purposeful and appropri­
ate, although not necessarily functioning independently or at premorbid levels.
Table 5 presents the range of Rancho levels and brief descriptions of the char­
acteristics for each level.
18
Traumatic Brain Injury
Table 5. Rancho Los Amigos Level of Cognitive Function Scale
Rancho Los Amigos Level
Description
I
No Response
Unresponsive to sound, light, touch, or pain.
The individual appears to be in a deep sleep.
II
Generalized
Response
Individual reacts inconsistently in a nonspecific
manner to stimulation. May be gross body
movements, unintelligible vocalizations, etc.
Earliest response is frequently to deep pain.
Responses to stimuli often are delayed.
III
Localized Response
Reacts to specific stimuli (e.g., eye blink
to strong light, turns toward sound, etc.).
Responses are often inconsistent. May
inconsistently follow simple, direct commands
(e.g., close your eyes, squeeze my fingers,
etc.).
IV
Confused - Agitated
Alert and active but has severely limited
ability to process information. Disoriented
to circumstances and responds primarily
to internal stimuli. Behavior is not purpose­
ful or is bizarre and the ability to focus and
sustain attention is extremely limited. Does
not differentiate among people or things.
Verbalizations may not be coherent or may
be patently bizarre. Short-term memory and
recall are impaired and may confabulate.
V
Confused - Inappro­
priate
Alert and active and can respond consis­
tently to simple commands. Disoriented to
circumstances and requires redirection but
is not responding primarily to internal stimuli.
Short-term memory and recall are impaired
and may confabulate. May be able to perform
self-care activities with assistance and super­
vision.
VI
Confused –
Appropriate
Alert and inconsistently oriented to time and
place. Follows simple directions consistently
and begins to show carry-over of new learn­
ing. Recognizes staff and has increased
awareness of self, family, and others.
Traumatic Brain Injury
19
Rancho Los Amigos Level
Description
VII
Automatic –
Appropriate
Alert and oriented to person, place, and time
but shows a shallow awareness of medi­
cal condition. Performs self-care and daily
routines with supervision but in a robot-like
manner. Performance may deteriorate in
unfamiliar circumstances. Shows carry-over
of new learning but at a reduced rate. Judg­
ment and problem-solving remain impaired.
VIII
Purposeful - Appro­
priate
Alert and oriented. Can recall and integrate
past and current events. Shows carry-over of
new learning and is independent, within physi­
cal limitations, at home and in the community.
Cognitive abilities may still be lower than
premorbid levels.
Adapted from Hagen et al., 1979.
Points to Remember
• For
those with mild TBI/concussion, the majority recover fully in a
short time period (days to weeks)
• Once
medically stabilized, those with more severe injury show the
most rapid improvement in the first six months after injury
• Ongoing
recovery can continue for at least 18-36 months following
moderate to severe TBI
• Individuals
who have sustained moderate to severe TBI frequently
never recover to pre-injury functional levels and may have ongoing
behavioral difficulties
• The
Rancho Los Amigos scale is frequently used to track cognitive
recovery from moderate to severe TBI
20
Traumatic Brain Injury
CHAPTER 3:
VA Care and Rehabilitation for
TBI and Polytrauma
Learning Objectives:
• The participant will be able to describe the Polytrauma/TBI continuum of care in the VA.
• The participant will be able to make referrals to the most appropriate
component in the Polytrauma/TBI System of Care based on Veteran’s
needs.
• The participant will identify which Veterans are eligible for TBI screening and which Veterans require comprehensive evaluation for TBI following screening.
Introduction
The Department of Veterans Affairs (VA) recognizes traumatic brain injury (TBI)
as a priority condition for healthcare services. With the initiation of combat in
Afghanistan and Iraq, the impact of TBI was raised to a new level of awareness
resulting in the need for an organized system of care to provide initial and life­
long services. Because TBI sustained in combat is frequently associated with
other injuries, the system of care was designed to provide services for those
with isolated TBI as well as multiple injuries or polytrauma. Besides providing
services for Veterans, a long-standing national agreement between the Depart­
ment of Defense and VA provides for transfer of active duty Service Members
who have incurred a brain injury to VA medical centers for care.
VA has implemented an integrated nationwide system of care for Veterans and
active duty Service Members recovering from TBI and polytrauma. This system
is designed to provide care for persons with TBI as an isolated condition or
in the context of polytrauma or other comorbidities. It consists of more than
100 VA medical centers; each offering specialized rehabilitation care by an
interdisciplinary team. Due to the range in severity and complexity of injuries,
Veterans and active duty Service Members with TBI and polytrauma require a
specialized model of care coordination and integration of clinical and other sup­
port services.
Traumatic Brain Injury
21
The polytrauma system of care (PSC) balances access and expertise to provide
specialized lifelong care. Specialized TBI and polytrauma care is provided at the
facility closest to the individual’s home with the expertise necessary to manage
his/her rehabilitation, medical, surgical, and mental health needs. For highly
specialized care, travel likely will be required.
The hallmark of rehabilitation care provided in the PSC is the collaboration of
specialists from different disciplines as an interdisciplinary team in the evalua­
tion and treatment of Veterans and Service Members with TBI and polytrauma.
Dedicated interdisciplinary teams (IDTs) participate in the assessment, plan­
ning and implementation of the plan of care for each patient served in the
PSC. The IDT for each patient is determined by their rehabilitation and medical
needs. Close interaction and integration among the disciplines on the team
ensure that all members interact to achieve the Veteran’s goals.
Polytrauma/TBI System of Care (PSC) Components
The VA PSC provides an integrated and coordinated continuum of services
for eligible Veterans and Service Members with polytrauma and TBI. The PSC
either directly provides, or formally links with, key components of care that
address the lifelong needs of individuals with impairments resulting from polytrauma and TBI. The tiered PSC integrates specialized rehabilitation services at
regional centers, network sites and local VA medical centers:
Polytrauma Rehabilitation Centers (PRC)
PRCs are located at the VA medical centers in Minneapolis, MN; Palo Alto,
CA; Richmond, VA; and Tampa, FL. The PRCs serve as regional referral cen­
ters for acute medical and rehabilitation care, and as hubs for research and
education related to polytrauma and TBI. They provide a continuum of rehabili­
tation services that include: specialized “emerging consciousness” programs,
22
Traumatic Brain Injury
comprehensive acute rehabilitation care for complex and severe polytraumatic
injuries, outpatient programs, and assistive technology evaluation and training,
and residential transitional rehabilitation programs (PTRP).
Polytrauma Network Sites (PNS)
Polytrauma Network Sites (PNS) provide post-acute rehabilitation for Veterans
and active duty Service Members with polytrauma and TBI who reside within
their VISN catchment area. This includes inpatient rehabilitation for those
transitioning closer to home, comprehensive outpatient TBI evaluations, a full
range of outpatient therapy services; evaluations for durable medical equip­
ment (DME) and assistive technology, access to other consultative specialists,
and follow-up care and case management for ongoing rehabilitation needs.
There is one PNS in each VISN, except VISN 8 which has two. In VISNs with a
PRC, the PRC facility also operates as the PNS.
Polytrauma Support Clinic Team (PSCT)
Polytrauma Support Clinic Teams (PSCT) provide interdisciplinary outpatient
rehabilitation services in their catchment areas for Veterans and Service Mem­
bers with mild and/or stable impairments from polytrauma and TBI. Services
include comprehensive TBI evaluations, outpatient therapy services, manage­
ment of stable rehabilitation plans referred from PRCs and PNSs, coordinating
access to VA and non-VA services, and follow-up care and case management
for ongoing rehabilitation needs.
Polytrauma Point of Contact (PPOC)
A PPOC is identified in every VA facility that is not otherwise designated as
one of the PSC components described above. The PPOC ensures that patients
with polytrauma and TBI are referred to a facility and/or program capable of
providing the level of rehabilitation services required. PPOCs commonly refer to
the PNS and PSCTs within their VISN
Polytrauma/TBI Regional Centers and Network Sites
Traumatic Brain Injury
23
Points to Remember
• VA has a Polytrauma/TBI national system of care composed of four
components:
• Polytrauma Rehabilitation Centers (PRCs) are regional referral
centers for acute and complex medical and rehabilitation Polytrauma/TBI care
• Polytrauma Network Sites (PNS) provide post-acute rehabilita­
tion, help transition patients closer to home, and provide
outpatient TBI evaluations and treatment
• Polytrauma Support Clinic Teams (PSCT) provide outpatient
interdisciplinary rehabilitation evaluation and treatment services
• Polytrauma Point of Contact (PPOC) at each VA facility ensures
that patients with polytrauma and TBI are referred to an appro­
priate program for their care
PSC Scope of Services
Persons having sustained a TBI may require different levels of TBI specific and
other supportive care throughout their lives. The typical treatment course be­
gins with evaluation and acute rehabilitation and progresses to post-acute care
in the community for ongoing sequelae. For patients who are unable to return
home, long term care settings, such as assisted living, medical foster home or
nursing home care, may be required. Care is provided in the least restrictive
setting possible. Ongoing follow-up assessment of the TBI survivor is key to
managing sequelae and preventing development of secondary conditions.
Comprehensive Interdisciplinary Inpatient Evaluations
Short-term admissions are scheduled to inpatient rehabilitation programs for
comprehensive interdisciplinary evaluations for patients with varying levels of
acuity and severity. These evaluations typically occur at PRCs or PNSs and help
determine the range and types of services needed to manage the full scope of
medical, rehabilitation, and psychosocial sequelae resulting from injuries and
the most appropriate setting in which to deliver those services.
Acute Comprehensive Interdisciplinary Inpatient Rehabilitation
This is highly specialized rehabilitation care provided at PRCs as soon as
patients are medically stable to tolerate rehabilitation programming. The
primary emphasis is on intensive interdisciplinary rehabilitation services in the
24
Traumatic Brain Injury
early months after the injury. These include cognitive, physical, emotional, and
behavioral interventions. Education and support for family or other care givers
are also important elements of the care provided.
Emerging Consciousness Program (ECP)
The ECPs are located at the PRCs and are designed for individuals with
severe TBI who are not yet ready to actively participate in acute rehabilitation
programs. These individuals require specialized treatments for their medical
conditions as well as specialized rehabilitation services. The ECPs provide the
necessary interdisciplinary medical, nursing, and rehabilitation program and
services to: 1) optimize long term functional outcomes after severe brain injury;
2) improve responsiveness/return to consciousness; and 3) facilitate advance­
ment to the next phase of rehabilitation care. The interconnected components
of the program include comprehensive rehabilitation nursing and medical ser­
vices; individualized stimulation program; active therapy involvement; intensive
social work and case management; inclusive family programming; and research
and program evaluation.
Polytrauma/TBI Assistive Technology Labs (AT Labs)
The AT Labs are designed to effectively support patients with cognitive, sen­
sory, and physical disabilities to reach their highest potential at home, school,
work, and play through appropriate assistive technologies. The AT Labs at
PRCs serve as regional referral centers for Veterans and active duty Service
Members with disabilities that would benefit from specialized AT services. Clini­
cal services and supports provided at the AT Labs include evaluation, selection
of technological devices, acquisition, trial use, follow up, and maintenance of
assistive technology devices.
Polytrauma Transitional Rehabilitation Program (PTRP)
The PTRPs located at the four PRCs are designed to provide rehabilitation ser­
vices to Veterans and Service Members to allow them to live independently in
their home communities. PTRPs offer a progressive return to independent living
through a structured program focused on restoring home, community, leisure,
psychosocial and vocational skills in a controlled, therapeutic setting. The tran­
sitional rehabilitation program functions to optimize physical abilities through
graduated exercise, and to normalize cognitive, communication, and behavioral
abilities by employing these skills in a challenging, “real world” setting.
Post-acute Comprehensive Interdisciplinary Inpatient Rehabilitation
Post-acute rehabilitation, provided by the PNSs, is clinically appropriate for
patients who have completed initial inpatient rehabilitation, but continue to have
significant deficits or medical conditions which make them unsafe or difficult to
be cared for at home and can be more effectively treated in an inpatient set­
ting. Post-acute rehabilitation typically includes treatment and management by
an interdisciplinary treatment team, with an emphasis on functional goals and
prevention of further impairment. This service is usually offered as a transition
to the home environment, or other less restrictive care environment.
Traumatic Brain Injury
25
Comprehensive Interdisciplinary Outpatient Evaluation
Comprehensive outpatient TBI evaluations are provided by the PNSs or PSCTs.
They include a detailed history of the patient’s injury, assessment of common
symptoms or sequelae of TBI, physical examination targeted to the veteran’s
reported symptoms and physical impairments, and a comprehensive treatment
plan.
Outpatient Interdisciplinary Rehabilitation
Outpatient interdisciplinary rehabilitation is provided by the PNSs or PSCTs and
is designed for persons who are able to reside in the community, but continue
to need rehabilitation services to meet their ultimate goals. Interdisciplinary
teams led by a rehabilitation physician provide individualized, coordinated, and
outcome focused outpatient services including rehabilitation medicine services,
therapy services, education, and psychosocial treatment and support to
patients who live in their local service areas.
Individualized Rehabilitation and Community Reintegration Care Plan
VHA mandates that an Individualized Rehabilitation and Community Reintegra­
tion Care Plan is provided to Veterans and active duty Service Members with
TBI who receive inpatient or outpatient rehabilitation services. A physiatrist is
responsible for establishing the plan and monitoring response to treatment
services. The care plan should be developed by an interdisciplinary team with
TBI expertise and with input from the patient and family (as appropriate). It
should include goals for improving the physical, cognitive, and vocational func­
tioning and for maximizing the independence and reintegration of the individual
into the community. Contact information for the physician and case manager,
treatment services recommended and the date when the plan will be reviewed
by the team are also contained in the plan. Documentation of the rehabilitation
and reintegration plan is entered in the progress note section of the patient’s
medical record under the title, TBI/Polytrauma Individualized Rehabilitation/
Reintegration Plan Of Care.
Follow-up
Regular follow-up for individuals with ongoing rehabilitation needs is provided,
at intervals as determined by the physiatrist responsible for the plan of care at
the PRCs, PNSs or PSCTs.
Consultation across the Polytrauma System of Care
The PRCs serve as regional consultants to other components of the PSC, the
VA, the military healthcare system, and non-VA care providers. PNSs serve as
consultants to PSCTs and PPOCs within their VISNs. Consultations are often
provided through telerehabilitation. (See Appendix B for the Polytrauma refer­
ral patterns among the four tiered components of care).
26
Traumatic Brain Injury
Polytrauma/TBI System of Care Scope of Services Referral Guideline
PSC Rehabilitation Programs and Services
PRC PNS PSCT
Acute Comprehensive Interdisciplinary Inpatient
Rehabilitation
▲
Emerging Consciousness Program
▲
Residential Polytrauma Transitional Rehabilitation
Program
▲
Post-Acute Comprehensive Interdisciplinary
Inpatient Rehabilitation
▲
▲
Comprehensive Outpatient Interdisciplinary
Evaluation
▲
▲
Outpatient Interdisciplinary Rehabilitation
▲
▲
▲
▲
Community Reintegration
▲
▲*
▲*
Isolated Outpatient Therapy
Evaluation And Management Of Emerging
Problems
PPOC
▲
Management Of Stable Problems
▲
▲*
▲
▲
▲
Follow-Up Specialty Care
▲
▲
▲
Driver Rehabilitation
▲
▲
▲*
▲*
Consultation
▲
▲
Polytrauma Telehealth Network
▲
▲
▲
▲
Note: *Dependent on local resources. When VA is unable to meet TBI specific care needs, or
the care is geographically unavailable, VA utilizes private sector sources through fee for service
arrangements to meet the needs of eligible Veterans. The PSC case managers are responsible for
being familiar with sources for various types of specialty care and are a resource to assist when
these services are needed.
PSC Case Management and Care Coordination
PSC case management is a distinct and customized approach to managing
care for Veterans or Service Members. When individuals are diagnosed with
a severe impairment, their physical, emotional, and psychosocial responses
vary significantly. Because healthcare circumstances will differ, a tailored and
customized approach to coordinating care is required. Additionally, extensive
monitoring and care coordination are often required to meet the needs of
these individuals.
PSC case management and care coordination is provided to TBI and polytrauma patients across the continuum and amongst various systems of care,
such as military, civilian, and state and community services. This involves
acting as the lead case manager for emerging medical, psychosocial, or rehaTraumatic Brain Injury
27
bilitation problems; managing the continuum of care; and assessing clinical
outcomes and satisfaction. An intensity model based on clinical and psycho­
social needs is the framework used for providing case management services.
As the patient’s recovery continues and their physical and psychosocial needs
stabilize, less intensive case management services are required, leading to
discharge from specialized case management when rehabilitation needs have
been met. Conversely, some patients may need to return to more intensive
case management services due to changes in health or psychosocial support.
Polytrauma/TBI System of Care Case Management
Intensity Based Model of Care
Intensive Case Management (Daily/Weekly)
Intensive case management is provided to all patients receiving inpatient
rehabilitation and those outpatients who have a high level of care management
needs. It might also be provided during times of transition or when there is
significant change in the patient’s clinical, psychosocial, functional, or mental
health status.
Progressive Case Management (Monthly +/-)
Progressive case management is provided for patients in the post acute reha­
bilitation phase. A rehabilitation plan of care is in place and services are being
provided to address specific goals; support systems are in place. This type of
case management is also employed whenever there is a change in rehabilita­
tion needs.
Supportive Case Management (Quarterly +/-)
Supportive case management requires at least quarterly contact and is recom­
mended when medical, rehabilitation and psychosocial issues are stable and
the patient is well established in the PSC. In such cases, the patient and/or
caregivers have developed the knowledge and skills to apply appropriate level
of care and the focus of rehabilitation is community reintegration, independent
living, supported employment, or vocational rehabilitation.
Screening and Evaluation of Possible TBI in OEF/OIF
Veterans
Beginning in April 2007, VA began screening all OEF/OIF Veterans receiving
medical care in the VA for possible TBI. A TBI Clinical Reminder within the
computerized medical record was developed and implemented throughout the
VA Healthcare System. The Clinical Reminder (1) identifies who needs screen­
ing, (2) presents the screening tool to the provider, and (3) enters results into
a progress note and into the electronic health record. Those identified by the
screen as potentially benefiting from further evaluation are referred to clini­
cians with expertise in the area of TBI.
The TBI screening instrument is composed of four sections designed to identify
exposure to high risk TBI events, signs or symptoms associated with alteration
28
Traumatic Brain Injury
in consciousness at the time of the event, symptoms immediately following
this event, and current symptoms. If the Veteran responds positively to one or
more questions in each of the four sections, the clinician discusses the results
of the screen with the patient, and offers referral for further evaluation. The
reminder prompts the user to place a consult for further evaluation, or to
document refusal.
VA policy (VHA Directive 2010-012) requires that Veterans who screen posi­
tive on the TBI screening tool be offered a follow-up evaluation with a specialty
provider who can determine whether the Veteran has sustained a TBI. The
comprehensive TBI evaluation includes a detailed history of the patient’s injury,
assessment of the neurobehavioral symptoms or sequelae of TBI, a physical
examination targeted to the Veteran’s reported symptoms and physical impair­
ments, and a comprehensive treatment plan. Given the expertise required
to establish the TBI diagnosis and implement appropriate treatment, the TBI
evaluation is optimally conducted by specialists in the PSC. If a PSC team is not
available in the facility, the medical center has the option of having the evalua­
tion completed by a specialist with appropriate background and skills, such as
a physiatrist, neurologist, or neuropsychatrist who has also had training in the
evaluation protocol.
Points to Remember
• VA has a TBI Clinical Reminder in place to screen OEF/OIF Veterans
for possible TBI
• The CPRS note entitled “TBI/Polytrauma Individualized Rehabilitation
Plan of Care” is the best source for finding:
• Contact information for a patient’s TBI physician and
case manager
• A patient’s current TBI treatment plan, and
• The date when the plan will be updated by the team
Traumatic Brain Injury
29
CHAPTER 4:
Initial Assessment and Management
of TBI
Learning Objectives:
• Formulate an assessment approach for acute TBI
• Describe the levels of severity for TBI
• Contrast the role of mechanism of injury on TBI presentation
• Compare the indications for acute neuroimaging after TBI
• Describe factors complicating the acute assessment of TBI
• Review the typical course of recovery from TBI based on severity of initial injury
• Outline common symptoms after TBI
• Discuss medical sequelae seen after TBI
Introduction
This chapter will discuss the evaluation, management and treatment of the
individual with traumatic brain injury (TBI), including the approach to individuals
who present with symptoms potentially related to a remote TBI. Because of
unique factors in the evaluation of mild TBI, particularly in the returning OEF/
OIF cohort, a special section will be devoted to this topic. This chapter is
divided into the following sections:
• TBI assessment
• Factors complicating the assessment of mild TBI
• Symptoms and management of mild TBI
• Symptoms and management of moderate to severe TBI
• Appropriate referrals of patients with TBI
TBI Assessment
In the evaluation of an individual with an acute traumatic event, particularly one
that has resulted in bodily injury, a high degree of suspicion for co-occurring
TBI is required. TBI may be easy to recognize in individuals who have readily
observed persistent neurologic deficits, including ongoing alterations of mental
status (i.e., confusion) or loss of consciousness at the time of acute evalua­
tion. However, determining that a TBI occurred is more challenging when these
overt sequelae have improved or are more subtle. With acute triage focused
on urgent care, health care providers at each stage of care must question
whether a concomitant brain injury may have occurred. Identification of an indiTraumatic Brain Injury
31
vidual with TBI allows for symptom management as indicated, rehabilitation if
required, educating the individual and their family on the natural course of TBI
recovery, and monitoring for return of full function.
Primary care providers are essential in the evaluation of patients who have
been injured in trauma, but may have been inadequately assessed or not
assessed at all for TBI. The use of a screening tool for possible TBI for all
patients seeing a primary care provider who may have been exposed to
trauma is recommended. A positive screen should prompt a referral to a quali­
fied TBI specialist for definitive diagnosis and initiation of care. Primary care
providers will play a collaborative role during the initial assessment and acute
post-injury rehabilitation care for individuals with TBI; therefore they should be
familiar with these components of their patient’s care to provide needed sup­
port and co-management of non-TBI related issues.
Assessing an individual who has not had recent trauma, but is presenting for
the first time to a primary care provider with symptoms that may be potentially
related to a remote TBI, especially in the case of a mild TBI, presents a unique
challenge to the clinician. However many of the same principles used for evalu­
ation of an acute injury apply.
History and Physical
In the assessment of an individual after TBI, either acutely or remotely, com­
pleting a history and physical is the first step. Ideally, this should be performed
by a TBI specialist to identify many of the subtleties and unique aspects of TBI.
The goal of the history and physical is to establish the nature and severity of
the TBI, define current impairments and functional limitations and to identify
all disability related factors. A detailed history of current, as well as past, func­
tional and psychosocial status and previous treatment are important. Physical
examination should focus on the neuromusculoskeletal systems and include
a careful mental status examination and cognitive assessment. Pertinent ele­
ments of the history and physical are listed in Table 1.
Table 1: Comprehensive Assessment of Acquired Brain Injury
History
Physical
Trauma related facts
Neurological
Initial neurologic presentation
Cranial nerves 1-12
Pre-Injury information
Deep tendon & pathological reflexes
Past medical and surgical history
Sensory exam
Substance abuse
Cerebellar exam
Developmental history
Motor exam
32
Traumatic Brain Injury
History
Physical
Educational history
Mental status exam
Prior Head Trauma
Behavioral assessment
Military and legal record
Emotional/Psychological status
Vocational history
Musculoskeletal
Psychosocial history
Head
Life stressors
Face and temporomandibular joints
Family history
Extremities
Post-injury treatment interventions
Axial structures (neck, back, pelvis)
Current functional status
Obtaining, reviewing and distilling all available supporting documentation (e.g.,
medical records, service records, emergent/urgent care records) is critical.
Necessary information includes relevant past medical, social, vocational and
behavioral history, indicators of severity of injury, mechanism and context
of injury, symptom presentation (type, timing, severity), neurologic (acute
alteration of consciousness, coma, duration of coma, amnesia), and medical
(including Glasgow Coma Scale) and functional status.
This information is also of use when evaluating symptoms potentially linked to
a distant TBI. When records supporting a remote injury are limited, a greater
emphasis must be placed on the time course (i.e., symptom onset should be
temporally related to injury) and intensity of symptoms (i.e., symptom intensity
is expected to stabilize or decline post-injury), and on the physical examination.
Severity of Injury
Severity of TBI is discussed in detail in Chapter 2. Injury severity is based on
the initial assessments of alteration of consciousness (from dazed and con­
fused to comatose), presence of neurologic deficits (e.g., command following,
focal weakness, sensory deficits, abnormal motor stretch reflexes), and neu­
roimaging results. The Glasgow Coma Scale (GCS), length of coma, and length
of posttraumatic amnesia (PTA) are common measures used to assess sever­
ity (see Chapter 2). Injury severity may be reclassified in 24 hours after injury
to account for the impact of intoxicants or behavioral components (e.g., acute
stress reaction), however once it is established it should not be modified based
on recovery. Initial severity of TBI has been shown to correlate with short- and
long-term functional and vocational outcomes.
Traumatic Brain Injury
33
Mechanism and Context of Injury
Mechanism of injury may provide insight into the likelihood of acute medical
needs, severity and presentation of sequelae, and short- and long-term out­
come. Injury mechanism may include: acceleration-deceleration (e.g., a motor
vehicle accident), blunt trauma (e.g., assault), penetrating (e.g., gun shot to
head), blast, and secondary ischemic or hypoxic events.
Included in the context of the injury are circumstances of injury and whether
drugs or alcohol were involved. Circumstances that should be considered
include whether the injury occurred while in combat, while in duty status, while
on the job, or during a leisure or recreational activity. All these factors may
assist in evaluating the severity of the injury, as well as in understanding the
lifestyle and expectations of the injured person, which will be relevant to recom­
mendations of how treatment may fit into the individual’s routine.
Assessment of Symptoms
While individuals with TBI may have unique symptom presentations and recov­
ery patterns, type of injury, injury severity, mechanism of injury, secondary
injuries, premorbid physical and psychosocial factors and patient demographics
have an impact. Individuals with severe TBI are likely to have obvious diffuse
and focal neurologic sequelae (e.g., hemiplegia, spasticity, aphasia), as well
as profound cognitive, behavioral, and functional deficits. Somatic complaints
(e.g., headache, dizziness) are less common acutely and may be overshadowed
by the severity of neurologic and functional deficits. Individuals with moderate
TBI will often have non-focal neurologic deficits (e.g., dizziness and imbalance)
with overt but less severe cognitive, behavioral, and functional deficits. Individu­
als with a single mild TBI are unlikely to have persistent neurologic deficits,
and more commonly have somatic complaints interfering with cognitive and
functional skills. As a rule of thumb, somatic symptoms, such as headache or
dizziness, will arise within 48 hours of injury and cognitive symptoms, such as
poor attention or concentration within a couple weeks. Behavioral and sleeprelated symptoms may take longer to present (given the complex nature of
these issues), perhaps as long as 1-2 months. Thorough assessment of postconcussive symptoms can be accomplished utilizing one of the validated scales
for this purpose, such as the Neurobehavioral Symptom Inventory (Cicerone &
Kalmar, 1995).
For individuals who have had previous assessment, diagnosis, and treatment
for TBI, it is important to understand prior treatment interventions and their
effectiveness, the patient’s beliefs about brain injury and long-term prognosis,
whether the patient has been provided with education about TBI and the typical
course of TBI, and whether or not the patient has pending litigation related to
TBI.
While individuals with stable symptoms and management programs after TBI
may be confidently managed by a primary care provider, new or worsening
symptoms are best evaluated and managed by a TBI specialist.
34
Traumatic Brain Injury
Neuroimaging in TBI
Neuroimaging methods are of considerable value for the acute assessment
and management of TBI, although their role in classifying the degree of injury
and in predicting outcomes remains more of an open question. Two of the
most widely used techniques are computerized tomography (CT) scans and
magnetic resonance imaging (MRI). A head CT is the imaging study of choice
in acute brain injury because it will reveal acute bleeding, either within the
brain tissue, within the ventricles, or involving the dura (i.e., epidural or sub­
dural hematoma). Availability, cost, and sensitivity to acute bleeding, offers
significant advantages of CT over the MRI scan in the acute phase. The likeli­
hood of intracranial pathology identified by CT varies depending on the initial
or Emergency Department GCS score. While intracranial abnormalities on CT
scan are seen in all individuals with moderate or severe TBI, there is contro­
versy about the use of CT in mild TBI. Studies have found that less than 10%
of patients that are considered to have minor head injuries have positive find­
ings on CT and less than 1% require neurosurgical intervention (Jeret et al.,
1993). Serial or repeat CT scanning is indicated during the initial several days
to weeks for individuals who have sustained a moderate or severe TBI to moni­
tor the course of the injury and assess for hydrocephalus. The only indication
for a repeat CT scan in an individual with a mild TBI would be evidence of acute
neurological decline.
Forty-eight to 72 hours after injury, MRI is generally considered to be superior
to CT (Lee & Newburg, 2005). MRI may be used in the subacute and chronic
phases if persistent and unexplained disabilities remain. Although CT is better
at detecting bony pathology and certain types of early bleeds, the ability of
MRI to detect hematomas improves over time as the composition of the blood
changes. MRI can depict nonhemorrhagic and hemorrhagic contusions and
is more sensitive for detection of diffuse axonal injury (Doezema et al., 1991;
Mittl et al., 1994). However, for mild TBI, MRI findings are frequently negative.
New and evolving MRI technologies such as Diffusion Tensor Imaging (DTI)
and Magnetization Transfer Imaging are more sensitive to structural changes
following mild TBI (Smith, Meaney et al. 1995; McGowan, Yang et al. 2000;
Rugg-Gunn, Symms et al. 2001), but are currently being used more for
research than clinical purposes. DTI can reveal injury to the axons and may
allow us in the future to better detect subtle injury to white matter tracts
in the brain. Another frequently used experimental neuroimaging technique
is functional MRI (fMRI), which allows researchers to measure markers of
neuronal activity while patients carry out various mental tasks in the scanner.
Other experimental measures of brain functioning include single photon emis­
sion computed tomography (SPECT) and positron emission tomography (PET),
both of which measure brain metabolism as a marker of function. It is impor­
tant to note that these techniques, due to their still experimental nature, are
not currently recommended for clinical use.
Traumatic Brain Injury
35
Points to Remember
• Symptom
presentation varies with severity of injury; however, specific
patterns exist for mild, moderate, and severe injury.
• Assessment
of mechanism and context of injury assists in understand­
ing acute medical needs, sequelae, and outcomes.
• Although
not always necessary, a head CT scan is preferable to an MRI
scan following a mild TBI because of its sensitivity to acute bleeding.
Other Testing
In the assessment of acute TBI, individuals who have neurologic or medical
problems that warrant either over night hospital observation or inpatient
admission should be managed by TBI specialists. During their acute care stay
individuals with moderate to severe TBI often receive additional diagnostic
testing (e.g., electrophysiologic, serial neuroimaging) and may be re-assessed
at regular intervals in the first 1-5 years post-injury (e.g., neuroimaging, neu­
ropsychological testing, and computerized posturography). These specialized
ongoing evaluations should be managed by the TBI specialist who follows these
individuals.
Individuals with mild TBI who do not require hospital-based monitoring or
who may have never even been seen in the Emergency Department or clini­
cian’s office and who are demonstrating progressive recovery do not require
additional testing of any type. Advanced diagnostic testing to qualify and/or
quantify persistent symptoms or deficits (e.g., cognitive, behavioral, balance) is
occasionally useful, but its usage should be directed by TBI specialists.
Factors Complicating Assessment of Mild TBI
Acute assessment of mild TBI may demonstrate some easily recognizable
cognitive, behavioral, or somatic difficulties (e.g., poor attention, irritability,
dizziness), however these are almost always self-reported problems and more
often the problems are subtle and not well described. While a referral to a
TBI specialist (i.e., specially trained physician or team) can help in verifying the
diagnosis or clarifying the management plan, it is vital for the primary care cli­
nician to understand both the recommended diagnostic approaches and tools,
and the factors that may complicate making the diagnosis. Occasionally, similar
difficulties may occur in individuals who have had a remote moderate or severe
TBI, have limited medical records available for review, and who have experi­
enced a near total recovery. The approach to these patients parallels mild TBI.
Although many of the neurological symptoms following TBI can be associated
with structural brain injury, association does not prove causation. The same
holds true for psychological symptoms, such as anxiety, depression, lability,
irritability, and aggression. Moreover, many of these symptoms are common in
healthy individuals, and increase under stressful situations or when sustaining
other, non-brain related trauma (e.g., extremity fracture). Thus, whether the
symptoms following a TBI are caused by the injury, a consequence of adjust36
Traumatic Brain Injury
ment to the accident, associated with comorbidities, secondary to dealing with
the medical-legal environment, or related to a combination of these factors can
be difficult to determine.
Unique Assessment Complications in the Returning OEF/OIF Population
There are multiple factors that complicate accurate assessment and diagnosis
of OEF/OIF Veterans presenting to healthcare professions. These include:
• both
Veteran and healthcare provider misinformation regarding TBI
• delayed
presentation for evaluation or treatment
• exposure
to multiple potentially injurious events
• multiple
symptoms common across various diagnoses or simply associated
with stress
• multiple
mental health comorbidities in addition to a history of mild TBI.
Misinformation about Blast Exposure. There appears to be a common
misconception among soldiers, the news media, and some healthcare provid­
ers that exposure to a blast event means that a person sustained a TBI. This
is incorrect. Exposure can mean multiple things. Unless a Service Member
experiences the direct force of a blast and that force is sufficient to cause a
physiological disruption of brain functioning (e.g., seeing stars, being disori­
ented, being in-and-out or being knocked unconsciousness for several minutes)
the Service Member did not sustain a TBI no matter how traumatic the event
may have been to them or others.
Self-expectations and Iatrogenic Factors. Research indicates that many of
the symptoms following mild TBI are the result of psychological mechanisms,
such as expectations following a mild TBI (Mittenberg, DiGiulio, Perrin, & Bass,
1992), poor coping styles (Bohnen & Jolles, 1992; Marsh & Smith, 1995),
or emotional reactions to an adverse event. This research suggests that the
information provided by medical personnel to individuals who experienced a
mild TBI can either amplify and increase their symptomology and distress (iat­
rogenic factors), or can minimize and normalize their symptoms. Mittenberg
and colleagues demonstrated minimization of symptoms when individuals who
sustained a mild TBI were provided with basic psychoeducational information
about mild TBI symptoms and their typical course of resolution.
Delayed Presentation for Evaluation or Treatment. VA screening for pos­
sible TBI in the returning OEF/OIF population typically occurs from several
months to as long as a year or more following deployment. Patients’ memories
have faded and merged with many other deployment-related experiences.
Veterans often describe multiple historical events in which a TBI may have
occurred, most of which are also psychologically traumatizing. Within the Vet­
eran’s mind, physically traumatic events and psychologically traumatic events
are often merged and overlapping. Under these circumstances, it is extremely
difficult to get an accurate history regarding details of the potentially injurious
events and the subsequent onset and course of symptoms. However, this his­
tory is essential to making the correct assessment.
Traumatic Brain Injury
37
Pre-existing Factors with Overlapping Clinical Symptoms. Comorbidities
are also a challenge when evaluating and/or treating a patient with mild TBI.
Many factors that tend to co-occur with mild TBI complicate both assessment
and treatment, including preexisting stress and social difficulties (Fenton et al.,
1993; Ponsford et al., 2000; Bohnen & Jolles, 1992), learning disabilities
(Dicker, 1992), history of previous neurologic or psychiatric disorders (Pons­
ford et al., 2000; King, 1996), and preinjury alcohol or drug abuse (Dikmen &
Levin, 1983). These factors complicate the clinical picture and make it difficult
to know which issues to address first.
Individuals with poor psychological coping or increased psychological distress
have a higher rate of prolonged postconcussive symptoms compared to
those with uncomplicated recoveries (Karzmark, Hall, & Englander, 1995).
Other research suggests that persistent (i.e., lasting more than 1-3 months),
post-concussive syndrome reflects, in part, anxiety regarding the experience
of an adverse event perceived as life-threatening (i.e., post-traumatic stress
response; DiGallo, Barton, & Parry-Jones, 1997; Bryan & Harvey, 1999).
Differential Diagnosis. In those individuals reporting long-term postconcus­
sive symptoms following mild TBI, their clinical presentation may be very similar
to related disorders, including PTSD or major depression. For instance, indi­
viduals may report sleep difficulties, memory problems, irritability and anxiety
that fit any of these diagnoses. Mittenberg and Strauman (2000) suggest the
following considerations in differential diagnosis:
Postconcussive Syndrome versus Post-Traumatic Stress Disorder. Postconcus­
sive syndrome is not associated with persistent re-experiencing of the accident
or numbing of general responsiveness, whereas PTSD is. In contrast, PTSD is
not characterized by dizziness, generalized memory problems, headaches, or
subjective intellectual impairment, while PCS is.
Postconcussive Syndrome versus Major Depression. Postconcussive syndrome
is not associated with changes in appetite or weight, psychomotor agitation or
retardation, suicidal ideation, or a history of depressive disorder.
Points to Remember
• Post-concussion
symptom complaints are complicated by overlap with
other conditions
• Referral
to a TBI specialist for careful evaluation may be helpful in dif­
ficult diagnostic cases
38
Traumatic Brain Injury
Symptoms And Management of Mild TBI
Mild TBI Symptoms
During the week or two following mild TBI, the vast majority of patients recover
fully without any noticeable symptoms. During this period individuals often have
initial cognitive symptoms of slowed information processing speed and difficulty
with attention. Eight out of 10 patients with a mild head injury show at least
some symptoms outlined in Table 2 during the first several weeks or months
after the accident. These symptoms are part of the normal recovery process
and are not signs of permanent brain damage or medical complications.
Immediate postconcussive symptoms, such as nausea, vomiting, drowsiness,
and dizziness are typically short-lived (Rutherford 1989; Bohnen and Jolles
1992). Headaches are commonly reported within the first few days and may
continue for several weeks. Other possible symptoms include decreased con­
centration, difficulty maintaining attention, fatigue, irritability, and depression.
A cluster of symptoms common following mild TBI, labeled postconcussive
syndrome (PCS), includes complaints of poor concentration, memory difficulty,
intellectual impairment, irritability, fatigue, headache, depression, anxiety, dizzi­
ness, blurred vision, light sensitivity and sound sensitivity (American Psychiatric
Association, 1994; World Health Organization, 1992). This symptom complex
typically occurs without demonstrable structural changes to the brain (Eisen­
berg & Levin, 1989) or neuropsychological dysfunction (Dikman et al., 1986;
Levin, Mattis et al., 1987). The most commonly documented persistent PCS
symptoms are noted in the Table 2 below. Although many of these symptoms
are common in normal individuals (e.g., difficulty concentrating, irritability, anxi­
ety, memory complaints, headaches), the incidence of the symptoms increases
acutely following mild TBI.
Table 2: Frequency of PCS symptoms following mild TBI and in the General Population
Symptom
Mild TBI PCS
Symptom
Frequency
Frequency in
the General
Population
PCS Symptom
Increase after Mild
TBI
% of Patients
% of People
Increase over base
rate
Poor concentration
71%
14%
57%
Irritability
66%
16%
50%
Tired a lot more
64%
13%
51%
Depression
63%
20%
43%
Memory problems
59%
20%
39%
Headaches
59%
13%
46%
Traumatic Brain Injury
39
Symptom
Mild TBI PCS
Symptom
Frequency
Frequency in
the General
Population
PCS Symptom
Increase after Mild
TBI
% of Patients
% of People
Increase over base
rate
Anxiety
58%
24%
34%
Trouble thinking
57%
6%
51%
Dizziness
52%
7%
45%
Blurry or double vision
45%
8%
37%
Sensitivity to bright light
40%
14%
26%
Table adapted from: Mittenberg, W., DiGiulio, D. V., Perrin, S. & Bass, A. E. (1992). Symptoms
following mild head injury: Expectation as aetiology. Journal of Neurology, Neurosurgery, and Psy­
chiatry, 55, 200-204.
Management and Treatment after Mild TBI
The majority of our current research and information about mild TBI is based
on non-combat mechanisms and circumstances, and single events. Knowledge
about combat and blast-related mild TBI and multiple mild TBI is currently
evolving.
The data from sports concussion studies demonstrates that impaired cognitive
performance follows concussion acutely and that there is an increased risk
for second injuries indicating the need for a period of rest (Macciocchi, Barth
et al. 1996; Warden, Bleiberg et al. 2001). This period of rest varies (from
hours to months) based on the severity of the concussion. As noted above,
second TBIs can result in everything from sudden death (i.e., Second Impact
Syndrome), to worse long-term functional outcomes, to protracted symptoms.
Treatment for mild TBI includes education, a period of rest and observation,
and treatment of persistent or disabling symptoms (e.g., headache). Validating
the patient’s symptoms (i.e. that postconcussive symptoms derive from the
physical injury) and setting the expectancy of resolution of these symptoms
over time are mainstays to management of mild TBI (Salazar & Warden,
1999). Cost-effective interventions (e.g., giving the patient an information
booklet about symptoms and coping strategies, a telephone follow-up, or “as­
needed services”) are effective in alleviating chronic symptom development
(Mittenberg et al., 1996; Paniak et al., 2000; Ponsford et al., 2002). Appen­
dix C is a patient treatment manual for individuals with mild TBI, Recovering
from Head Injury: a Guide for Patients. It is intended to educate patients and
their families about mild TBI, support the reattribution of symptoms to normal
transient responses to stress, selective attention to symptoms, and resulting
adjustment anxiety. Finally, depending on the speed of recovery, recommenda­
tions regarding return to partial or full work should be tailored to the individual.
40
Traumatic Brain Injury
TBI specialists are valuable resources in assisting with return to work/activity
recommendations and in directing vocational rehabilitation programs.
Pharmacologic and nonpharmacologic interventions are used to treat specific
symptoms following mild TBI, especially when those symptoms, e.g., headache
and sleep disorder, are disabling or not improving. The VA-DoD Joint Clinical
Practice Guidelines for Concussion/mild TBI is a valuable tool in the structured
management of these individuals, under the direction of TBI specialists. A
crucial and often omitted component of mild TBI management is the provision
of education to individuals with TBI regarding fatigue, irritability, and mood
lability that may occur during mild TBI recovery. Mittenberg and colleagues
(1996) demonstrated that patients with mild TBI who met with a therapist who
reviewed the nature and incidence of expected symptoms experienced signifi­
cantly less symptom duration, significantly fewer symptoms and significantly
lower average symptom severity levels at 6 months follow up.
Points to Remember
• Symptoms following mild TBI may be physical (e.g., headaches and
dizziness), emotional (e.g., anxiety and depression), or cognitive (e.g.,
attention and memory problems)
• There are significant long-term residual neurological symptoms in
a small proportion of individuals who sustained a mild TBI (about
10-15%), with consequent psychosocial, employment, and relationship
problems
• Psychoeducational intervention, combined with support and cognitivebehavioral interventions can significantly reduce the extent of
postconcussive symptoms
• Pharmacologic and nonpharmacologic interventions can be used to
treat specific symptoms following MTBI such as headaches, insomnia,
depression, irritability, or emotional dysregulation
Symptoms and Management of Moderate to Severe TBI
Common Medical Complications and Problems following Moderate and
Severe TBI in the Acute and Post-Acute Period
Following a moderate to severe TBI, Veterans often need continued care
in a variety of settings. TBI is characterized by substantial heterogeneity in
its pathophysiology and ongoing cognitive deficits and emotional/behavioral
problems are common. The most prominent cognitive sequelae following
moderate to severe TBI are: (a) attention and concentration problems, (b)
deficits in new learning and memory, and (c) executive control dysfunction.
Common emotional difficulties and behavioral problems include: (a)
emotional adjustment difficulties, (b) emotional dysregulation (i.e., difficulty
controlling ones emotional responses), (c) irritability, (d) interpersonal intrusive­
ness or withdrawal, (e) relationship problems, and (f) problems with impulse
control. Assessment and treatment of these two sets of problems are disTraumatic Brain Injury
41
cussed in Chapters 6 and 7. Acute and post-acute medical problems and
complications will be discussed below, while more chronic medical sequelae
are discussed in Chapter 5.
Following moderate or severe TBI, the following acute or post-acute medical
complications may develop.
Seizures. All patients with TBI are at increased risk for new-onset seizures,
termed post-traumatic seizures, proportionate to their severity of initial injury,
the presence of dural penetration, and their age. The risk of seizure following a
mild TBI is extremely low. The epileptic episodes may be due to direct damage
of brain tissue which has resulted from shearing forces, infarction, or due to
secondary irritation caused by hemorrhage. Seizures may also be triggered by
secondary insults including metabolic disturbances and hypoxic episodes.
Most studies have failed to demonstrate the benefit of anticonvulsant pro­
phylaxis for posttraumatic seizures after the first week following head injury.
Therefore, seizure prophylaxis is not recommended for an extended duration
(Liebert, 2000). When late (occurring beyond the first week post injury)
posttraumatic seizures present, investigation for possible underlying triggers
should ensue (metabolic, substance abuse, structural). If no correctable
sources are uncovered, or if a second seizure occurs, treatment with anticon­
vulsant medication is warranted. New onset of late posttraumatic seizures can
occur at any time, but the likelihood diminishes over time. Patients experienc­
ing the onset of posttraumatic seizures should be referred to a neurologist for
thorough evaluation and management.
Spasticity. TBI, like other upper motor neuron diseases, is associated with
spasticity. The degree of spasticity usually correlates with the degree of motor
weakness in the effected extremity. Spasticity must be distinguished from
other causes of resistance to passive movement including anxiety, pain, hetero­
topic ossification, and contractures. Spasticity, by impeding normal physiologic
range of motion, can both interfere with functional activities and lead to joint
contractures. Contracture presents a formidable obstacle to treatment once
it develops. Spasticity can also lead to pain syndromes, skin breakdown, prob­
lems with hygiene, positioning, and cosmesis. On the other hand spasticity can
provide benefits, as when extensor tone in the leg aids standing activities. Sud­
den worsening of spasticity warrants a search for potential triggers including
infection, ulcers, and metabolic disturbance.
A myriad of treatment options are available for spasticity including physical
modalities, splinting, neurolytic or botulinum injections, oral medications, and
surgical procedures. The decision to employ them is based on careful evalu­
ation of the severity of the spasticity, the distribution of involved joints, the
functional status, and risk-benefit analysis of each individual treatment option.
Management of spasticity is often best accomplished by physiatrists or other
TBI specialists. Occupational therapists and physical therapists also provide
important expertise in the treatment of spasticity and resulting complications.
42
Traumatic Brain Injury
Neuroendocrine Dysfunction. Dysfunction of the endocrine system can occur
anywhere along the hypothalamic-pituitary-end-organ axis. For patients with
TBI, the most likely source of dysfunction is in the central aspect of this axis.
Skull fracture, hemorrhage, ischemia, and brain edema can all cause damage
to the hypothalamus or pituitary gland. The most common resulting endocrine
abnormalities are SIADH and diabetes insipidus (Watanabe & Sant, 2001).
Because endocrine dysfunction is so common in TBI (affecting up to 20%), it
is important to be able to determine the underlying cause of any electrolyte
abnormalities. This will allow for the use of appropriate methods for correction
of imbalances in a given patient.
Hydrocephalus. Non-obstructive hydrocephalus is a frequent complication
after severe TBI. The usual cause is disruption of the absorptive capability
of the arachnoid villae. The classic clinical signs are similar to normal pres­
sure hydrocephalus (imbalance, incontinence, and dementia), though a high
index of suspicion is required of the treating physician because the onset in
the severely injured is typically slow, with the earliest indication often a vague
decline or plateau in functioning and/or subtle mental status changes. Head
CT is the investigative study of choice, and when enlarged ventricles are seen,
true hydrocephalus must be distinguished from hydrocephalus ex vacuo. In
hydrocephalus ex-vacuo, loss of parenchymal volume allows the ventricular
system, which is under pressure, to expand, giving the appearance of hydro­
cephalus on imaging studies (Bigler, 2001). If the CT findings are inconclusive,
serial CT scans and sometimes CSF tapping tests may be needed.
Heterotopic Ossification. The formation of new bone in non-boney tissue
can be seen in the acute recovery period following TBI occurring in 11-77%
of cases (Watanabe & Sant, 2001). Risk factors include prolonged coma (>
2 weeks), immobilization, skeletal trauma, and spasticity. The most commonly
affected joints include the hip, knee, shoulder, and elbow. Complications include
decreased range of motion, nerve and/or vascular compression, lymphedema,
and ankylosis. The early signs of heterotopic ossification (HO) typically pres­
ent with pain, erythema, warmth, swelling and fever, and can resemble local
trauma, fracture, cellulitis, or DVT. Therefore, it is important to keep HO in
the differential when a patient with TBI presents in this manner. Heterotopic
ossification typically begins within the first 2-3 weeks following injury, but onset
can occur from 1 to 7 months post TBI (Watanabe & Sant, 2001). Treatment
remains controversial, with options including etidronate, non-steroidal antiinflammatory drugs, range of motion, and surgery. Referral to a physiatrist for
recommendations regarding treatment is recommended.
Urinary Incontinence. Urinary incontinence is common acutely after TBI, and
in some may continue chronically. The usual etiology is loss of normal cerebral
inhibition and control over bladder and sphincter activity, secondary to frontal
or diffuses cognitive injury. Detrusor hyperreflexia and urinary retention can
also occur, particularly early on. In the absence of hyperreflexia, retention, or
obstruction, the preferred treatment is bladder “training” with scheduled timed
Traumatic Brain Injury
43
voiding attempts. New incontinence in the previously continent patient should
elicit a search for inciting causes such as urinary tract infection or a new
structural insult like hydrocephalus.
Management and Treatment after Moderate or Severe TBI
Inpatient Rehabilitation Setting. Following acute emergency evaluation
and medical stabilization, the individual with a moderate to severe TBI usually
requires a period of inpatient rehabilitation. These services are best provided
in an established interdisciplinary brain injury program. These interdisciplinary
programs are staffed with TBI-trained specialists and directed by physiatrists,
physicians specially trained in physical medicine and rehabilitation. The interdis­
ciplinary team includes the patient and family as well as the physician, nurses,
therapists, social workers and psychologists. The team communicates regu­
larly and works toward common goals. Better outcomes have been shown in
interdisciplinary compared to multidisciplinary programs, and in TBI dedicated
programs.
During this phase of treatment, the individual with TBI requires frequent
contact with a physician to monitor new or ongoing complications of the brain
injury and the services of nurses specializing in rehabilitation care. There
should be a reasonable expectation for functional improvement. The focus in
the early rehabilitation phase is to restore the individual to maximal functional
independence. To be eligible for admission to an inpatient brain injury program,
the individual should be medically stable and able to participate in rehabilita­
tion therapies. The exception to this is that VA Polytrauma/TBI Rehabilitation
Centers, and a few private sector hospitals, have specialized programs for
individuals who are minimally responsive and not yet ready to actively partici­
pate in rehabilitation. The focus of these emerging consciousness programs
is to optimize medical management, undo any reversible causes of reduced
consciousness, and provide trials of controlled stimulation and pharmacologi­
cal interventions as indicated. Family support and education are also a critical
component of these programs.
The benefits of rehabilitation after TBI have been well documented in the
medical literature. Short-term outcomes are better when structured reha­
bilitation interventions begin in the ICU. Principles of early rehabilitation
include controlled mobilization out of bed, sensory regulation (avoiding over
or under-stimulation), avoiding cognitively impairing medications, regular pain
assessment, and early removal of urinary catheter with implementation of
timed voids.
Individuals who do not reach a level at which they are able to function relatively
autonomously after reaching maximum benefit from inpatient rehabilitation can
be transitioned to other treatment settings based on their need for medical
care, nursing care and supervision. Some individuals may require long term
care in a setting able to provide total care, rather than an acute rehabilitation
44
Traumatic Brain Injury
facility. These individuals should have rehabilitation monitoring and evaluation
available on a long-term basis to address problems and complications that may
arise as a result of their brain injury. Others may require long term supervi­
sion that their families are unable to provide. These services can be provided
through group homes or supervised apartments. Identification of such facilities
or programs can be facilitated through contact with specialized TBI case man­
agers.
For patients who have progressed beyond, or did not require acute inpatient
rehabilitation, a variety of other services can be accessed for specific impair­
ments. These services include transitional rehabilitation, outpatient therapies,
community programs, and vocational rehabilitation.
Long term monitoring and management by rehabilitation professionals is gen­
erally recognized as beneficial to individuals who have sustained a moderate to
severe brain injury. Individuals with acute and/or persistent neurologic seque­
lae or medical complications after moderate to severe TBI should be closely
managed by TBI specialists in close collaboration with the individual’s primary
care provider. Once the individual’s status has stabilized and their rehabilitation
care plan goals have been met, the primary care provider may resume much
of the care and the TBI specialist may be utilized for specialized problems
(spasticity management, symptom management), formal re-evaluations (e.g.,
annual re-assessments) and for new problems related to brain injury.
Appropriate Referrals of Patients with TBI
The short- and long-term management for individuals with TBI, regardless
of injury type or severity, should be directed by the TBI specialist or specialty
team in close collaboration with the primary care provider.
Although a thorough physical examination and history are the initial elements
of a postconcussion clinical workup, a variety of other tools are available to the
TBI specialist and TBI teams to clarify examination findings. The TBI specialists’
assessments could entail repeat neuroimaging, electrophysiological testing,
computerized posturography, neurologic or neurosurgical consultation, pain
specialist referral, neuropsychological testing or other evaluations. These refer­
rals are best coordinated by the TBI specialist.
Individuals with stable symptoms, sequelae, function and management
programs can be managed by primary care providers with problem specific
management (spasticity, etc.) and annual re-evaluation by the TBI specialists.
However, individuals with new, variable or worsening symptoms and/or seque­
lae or with fluctuating management strategies are best managed with more
frequent visits to their TBI specialists. This referral should be made for individu­
als who continue to report persistent or worsening difficulties with spasticity,
seizures, headaches, sleep, concentration, attention, memory, irritability and
other common issues.
Traumatic Brain Injury
45
Clinically-directed appropriate referrals for additional assessment may include
consults to the following disciplines:
• Physiatrist
• Neurologist
• Psychiatrist
• Neuro-ophthalmologist
• Neuro-optometrist
• Neurosurgeon
• Endocrinology
• Audiologist
• Neuropsychologist (psychologist)
•
•
•
•
•
•
•
•
•
Clinical Psychologist
Speech and Language Pathologist
Physical therapist
Kinesiotherapist
Occupational therapist
Recreation Therapist
Social Worker (counselor)
Vocational Rehabilitation Counselor
Case Manager
A more detailed description about each of these disciplines is provided in
Appendix D.
Points to Remember
• Serious medical sequelae can result from the moderate or severe TBI;
management by a TBI specialist is recommended
• Most patients with moderate to severe TBI will require a period of inpa­
tient specialized interdisciplinary TBI rehabilitation
• TBI specialists or specialty teams should be involved in the short- and
long-term assessment and management of TBI
• Long-term medical management of the stable moderate to severe TBI
patient can be done by primary care providers, with TBI specialty con­
sultation as needed
46
Traumatic Brain Injury
CHAPTER 5:
Post-Acute/Chronic Sequelae:
Medical and Physical Problems
Learning Objectives:
• Identify common post-acute medical sequelae following TBI
• Define persistent postconcussive syndrome
• List common visual impairments and dysfunction following TBI
• Describe principles for prescribing treatment for post TBI issues
• Identify types of headache following TBI and potential treatment options
Introduction
A variety of issues can persist following the acute management of moderate
to severe TBI. TBI typically involves a complex interplay of brain injury, extra-cra­
nial tissue injury of the head and neck, and secondary or reactive symptoms.
The resulting symptomatology can have somatic, cognitive, and affective/
psychological/behavioral components. Common post-TBI medical and physical
problems are discussed below, while the common cognitive and affective/psy­
chological problems are discussed in Chapters 6 and 7, respectively.
When to Suspect TBI Related Issues
Patients with prior TBI may present in a variety of ways and in a variety of clini­
cal settings. Rarely would a patient present noting that a symptom was directly
related to prior brain injury. Providers should consider possible relation to TBI if
a patient presents with the following complaints:
• Complaints of inability to stay on task/easy distractibility
• Headaches that have started after trauma or have worsened after trauma
• Problems with work performance following trauma
• Identification of behavioral or personality changes after a fall or motor vehicle accident.
• Complaints of vision changes or balance/coordination with recent history of trauma
• Complaints of fatigue or sleep disturbance with recent trauma
Traumatic Brain Injury
47
Guiding Principles for Treating TBI Patients
A Team Approach to Address Multiple Persistent Symptoms.
Patients who have sustained TBI often feel misunderstood by family, friends,
and colleagues. While patients are keenly aware of post-injury changes, lay
persons may perceive that they “look and sound normal.” Conversely, treating
professionals during the course of assessment and therapy sometimes focus
exclusively on patients’ symptoms. Thus, many people with brain injury experi­
ence significant frustration and failure.
A “dose effect” understanding of head trauma suggests that higher levels
of long-term impairment are associated with greater initial severity of injury
(Levin, Benton, Grossman, 1982). However, research has shown that patients
with mild TBI may report problems at equivalent or even greater rates than
patients with more severe TBI (Larrabee, 1997, 1999). As a rule of thumb,
regardless of the severity of the initial injury, patients with multiple sustained
and severe symptoms are likely to require a team approach in order to
increase the chance of successful remediation of their symptoms; an inter­
disciplinary, holistic approach is preferred (Prigatano, 1989; Ben-Yishay &
Prigatano, 1990; Prigatano, 1999). This holistic framework emphasizes not
only the treatment of specific physical and cognitive symptoms, but attending
to the patients’ individual needs which might include providing information, help­
ing to motivate, instilling hope, and taking environmental factors into account.
Developing a successful TBI treatment framework is not limited to just attend­
ing to the patients’ cognitive and physical symptoms. Successful treatment will
often include multiple additional interventions including educating, advocating,
counseling, and support. Providing caring attention, helping the patient to feel
understood, providing accurate information on symptoms and outcomes, and
instilling hope contribute to symptom improvement and return to pre-injury
functioning. Team treatment necessitates effective and ongoing communication
between both team members and with the patient and family.
General Rules of Thumb When Prescribing Treatments
At the risk of oversimplifying the diagnosis and treatment of TBI sequelae,
it is often helpful to have a general starting point from which to individualize
approaches and treatment plans. The following four rules of thumb provide a
general compass for directing treatment of TBI sequelae.
1. The relationship between initial injury severity and current symptom pre­
sentation should guide the general approach to prescribing interventions.
• More severe injury / severe, diffuse symptoms » Multidisciplinary care
• More severe injury / few or focal symptoms » Symptom-specific inter­
ventions and Monitor Progress
• Less severe injury / more severe, diffuse symptoms » Psychological
coping interventions
• Less severe injury /few or focal symptoms » Provide Education
and Monitor
48
Traumatic Brain Injury
2. Investigate prior treatments to avoid repeating ineffective strategies.
3. Don’t take on the “savior” role. If several other physicians haven’t “fixed”
the symptoms from a relatively mild TBI, then you won’t either.
4. If the patient has not responded to initial interventions, a comprehensive
interdisciplinary approach to treatment coordinated by an experienced
TBI-case manager or physiatrist is highly recommended. If this is not
available at your facility, then the patient should be referred to the next
higher level within the VA PSC as outlined in Chapter 3.
Addressing Specific Symptomatology
Common Problems post-TBI
There are a number of common somatic medical problems that occur fol­
lowing TBI. Treatment for these conditions is similar regardless of severity or
acuteness of the original brain injury. Listed below are common acute medical
complications that usually present during the hospitalization or acute rehabilita­
tion phase and were discussed in Chapter 4:
• Seizures
• Spasticity
• Neuroendocrine Dysfunction
• Hydrocephalus
• Heterotopic Ossification
• Urinary Incontinence
This chapter discusses common somatic complaints that the post-acute or
chronic TBI patient may present with regardless of initial TBI severity.
Post-Traumatic Headaches (PTHA)
Post-Traumatic Headaches (PTHA) can be present in 30-90% of patients
following TBI and can be very challenging to manage. Numerous types of
headaches can present following TBI but headache patterns are often divided
into tension-like, migraine-like, and mixed tension/migraine (Lew et al., 2006).
Treatment should be based on the category of headache as determined during
the assessment and should target not only the physical pain but also the per­
son’s reaction to pain in daily life. Specific treatment options include short-term
use of medication, conventional physical therapy, biofeedback, and psycho­
therapy for the development of coping techniques. Counseling sessions should
include gradual exposure to the cause of the anxiety, cognitive reinterpretation,
and systematic desensitization. “Habit reversal” involves detection, interrup­
tion, and reversal of maladaptive habits. These include jaw clenching/tension,
head posture, and negative cognition or thinking. Awareness training and deep
breathing exercises are also beneficial.
Tension headaches. Tension headache, including the cervicogenic variety, is
the most common form. Directed treatments include physical therapy, relax­
ation techniques, medications, and myofascial trigger point injections. Choice
of analgesic medications is based on the principle of avoiding side effects that
Traumatic Brain Injury
49
might precipitate or exacerbate cognitive or behavioral symptoms. Thus the
analgesic of choice is acetaminophen, followed by non-steroidal anti-inflamma­
tory drugs, which occasionally cause neuropsychiatric effects.
Migraine headache. The treatment of migraine type headaches involves
prevention and abortive strategies and pharmacologic interventions include a
variety of classes of medications. There is minimal literature evidence, espe­
cially randomized controlled clinical trials, verifying treatment and prevention of
posttraumatic migraine headache. Therefore it is recommended that standard
evidence based pharmacologic interventions for migraine headache in the gen­
eral population be used.
Temporomandibular joint pain. For post-traumatic TMJ syndrome, dental
management is recommended with possible treatment by a physical therapist.
Headache treatments. Botulinum toxin has been used for treatment of vari­
ous headaches, both tension and migraine. Recent studies have indicated
that Botox may be more effective in treating those patients describing their
headache as imploding (crushing/clamping/stubbed by external forces) than
exploding (buildup of pressure inside their head) headaches (Jakubowski et al.,
2006). Neuralgic headache types including occipital neuralgia may respond
to nerve injections or neuropathic pain medications (anticonvulsants-especially
gabapentin or topiramate, and tricyclic antidepressants). The following classes
of medication may be used to manage headaches: pain relievers, anti-epileptic
agents, antidepressants, beta blockers, ergotamines, therapeutic injections
(nerve blocks, Botulinum toxin). Please refer to Appendix E on pharmacology
for further details.
Persistent Postconcussive Syndrome (PCS)
As discussed in Chapter 4 a small subset of patients with mild TBI (10-15%)
will exhibit ongoing symptoms several months post injury consisting of some
combination of physical, cognitive, and emotional symptoms. Those patients
with PCS lasting greater than 12 months are classified with persistent postconcussive syndrome (persistent PCS). These patients can be very challenging
to manage due to the multiplicity of symptoms and a team approach may be
beneficial. Focus should include the patient and how symptomatology affects
their function rather than focusing on merely treating symptoms. A variety of
medications can be utilized to treat symptoms of persistent PCS. The reader is
referred to Appendix E for general prescribing rules and to the remainder of
this chapter for specific symptoms/impairments.
Pain (Acute and Chronic)
Both acute and chronic pain may develop following TBI. Headache is the most
common pain complaint in this patient population but other pain sources are
also frequent. Given the traumatic mechanism of the brain injury, it is likely
that other areas of the body are also injured. Fractures, nerve injuries, and
internal organ injury can also occur and may not have been diagnosed in the
50
Traumatic Brain Injury
acute care setting. Pain should be classified into either musculoskeletal or neu­
ropathic, if possible. Treatment depends on the etiology of the pain and should
focus on interventions that are least likely to cause cognitive side effects and
abuse. A thorough work-up should be completed and non-pharmacological
treatments should be maximized before starting medications. Physical modali­
ties that may be helpful include heat, ultrasound, transcutaneous nerve
stimulation, and cyrotherapy. Other options such as relaxation training and
cognitive behavioral therapy may be more difficult to utilize in patients with TBI
due to cognitive demands, but can still be very effective.
When choosing a pharmacologic agent one must consider concomitant symp­
toms. For instance, if a patient has neuropathic pain and mood instability then
carbamazapine, gabapentin, or duloxetine could be considered as a means to
treat both problems. As a general rule, narcotics should only be used for the
treatment of acute pain and used for the shortest duration possible. Analgesic
balms, acetaminophen, and NSAIDS should be considered as a first line treat­
ment choice for most types of pain. Physical therapy is beneficial for many pain
syndromes. For non-responders, referral to a specialized pain program should
be entertained.
Dizziness
Dizziness and balance problems, while common immediately after mild TBI, will
often spontaneously subside. Persistent dizziness and vertigo require careful
evaluation to find the true cause. This could include hypertension/hypotension,
medication effects, alcohol/drug use, visual dysfunction, or other medical
conditions. In one of the few long term studies on untreated patients with mild
head injury, vertigo persisted in 59% of patient’s after five years of recovery
(Berman & Fredrickson, 1978). The most common cause of dizziness fol­
lowing mild TBI is related to post-trauma vestibular system dysfunction, also
known as benign paroxysmal positioning vertigo (BPPV). BPPV is characterized
by brief (a few seconds or a minute) severe vertigo associated with changing
head positions such as looking up or rolling over in bed. Treatment is complex
(Furman & Cass, 1999) and is covered below under Vestibular Impairment.
Cervical vertigo symptoms often respond to multiple therapeutic interventions
provided by a physical therapist. Often, medications are ineffective at treating
posttraumatic dizziness and may actually delay spontaneous resolution.
Sleep disturbances
Insomnia is common following TBI. Poor sleep often leads to progressive prob­
lems with daytime fatigue that contribute to increased irritability and reduced
cognitive performance. Treatment should begin with removal, when feasible, of
all medications with stimulant properties, both prescription and non-prescrip­
tion (including caffeine and alcohol). Once other confounding factors like sleep
apnea, nocturnal seizures, and pain are ruled out, behavioral strategies should
be implemented (avoiding daytime naps, avoiding caffeine after the morning,
avoiding late night snacks, avoiding alcohol, and avoiding use of bed for activi­
ties other than sleep). Sleep inducing medications can be judiciously added with
Traumatic Brain Injury
51
the understanding that their effects can carry over into the daytime contribut­
ing further to memory impairment, increased irritability and depression. Some
individuals can also react with paradoxical worsening of insomnia. The follow­
ing classes of medication may be used to manage insomnia: sleep agents,
antidepressants. The following classes of medication are not recommended to
manage insomnia after TBI: antihistamines, narcotics, benzodiazepines. Please
refer to Appendix E on pharmacology for further details.
Fatigue
Fatigue is a common complaint of patients who have sustained a brain injury
and the complete differential diagnosis is extensive. Potential medical causes
such as sleep disturbance, endocrine dysfunction and anemia should be
considered as well as psychological causes such as frustration, depression,
and vocational, family, and social demands. For patients with multiple social
stressors, a reduction in environmental demands may be a practical first step
intervention. Occasionally rehabilitation providers may prescribe medication for
treatment of fatigue but only after treatable causes have been ruled out. These
medications have significant potential adverse side effects and addiction risk
and should only be used after non-pharmacologic options have been exhausted.
The following classes of medication may be used to manage fatigue; traditional
antidepressants, stimulants, and Parkinsonism agents. Please refer to Appen­
dix E on pharmacology for sleep problems for further details.
Spasticity, Hydrocephalus, and Seizures
The post-acute TBI patient, especially in cases of moderate-severe injuries,
may present with signs or symptoms related to spasticity, seizure, or hydro­
cephalus. Occult seizures or hydrocephalus should be considered for patients
with deteriorations in functional status. For further discussion of these condi­
tions, refer back to Chapter 4.
Visual Impairments/Dysfunctions
Visual impairments and dysfunctions frequently go undetected following brain
injury, in part because of the patient’s unawareness of visual changes or
inability to communicate their altered experience (Gianutsos, Ramsey, & Perlin,
1987). The primary visual impairments associated with TBI include visual acu­
ity loss and visual field loss (Goodrich et al. 2007; Suchoff et al., 2008). Visual
dysfunctions, including disorders of accommodation, oculomotor control, and
binocularity also occur (Lew, Poole et al. 2007; Brahm et al 2009). Impair­
ment may negatively impact the individual’s mobility and ability to engage in
education, employment, and activities of daily living. Comprehensive eye and
vision examinations in Polytrauma Rehabilitation Centers are mandated
(VHA Directive 2008-065) and rehabilitation for these conditions should be
integrated into the over-all rehabilitation plan for patients having these condi­
tions. The following are various types of visual impairments which may occur
following TBI:
52
Traumatic Brain Injury
• Visual Acuity Loss: Acuity is the eye’s ability to distinguish the details and
shapes of objects, with impairments typically involving central vision.
• Visual Field Loss: Visual field refers to the entire area than can be seen when looking straight ahead, with impairments resulting in reduction or disruption in visual field.
• Accommodative Dysfunction: Accommodation is the ability to focus on an
object at various distances with impairments resulting in blurred vision.
• Oculomotor Dysfunction: Oculomotor function refers to control of eye
movements with impairments resulting in difficulty with fixation, saccades
and pursuits, and consequent functional problems with scanning, tracking,
and nystagmus.
• Binocular Dysfunction: Binocular vision refers to the ability to align the
two eyes so that they focus on the same point in space. Impairments result
in double vision, eyestrain, and headaches.
Visual Impairment Treatments. The remediation of visual acuity loss gener­
ally includes the prescription of magnification, lighting (optical or electronic),
and eccentric viewing training which teaches the individual to use a preferred
retinal locus adjacent to damaged central area.
Prisms and augmented-vision displays have been used to compensate for the
field loss (Bowers et al. 2008; Apfelbaum et al. 2008). Other visual rehabilita­
tion strategies include scanning training which teaches more effective use of
remaining visual fields (Bouwmeester et al. 2007). Field loss is also treated
in rehabilitation programs for the blind and visually impaired through training
paradigms that combine scanning and Orientation and Mobility training (Ver­
lander et al. 2000).
Vision therapy can be used to treat accommodative and oculomotor dysfunc­
tion and is typically conducted by optometrists or occupational therapists
(Suchoff et al., 2001). An eye patching regimen can be used to treat binocular
dysfunction, although Fresnel prisms (stick-on prisms), vision therapy, correc­
tive surgery, or any combination of these may be necessary (Falk, & Aksionoff,
1992).
Vestibular Impairment
Vestibular injuries manifest as complaints including dizziness, vertigo, balance
problems, disorientation, or visual disturbances. Vestibular injury can occur
to one or both ears and may affect the sensory organs, the vestibular nerve,
or other components of the vestibular pathway. BPPV is commonly identified
following TBI, occurring in 10-25% of head trauma patients (Barber, 1964;
Cohen et al., 2004; Davies & Luxon, 1995). Patients with mild TBI and
symptoms of dizziness and imbalance often experience a slower recovery and
are less likely to return to work than patients without dizziness (Chamelian &
Feinstein, 2004). However, that does not mean these symptoms necessarily
indicate underlying vestibular impairment. Non-vestibular causes of dizziness
can include visual impairment, central pathology, medications and propriocep­
tive changes.
Traumatic Brain Injury
53
A formal vestibular function evaluation may be indicated for patients reporting
sustained symptoms of dizziness, vertigo or unsteadiness. Screening tests,
typically administered by physical therapists during the vestibular portion of the
TBI evaluation, include a cervical assessment, oculomotor evaluation, postural
stability, gait assessments and vertebral artery test to assess for potential
vertebral insufficiency and vascular causes of dizziness.
Vestibular Impairment Treatments. Treatment of balance problems is
patient and deficit specific and is typically provided in collaboration with physi­
cians and physical therapists. Those with a bilateral complete loss of function
may benefit from an exercise program that focuses upon compensatory
strategies for postural control. Emphasis upon the remaining visual and pro­
prioceptive systems and balance control may optimize therapeutic outcome.
Those with unilateral lesions often respond to a program of habituation exer­
cises, patient education, and postural/balance retraining. Otolith disorders are
more difficult to treat as little is known regarding the adaptation process that
occurs following otolith damage. Traditional vestibular rehabilitation therapy is
not effective for many patients with otolith disorders (Basta et al, 2008).
Auditory and Mixed Sensory Impairments
Damage to the auditory system from trauma can occur anywhere from the
outer ear, middle ear, and inner ear to the auditory cortex. The resultant
disruption of peripheral and central auditory systems can combine to produce
complex symptoms. Audiometry is indicated as head injury can also cause
auditory dysfunction and a thorough neuro-ontologic evaluation may also be
indicated. In studies of patients with TBI, hearing impairments were reported
in approximately 30% of patients, and complaints of tinnitus were reported in
approximately 25% (Jury et al, 2001, Lew, Jerger, & Guillory, 2007). Although
there are anecdotal reports of dual sensory impairment (both auditory/
vestibular and visual/ocular) in the TBI population, its prevalence and effect on
functional recovery remain to be described.
Transitioning Medical Management Along the Continuum
Caring for patients with TBI along the healthcare continuum can be challeng­
ing. As patients move from one level of care or location to another, the new
clinician has the challenge of assessing the patient for needed interventions as
well as assessing for any functional decline. In the acute and post-acute phase
of TBI recovery, it is not uncommon for there to be a temporary functional
decline as a patient moves from one familiar structured setting to an unfamil­
iar setting. However, outside such environmental changes, functional decline
following stabilization of the initial injury is not the normal course of recovery
after TBI. If a patient experiences a functional decline, they should undergo a
thorough evaluation to determine the cause of the decline. Potential causes
of functional decline may include infection, medication, substance abuse, psy­
chological issues, sleep disturbance, pain, and other medical issues such as
endocrine disturbance or seizure activity.
54
Traumatic Brain Injury
Points to Remember
• Treatment for medical conditions following TBI is similar regardless of severity or acuteness of the original brain injury. • Patients with physical, emotional, and/or cognitive symptoms persist­
ing 12 months post brain injury are classified as having persistent Postconcussive Syndrome(persistent PCS). • Due to multiple problems, a team approach may be beneficial for man­
aging patients with persistent PCS.
• Treatment focus should be the patient and how symptomatology affects
their function rather than focusing on merely treating symptoms.
Traumatic Brain Injury
55
CHAPTER 6:
Assessment and Management
of Cognitive Problems
Learning Objectives:
• Identify common cognitive problems of TBI
• Understand the effects of cognitive problems on the daily functioning
of individuals with TBI
• Identify the basic elements of cognitive rehabilitation and pharmaco­
logical management of cognitive problems
• Understand the role of the primary care physician in managing cogni­
tive problems
Introduction
As used in this section, cognition refers to the intellectual or mental processes
through which information is acquired and processed to mediate behavior
and achieve goals. It includes the ability to attend to and process information
(attention), acquire new information (memory), and use information strategi­
cally in planning, problem-solving, and self-monitoring (executive functions).
Cognitive impairment denotes a decline in cognitive function caused by injury or
disease process.
Cognitive difficulties are common during the time immediately following TBI.
The severity of cognitive difficulties tends to correlate with the severity of the
injury. Therefore, concussions generally cause mild transient cognitive symp­
toms, while more severe injuries may have more persistent and pervasive
cognitive consequences. The long-term cognitive impairments associated with
TBI are variable. Severity of trauma, neuroanatomical location of injury, age,
and time since injury affect the rate and degree of recovery, along with other
individual and environmental factors.
Cognitive difficulties in TBI occur as a result of the physiological events associ­
ated with brain trauma, specifically fronto-temporal damage superimposed on
more diffuse pathology. Orbitofrontal and anterior temporal regions are par­
ticularly susceptible to contusional injuries secondary to impact with the skull
during acceleration/deceleration motor vehicle accidents. Although a variety of
other problems may be present depending upon injury specifics and premorbid
factors, the following symptoms are the most prominent cognitive sequelae
Traumatic Brain Injury
57
following TBI:
• Attention and concentration problems
• New learning and memory deficits
• Executive control dysfunction
Characteristics of TBI-Related Cognitive Problems
Cognitive effects following TBI often co-exist with other psychological conditions
such as adjustment difficulties, depression, interpersonal conflicts, and PTSD.
As a result, the functional consequences of this interface on the individual can
greatly exceed the cognitive effects of the TBI alone. The combination of emo­
tional and cognitive symptoms, particularly unawareness of deficits, irritability,
impulsivity, and emotional reactivity, can negatively affect cognitive recovery and
the potential benefits of cognitive rehabilitation. The overlap of cognitive and
emotional symptoms is best addressed through collaborative interventions by
rehabilitation and mental health specialists.
Cognitive effects similar to those of TBI may occur as a result of other organic
and mental health conditions. Moreover, there is some evidence that cognitive
difficulties may also occur in healthy individuals in the post-deployment period
(Vasterling et al., 2006). In cases where there is historical evidence of TBI, it
may be very difficult to attribute which cognitive effects are due to direct brain
trauma and which are due to other mental health or physical conditions. It is
important in such cases to intervene in order to reduce the level of functional
disability caused by the presenting cognitive symptoms irrespective of whether
the underlying etiology has been definitively determined.
There is preliminary evidence from the research literature that the cognitive
and functional effects of blast-related TBI are similar to those of non-blast TBI,
e.g., motor vehicle accidents (Belanger et al., 2009; Sayer et al., 2008).
These findings give us some level of confidence that the therapies found to
be efficacious for non-blast TBI will have the same effects on TBI from blast
injuries.
Cognitive Recovery Following TBI
In the days and weeks following TBI, many aspects of cognition improve, some
quite rapidly. In fact, rapid improvement in the first few months is considered
the rule. Cognitive symptoms of mild TBI typically resolve within a few weeks
after the injury. Early education after injury about possible cognitive symptoms
and expectations for full recovery have been shown to have a positive impact
on the resolution of cognitive problems (Mittenberg, 1996). A small minority of
individuals who sustain mild TBI may develop cognitive symptoms that persist
beyond 12 months following injury. Some of these individuals have a constel­
lation of other problems that contribute to the persistence of the cognitive
symptoms including pain, sleep disorders, emotional distress, psychosocial
issues, and financial problems. Intervention should first focus on managing
the key factors that contribute to the overall picture of disability. For example,
initial stabilization of pain and sleep issues may improve the individual’s ability
58
Traumatic Brain Injury
to concentrate on cognitive interventions and facilitate successful treatment
outcomes.
Many patients with moderate injuries can and, for the most part do, recover
cognitive skills to a level of independent function so that they can return to
work or resume their usual responsibilities. However, they tend to differ from
how they were prior to the brain injury in that most continue to experience
cognitive problems associated with frontal and temporal lobe damage. Com­
mon cognitive problems are impaired memory, decreased initiation, diminished
spontaneity and difficulty managing unplanned activities. Problems related to
frontal lobe damage, in particular, tend to show up in subtle ways and may not
be recognized as a consequence of the brain injury
Fewer patients with severe injuries return to work or independent living. Per­
sistent long-term cognitive problems include cognitive slowness, poor memory,
and executive control dysfunction. Fluctuations in performance are common in
patients with impaired executive functions, which reflects the lack of internal
stability and self-regulation in this population. Physical impairments may be
prominent early in the recovery process; however cognitive and behavioral
impairments are more persistent and make greater contribution to long-term
disability (Brooks et al, 1986; Jennett et al, 1981).
The rate of cognitive recovery tends to slow down at 1-2 years post injury, but
there is increasing evidence that functional cognitive improvements may
continue 5-10 years post injury (Draper & Ponsford, 2008). Long-term gains
are related to increased adaptability to the environment through
compensation. Compensation training has been shown to be effective when
used in cognitive rehabilitation delivered long after the initial injury.
Points to Remember
• Concussions generally cause mild transient cognitive symptoms, while
more severe injuries may have more persistent and pervasive cogni­
tive consequences
• In the first few months post-TBI, rapid improvement is considered
the rule
• Compared to patients with mild to moderate TBI, fewer patients with
severe injuries return to work or independent living
Common Cognitive Symptoms of TBI
Attention Problems
Attention problems after TBI are seen particularly with novel and timed tasks,
and in part are due to slowed information processing speed associated with
diffuse axonal injury. Injury to the dorsolateral aspects of the frontal lobes
is also responsible for difficulties with controlling and allocating attentional
resources. Common functional complaints related to attentional problems
include:
Traumatic Brain Injury
59
• Difficulty completing tasks, reading longer materials, or following the plot line of a movie – may indicate problems with sustained attention
• Distractibility or poor concentration when other activities are going on in the
immediate environment – may be related to impaired selective attention
• Decreased ability to shift from task to task – may indicate impaired alternat­
ing attention;
• Difficulty responding to two tasks simultaneously – may be due to impaired divided attention
Memory Difficulty
Difficulty learning new information, retaining, and then retrieving it at a later
time are the most common memory complaints. Memory problems are typi­
cally associated with medial inferior temporal lobe damage, but may also be
secondary to problems with attention and concentration. Recall of overlearned
facts and of autobiographical information prior to the injury event tends to be
relatively spared after TBI. Memory problems are a major reason for failure to
return to work or school, or for difficulty performing complex activities of daily
living. Common functional complaints related to memory problems include:
• Difficulty following directions or passing on messages – may be indicative of deficits in working memory
• Difficulty retaining information about specific events that occur in the per­
son’s life since the injury – may be related to problems with episodic memory
• Difficulty remembering to go to appointments or to complete household chores – may be indicative of difficulties with prospective memory
Executive Dysfunction
Executive functions are those capacities, most commonly linked to the frontal
cortex, that guide complex behavior over time through planning, decisionmaking and response control. Individuals with executive dysfunction may
perform well on familiar, highly structured tasks but are likely to have difficulty
functioning independently. Deficits associated with frontal lobe injury often are
the most handicapping as they interfere with the ability to use otherwise intact
skills adaptively. Patients with executive dysfunction may present with problems
including:
• Loss of initiative and drive
• Difficulty moving flexibly from task to task
• Diminished awareness of deficits
• Inability to monitor performance properly.
• Difficulty planning and organizing complex activities
• Poor reasoning, problem-solving and conceptualizing
Communication Problems
After a TBI, problems communicating effectively with others are a result of
the cognitive deficits underlying these processes. They may include problems
with organizing and integrating language in order to comprehend and express
complex concepts, difficulty with finding words in conversation, problems
understanding abstract language and figures of speech, and poor adherence
60
Traumatic Brain Injury
to conventional rules of social communication. Aphasia is relatively rare in TBI,
but can occur with focal lesions in the left frontal and/or temporal lobes.
Assessment of Cognitive Problems After TBI
The purpose of the assessment by specialists with expertise in cognitive reha­
bilitation is to:
• Determine if there is a cognitive problem
• Establish the nature and characteristics of the problem
• Evaluate the implications of the cognitive symptoms on the ability to carry out functional everyday activities
• Estimate the individual’s capacity to participate in rehabilitation services
• Determine the most effective means to facilitate learning
• Plan rehabilitation interventions
• Measure recovery and treatment progress
Neuropsychological evaluations are assessments of cognitive and psycholog­
ical functioning vis-à-vis an individual’s brain injury. They may entail assessments
of overall intellectual capacity, attention and concentration, learning and
memory, language, visual cognitive abilities, executive functions, psychological
adjustment, and personality. These evaluations may take 2-5 hours and consist
of variety of measures. A neuropsychologist, by taking a careful history from
the patient, may be helpful in diagnosing mild TBI. Unlike moderate to severe
TBI which typically is self-evident due to abnormalities on neuroimaging (e.g.,
MRI) and initial prolonged loss of consciousness, the diagnosis of mild TBI
often may be based on solely on self-report. In those cases, eliciting a detailed
history of the patient’s experience of the injury may help determine if there was
an alteration or loss of consciousness (and hence, a mild TBI).
However, it is important to realize that neuropsychological tests do
not determine whether or not a brain injury occurred. Rather, they help
ascertain overall dysfunction due to brain injury and assess cognitive and
psychological functioning. Other functions of a neuropsychological assessment
include:
• Establishing a baseline level of cognitive functioning (for comparison pur­
poses later)
• Assisting with decision-making with regard to degree of independence and level of care required
• Assisting with vocational and educational planning
• Assisting with treatment planning
Evaluations by rehabilitation specialists, including speech-language pathologists,
occupational therapists, and vocational counselors, focus on the effects of
cognitive impairments on the individual’s daily function and participation in com­
munity activities. These evaluations use a combination of standardized tests,
structured observations in functional settings, and standardized ratings by the
client, family, and caregivers to yield accurate and complete information about
the individual’s functional capacity.
Traumatic Brain Injury
61
Points to Remember
• Memory problems are among the most commonly reported deficits
after brain injury
• Neuropsychological evaluations assess cognitive and psychological
• functioning vis-à-vis an individual’s brain injury, but do not determine
weather a brain injury occurred.
• If patients present with cognitive and/or emotional complaints postTBI, consider referring them to rehabilitation specialists
Treatment Interventions for Cognitive Problems After TBI
Common interventions for the cognitive symptoms of TBI fall into two broad
categories: cognitive rehabilitation and pharmacologic interventions. The
evidence for the effectiveness of both types of interventions is growing in the
specialty literature.
Cognitive Rehabilitation
Cognitive rehabilitation is one component of a comprehensive brain injury reha­
bilitation program. It focuses not only on the specific cognitive deficits of the
individual with brain injury, but also on their impact on social, communication,
behavior, and academic/vocational performance. Some of the interventions
used in cognitive rehabilitation include modeling, guided practice, distributed
practice, errorless learning, direct instruction with feedback, paper-and-pencil
tasks, communication skills, computer-assisted retraining programs, and use
of memory aids. The interventions can be provided on a one-on-one basis or in
a small group setting.
Treatment of Attention. Treatment employing direct attention training in
conjunction with metacognitive training (i.e., feedback, self-monitoring, and
strategy training) is a practice guideline in cognitive rehabilitation following
brain injury (Sohlberg et al, 2003; Cicerone et al., 2000 & 2005).
Direct attention training involves repeated stimulation of attention processes
with the goal of strengthening the underlying neural processes. Exercises are
organized hierarchically according to theoretically grounded models of atten­
tion. Direct attention training is rooted in the concept of neuroplasticity. Key
mechanisms involve unmasking of existing circuits, modification of synaptic
connectivity and inter-hemispheric competition. Sufficient repetition is essential
to ensure generalization of gains achieved in therapy.
Metacognitive training consists of teaching the individual behaviors that
facilitate information processing, including self-monitoring and self-instruction.
Frequently mentioned strategy “tips” include:
• pace yourself
• frequently check work for errors
• work on one task at a time
• take regular breaks to refocus attention
• work in a quiet environment with minimal noise and few interruptions
62
Traumatic Brain Injury
It is important to recognize that providing a list of strategies does not con­
stitute cognitive rehabilitation. In order for strategies to work, they need to
be individualized, goal-directed, practiced repeatedly, and have measurable
outcomes that can be monitored by the individual. Without the appropriate
training, the probability of the compensatory strategies being adopted and
used consistently is very small.
Treatment of Memory. Recent reviews of the evidence for memory train­
ing conclude that strategy training for mild memory impairment should be a
practice standard after brain injury (Cicerone et al, 2000 & 2005). The use of
memory aids with direct application to functional activities is recommended as
a practice guideline (Sohlberg et al, 2007; Cicerone et al, 2000 & 2005).
Strategy training in memory rehabilitation targets behaviors or sequences of
behaviors that facilitate the individual’s information processing, retention, and
retrieval. Examples include rehearsal, self-questioning, mnemonics, etc. Strate­
gies provide alternative ways of learning and require adaptation to the specific
needs of the individual, systematic training, and evaluation/modification based
on the level of success and acceptance. Again, strategy training must be indi­
vidualized, goal-directed, practiced repeatedly, and monitored and adjusted for
maximal effectiveness.
Compensatory techniques for memory problems may involve training in the use
of memory aids such as timers, pocket computers, personal organizers, and
digital recorders. Among the demonstrated benefits of memory aids are sup­
port for completion of functional activities, flexibility of treatment options, and
high consumer acceptance. It is important that these devices be prescribed by
professionals with specialized expertise in cognitive technology. These profes­
sionals have the skill to conduct the individualized needs assessment, prescribe
the device that matches the needs, and provide the training necessary to
ensure successful and consistent use of the device.
Executive Function Treatment. Reviews of the evidence-based practice for
executive function problems conclude that interventions using problem-solving
strategies with application to everyday situations are a practice standard and
that interventions to promote and practice internalization of self-regulation
strategies, self-instruction, and self-monitoring are a practice guideline (Cice­
rone et al, 2005).
Many of the same strategies that assist with attention and memory problems
are useful in managing executive function difficulties. Interventions using these
strategies should emphasize the need for patients to anticipate and monitor
the outcomes of their behaviors. In most cases, the goal of remediation should
not be limited to training a task-specific performance, but rather the training
and internalization of regulatory cognitive processes (Cicerone et al., 2006).
Traumatic Brain Injury
63
Specific interventions for executive dysfunction may include:
• Treatment of unawareness using educational components and controlled experiential tasks aimed at enhancing awareness of problems
• Environmental modifications, particularly setting up routines that circumvent
the difficulties of initiating and planning activities
• Use of external cueing and monitoring to increase the probability of suc­
cessful initiation and completion of certain tasks
Treatment of Social Communication. Interventions directed at improving
pragmatic communication and conversational skills after TBI are recommended
as a practice standard based on the review of existing literature (Cicerone et
al., 2000; Struchen, 2005).
Changes in social communication skills are thought to be a major contributor
to problems with social isolation following TBI. They co-occur with cognitive and
personality changes and are affected by premorbid and environmental factors.
Consequently, treatments for social communication need to address these
factors concurrently. Some of the techniques used for the treatment of social
communication include:
• Developing active listening skills
• Group treatments
• Videotaped interactions
• Modeling and rehearsal
• Training of self-monitoring strategies
Pharmacological Treatments
Medications to help improve cognitive functioning after TBI should be tried
only after medical and behavioral factors have been mitigated (e.g., poor sleep
hygiene, stabilizing medical issues that impact arousal, discontinuing centrallyacting medications, reducing environmental distractions, and managing
depression). The efficacy of medications to improve cognition has been limited.
However, evidence exists to support the use of stimulating agents to enhance
arousal and attention after brain injury. These stimulating agents can include
true stimulants, antidepressants and dopaminergic agents. Little evidence
exists to support the use of memory enhancing agents (e.g., cholinesterase
inhibitors) following TBI or medications to promote awakening from coma. The
sections below describe the following categories: (1) neurostimulants, (2) anti­
depressants, (3) dopaminergic agents, and (4) other agents.
Neurostimulants. (Methylphenidate (MPH or Ritalin), dextroamphetamines,
pemoline (Cylert)). There have been mixed reports addressing the effects of
methylphenidate on memory and attention after traumatic brain injury (TBI).
Several review articles have been published (Challman & Lipsky, 2000; Kraus,
1995; Siddall, 2005). The authors concluded that neurostimulants have some
utility for certain types of cognitive symptoms following brain injury. The most
consistent and robust findings have been for MPH resulting in improved speed
of mental information processing (Whyte et al., 1997, 2004; Willmott &
64
Traumatic Brain Injury
Ponsford, 2009). Findings are consistent in that there is a state-dependent
beneficial effects on mental processing speed in the post-acute period, and
a suggestion of potential carryover effects after discontinuation of MPH.
However, these same studies found that MPH was not effective at improving
working memory abilities.
Antidepressants.
Tricyclic antidepressants (TCA’s). The tricyclic antidepressants which seem
to have the best potential for the brain injury population are those with a stimu­
lant effects, such as protriptyline, nortriptyline, and desipramine (Joseph &
Wroblewski, 1995; Reinhard, Whyte, & Sandel, 1996).
SSRI’s (Sertraline (Zoloft) and Fluoxetine (Prozac)). Fann et al. (2001) reported
improvements with sertraline in recent verbal memory, recent visual memory,
and general cognitive efficiency in patients with depression after mild TBI.
However, Meythaler et al. (2001) failed to show any significant improvement in
arousal and alertness following SSRI intervention in 11 individuals with severe
TBI
Dopaminergic Agents. Amantadine (Symmetrel), Seligiline/Deprenyl
(Eldepryl), Bromocriptine (Parlodel), Pergolide (Permax), L-Dopa/Carbidopa
(Sinemet), Ropinirole, and Pramipexole.
There is some evidence from non-controlled studies or case studies that these
medications may provide some benefit for cognitive problems following TBI
(Sawyer, Mauro, Ohlinger, 2008; McDowell et al., 1998; Lal et al., 1988);
however, there are also negative findings (Schneider et al., 1999). Similarly,
there are a limited number of animal studies demonstrating some cognitive
benefits from these medications (Kline et al., 2002).
Other Pharmacological Agents.
There are a number of other agents which are actively being studied for poten­
tial recovery post-brain injury; many are still in the animal model stages. The
nootropics (nefiracetam, piracetam, pramirecetam) potentially increase the
glucose and oxygen consumption in the ischemic nervous tissue and increases
blood flow through cerebral terminal vessels. McLean (1991) reported that
pramirecetam improved memory in young males with head injury or anoxic
injury.
In conclusion, there are a number of pharmacologic agents that show poten­
tial to improve cognitive sequelae post brain injury. However, the number of
clinical trials for these agents in head injury has been limited to date. With
the newer, more specific neuronal agents now available, there is potential for
targeted use of such agents in both acute and possibly subacute stages of
brain injury. Table 1 provides suggestions for medications for various cognitive
problems.
Traumatic Brain Injury
65
Table 1. Pharmacotherapy and Associated Treatments for Behavioral and Cognitive Symptoms following TBI (Adapted
from the VA/DoD Mild TBI Clinical Practice Guidelines)
Common Symptoms Post
Concussion/mild TBI
• Fatigue
• Loss of energy
• Getting tired easily
• Cognitive difficulties
• Concentration
• Memory
• Decision-making
• Feeling anxious
• Emotional difficulties
• Feeling depressed
• Irritability
• Poor frustration toler­
Job
Review
Pharmacologic
Treatment
Non-Pharmacologic
Treatment
Referral after failed
response to initial
intervention
• Stimulant*
• Sleep hygiene
• Mental Health
Education
• Reassurance
• Encourage regular
scheduled aerobic
exercise
• Activity restriction
• TBI specialist for cogni­
✓
✓
• SSRI
• Stimulant*
tive rehabilitation or
mental health
adjustment
✓
• Anxiolytic
• SSRI
• Sleep study
• Mental Health
• Social support
• Anti epileptics
• SSRI
✓
ance
* Consider in the specialty care setting after ruling out a sleep disorder
Appendix F provides information about potential side effects, contraindications, and dosing
suggestions for various medications used to manage cognitive issues, particularly following
mild TBI.
Role of The Primary Care Physician In The Management
of Cognitive Deficits
Patients and their families often present to the primary care physician with complaints related
to cognitive problems following TBI. These may be new problems, worsening problems, or
stable problems that can no longer be managed adequately due to social or environmen­
tal changes. Common symptom complaints are likely to be memory problems, behavioral
changes, failure at work or school, as well as social and familial stressors. The assessment
of symptoms, physical exam, and review of the patient’s treatment history will provide the
roadmap for initial treatment steps. Depending on prior medical workups and previous rehabili­
tation interventions, first steps may include referrals to rehabilitation specialists with expertise
in cognitive rehabilitation. Providing patients and families with education materials and support­
ive listening are likely to be useful interventions.
Points to Remember
• Common interventions for the cognitive symptoms of TBI fall into two broad categories: cognitive rehabilitation and pharmacologic interventions
• Providing a list of strategies does not constitute cognitive rehabilitation
• Cognitive rehabilitation should address the impact of cognitive deficits on social, com­
munication, behavior, and academic/vocational performance.
66
Traumatic Brain Injury
CHAPTER 7:
Emotional and Behavioral Sequelae
and Treatment
Learning Objectives
• Recognize common neuropsychiatric sequelae of TBI
• Understand the interplay of cognitive and emotional problems following TBI
• Identify the assessment data needed to prescribe efficacious treatments for TBI
• Recognize symptoms and problems that may require referral to mental health professionals
• Learn basic pharmacological treatment for these sequelae
Introduction
Emotional difficulties, adjustment issues, and behavioral problems are common
following moderate to severe brain injury (Morton & Wehman, 1995; Sohlberg
& Mateer, 2001). Furthermore, premorbid psychiatric problems, such as
impulse control difficulties, substance abuse, and family problems increase the
risk for brain injury (Vassallo et al., 2007). Psychiatric Risk Factors for Head
Injury. Brain Injury, 21, 567 – 573.), and are unlikely to improve following
brain injury (Bennett & Raymond, 1997; Hanks, Temkin, Machamer, & Dik­
men, 1999; Kersel, Marsh, Havill, & Sleigh, 2001; McCauley, Boake, Levin,
Contant, & Song, 2001; Sarapata, Herrmann, Johnson, & Aycock, 1998).
Following a brain injury, one has to deal with both pre-injury characteristics as
well as the emergence of new post-injury emotional/behavioral problems.
The vast majority of individuals with concussion/mild TBI will have no difficulties
or complaints beyond a few weeks following injury. Early educational interven­
tions, reassurances regarding an expected positive recovery, and instructions
to gradually resume activities have been shown to enhance the recovery
process (Ponsford et al, 2002; Mittenberg et al., 1996). However, the term
“mild TBI” refers only to the initial injury severity and should not be interpreted
unequivocally as suggesting mild ongoing problems. In fact, the relationship
between original severity of TBI and long-term emotional and behavioral prob­
lems is not linear. Some individuals with a concussion may have significant
adjustment issues and long-term functional impairments, while someone who
was in a coma for weeks may show minimal long-term emotional problems.
Each patient with TBI, regardless of severity, is unique.
Traumatic Brain Injury
67
A minority of individuals who sustained a mild TBI may develop persistent
postconcussive symptoms. Sleep disturbance is particularly under appreciated
as a problem following mild injuries (Kelly, 2002). Sleep problems can worsen
other acute problems that frequently occur in mild head injuries such as head­
aches, poor concentration, depression, relationship difficulties, and decreased
problem solving abilities. For a small percentage of individuals this becomes a
self-perpetuating cycle with a somatic focus. As a result, a minority have been
found to change or lose their jobs within six months of the injury (Gasquoine,
1997) and are at risk for not understanding why they now are having prob­
lems in their life (Prigatano & Schacter, 1991).
Following moderate to severe brain injury emotional problems are common.
Damage to the frontal lobes in severe motor vehicle accidents can cause
specific behavioral problems including difficulty tolerating frustration or higher
levels of stimulation. This in turn can lead to agitation, excessive use of pro­
fanity, aggression, and potentially destructive behavior. In addition, behavior
problems can be the result of an impaired ability to process information or
understand situations accurately. Finally, post-TBI behavior problems can
also occur because individuals become fatigued much more easily, increasing
irritability and lowering frustration tolerance. As a result, emotional sequelae
following a brain injury often include increased anger, lowered frustration toler­
ance, increased anxiety, depression, and low self-esteem.
Behavioral and emotional problems may be long-lasting following moderate to
severe brain injury and take a tremendous toll on family members, caregivers,
and friends. In addition, they tend to lead to social problems including overdependency, tangential or excessive talking, immature behavior, inappropriate
use of humor, inappropriate sexual behavior, poorly controlled spending, self­
centeredness, and/or general difficulty appropriately reciprocating in social
interactions. Although more recent studies show less frequent divorce rates
(Kreutzer, 2007), divorce is common. This is often accompanied by a loss of
social group membership for the person injured, further resulting in long-term
obstacles for a successful recovery (Wood & Yardukal, 1997).
Resources (e.g., emotional, physical, financial, social, etc.) are much more
likely to be exhausted in the recovery of someone with a more severe injury.
The family burden can be substantial and may result in family disintegration.
The loss of family and other social supports is paramount because these
supports play a major role in obtaining a successful outcome for the person
injured.
68
Traumatic Brain Injury
Points to Remember
• Damage to the frontal lobes is common in serious motor vehicle
accidents and can cause specific behavioral problems or changes in
personality
• Behavioral and emotional problems may be long-lasting and take a tre­
mendous toll on the family
• The relationship between original severity of injury and long-term out­
comes is not one-to-one
Interplay of Cognitive and Emotional Problems
It is important to realize that cognitive deficits (e.g., mental slowness, memory
problems, inattention, impaired problem-solving skills, etc.) can impact emo­
tional reactions. Similarly, emotional reactions such as anger and irritability can
interfere with attention, memory, and thinking abilities. Impaired self-aware­
ness (i.e., difficulty seeing one’s strengths and deficits) is common in moderate
to severe injuries and typically results in the person having unrealistic goals
and expectations. It can also lead to difficulties with getting services and main­
taining the injured person’s involvement or willingness to participate in needed
services.
Sometimes, emotional symptoms are the direct result of neurological damage
rather than psychological reactions, despite similar clinical appearance. Table
1 illustrates this point by comparing mental health symptoms with similarly
appearing neurologic-based problems.
Table 1: Mental Health and Neurogenic Symptoms of TBI
Mental Health Symptoms
Neurogenic Symptoms
Denial of problems
Anosognosia (lack of awareness of impairment)
Anger and irritability
Agitation
Depression
Apathy, impaired emotional expressiveness, lowered cry­
ing threshold, pseudobulbar palsy
Emotional lability
Lability of emotional expressiveness (not the underlying
feeling state), pseudobulbar palsy
Social withdrawal
Lack of initiative, Apathy
Thought disorder
Cognitive impairments and thinking problems
Personality or conduct disorder
Impulsivity, social disinhibition
Traumatic Brain Injury
69
Points to Remember
• Impaired self-awareness is common in moderate to severe injuries
and often results in the person having unrealistic goals and expecta­
tions
• Emotional and behavioral problems can be the result of either neuro­
logical damage due to the TBI or psychological reactions secondary to
having a brain injury
Context of TBI and Mental Health Comorbidities
When TBIs occur within a military context, combat-related mental health
issues are common, regardless of the original severity of the TBI. PTSD, anxi­
ety, and depressive symptoms are common even if individuals do not meet full
diagnostic criteria for these disorders (Hoge et al., 2006, 2008; Tanielian,&
Jaycox, 2008).
Returning military personnel may have sustained one or more concussions/
mild TBIs while in theatre, and now present months later to medical provid­
ers with multiple symptoms such as insomnia, fatigue, irritability, headaches,
and memory and concentration complaints. Many of these symptoms are
consistent with both mental health conditions (PTSD, depression, and anxiety)
and possible postconcussion residuals (Nampiaparampil, 2008). Disentangling
primary etiologies for various symptoms is almost impossible and typically not
helpful. However, determining whether or not mental health conditions are
present is possible, and if so referral to mental health professionals for ongo­
ing treatment is indicated.
Following TBI in the civilian context, PTSD is less common than in military
combat population (Creamer, 2005). In the combat context, military personnel
frequently have multiple traumatic exposures prior to their TBI and comorbid
PTSD is not unusual (Hoge, 2008; Tanielian,& Jaycox, 2008). When present­
ing in the postacute or chronic phase of TBI recovery, particularly after a more
severe TBI, the PTSD may be become apparent for the first time. When this
occurs, referral to mental health professionals for treatment is indicated. As
individuals who have had a moderate to severe TBI return home, they may be
faced with the consequences of their residual deficits for the first time and
may develop adjustment reactions, depression, anxiety, or higher levels of
irritability and frustration.
Emotional and Behavioral Assessment
Obtaining information from both the patient and a collateral source (family or
caregiver) is important to get a more balanced understanding of the reporting
by the patient. A sample of structured interview questions to assess emotional
and behavioral issues include:
• How has your injury changed your life?
• Have you experienced changes in frustration level or anger control?
70
Traumatic Brain Injury
• Have you experienced increased difficulties in interpersonal relationships with your spouse or friends? • What resources (e.g., family, friends, doctors) have been the most helpful for you? Consider a referral to psychology if a more detailed diagnostic mental health
interview, psychological testing, and/or psychotherapy appear to be war­
ranted. Consider a referral to psychiatry for a diagnostic interview, medication
management of emotional or behavioral difficulties, and/or psychotherapy.
Etiology of particular symptoms frequently cannot be determined, and are
therefore best approached in an interdisciplinary team manner. Consultation
with neurology, neuropsychology, and/or mental health is recommended if it is
uncertain whether the emotional/behavioral problems are neurologic versus
psychogenic in origin. The more information provided to consultants about the
problems for which one is seeking analysis and recommendations, the more
likely the referral will provide useful information and a targeted answer that will
assist future decision-making.
Suicidality and Depression
Depression and suicidality should always be assessed in TBI patients. Postinjury, as individuals attempt to return to their prior roles, physical and
cognitive difficulties may become more apparent and, consequently, psycho­
logical adjustment problems develop. Depression may develop and suicidal
thoughts are possible. Lower levels of impulse control and impaired judgment
increase suicidality concerns. Sample questions to assess these issues
include:
• Have you experienced changes in your mood such as sadness, depression,
or anxiety?
• Do you ever feel like harming yourself or anyone else? (If yes, assess cur­
rent thoughts regarding active suicidal or homicidal intent)
• Do you have a plan?
• Do you feel like killing yourself right now?
Substance Abuse
Pre-injury alcohol and drug abuse increases the risk for sustaining a TBI (Vas­
sallo et al., 2007). In the ongoing management of individuals who sustained
a TBI, careful assessment of substance use is essential. This should include
not only alcohol and illegal drug use/abuse, but also overuse of caffeinated
beverages and “power drinks” which can increase irritability and impair sleep.
Counseling regarding abstinence should be encouraged. If clear substance
abuse or dependence is apparent, referral to substance abuse program
should be made.
Irritability
Increased irritability and lower frustration tolerance are common following TBI.
Complaints may come from the patient but sometimes they may come primar­
ily from caregivers and/or family members because these problems typically
Traumatic Brain Injury
71
result in increased difficulties in interpersonal relationships. Irritability can be
increased with higher levels of stimulation (group activities, parties, shopping,
etc.), substance use/abuse, and sleep problems. Assessing and monitoring
these symptoms and their interactions should be a part of ongoing care man­
agement. Referral to mental health professionals may be indicated if problems
persist and are causing significant day-to-day functional difficulties.
Severe Neurobehavioral Disorders
A small number of individuals who sustained a more severe TBI will have
significant ongoing problems with impulse control, anger management, and
behavioral self-control. Such individuals are likely to have episodes on a weekly
or monthly basis of “acting out” or getting into verbal or physical altercations.
Although they may be able to obtain jobs and function for short periods of
time, they often get fired and move from job to job. This may become a chronic
pattern and management on an outpatient basis is difficult. Such individuals
should be referred to mental health or TBI rehabilitation professionals and may
require a neurobehavioral residential program. Currently such programs are
not available within the VA but contract providers may be available.
Point to Remember
• Obtaining collateral information from family is important due to the
frequent lack of self-awareness or denial of impairments common fol­
lowing moderate to severe TBI
• Mood, suicidality, and substance use should always be assessed in
the ongoing management of individuals who sustained a TBI
• Irritability is a common post-TBI symptom and can interfere with dayto-day functioning
Therapies to Address Emotional and Behavioral Issues
The main goal of this section is to increase understanding of the common
neurobehavioral disorders affecting TBI patients and appropriate treatment
strategies. General principles to the management of psychological and behav­
ioral sequelae include:
• Patient and caregiver education and support
• Interdisciplinary approach
• Psychotherapy/behavioral management
• Pharmacotherapy
Common Non-Pharmacological Behavioral Interventions
Mild TBI with Persistent Emotional and Behavioral Complaints
or Problems
Some individuals with mild TBI present months after injury with multiple physi­
cal, cognitive, and emotional complaints. Treating prevailing symptoms such as
insomnia and headaches may result in a significant reduction in emotional and
behavioral complaints (http://www.healthquality.va.gov/management_of_con72
Traumatic Brain Injury
cussion_mtbi.asp). However, if emotional or behavioral problems continue after
several weeks of treatment, a referral to a TBI or mental health specialist may
be indicated. Common therapeutic approaches used by these specialists might
include:
• Cognitive-behavioral psychotherapy including teaching self-monitoring, self-instruction, and relaxation techniques may be particularly useful for treatment of: • Irritability and low frustration tolerance
• Anger management
• Adjustment difficulties
• Depression
• Anxiety
• Inappropriate or disinhibited behaviors
• Social skills deficits
• Group Therapy to address issues of interpersonal interactions
• Family or Marital Therapy to help families deal with the common post-injury
issues such as change in family roles, caretaker burden, relationship con­
flicts including sexuality, and expenditure of family resources for the injured
person
• Spiritual guidance to provide hope, comfort, and support
• Education regarding brain injury, what to expect, and how to handle difficult
circumstances
Moderate to Severe TBI with Emotional and Behavioral Problems
In the postacute phase of care following a moderate to severe TBI psychologi­
cal adjustment issues are common, as are increased rates of depression,
anxiety, anger control problems, and other interpersonal and relationship
problems. If patients present to the primary care setting and are not receiving
services for these issues through mental health or TBI specialty care provid­
ers, a referral for mental health services at any time post injury is appropriate.
Providing patients and families specific information about available resources is
also helpful:
• Contact information for state and national brain injury organizations
• Information about local self-help and support groups
Points to Remember
• There are multiple psychological interventions that can be helpful in
dealing with the emotional and behavioral problems following mild TBI
• Information and education to patients and families are potentially pow­
erful interventions
Psychopharmalogical Treatment - Post-Acute Symptom Management
The following recommendations are based on available research base and
expert consensus. The use of pharmacologic agents has become standard
Traumatic Brain Injury
73
practice in the treatment of emotional and behavioral sequelae of TBI (Arcinie­
gas & McAllister, 2008; Warden et al., 2006). While few FDA indications
exist for the treatment of TBI-related symptoms, many medications are com­
monly used for these conditions. When possible, treatment should be based
on a specific diagnosis, however often clinicians must use a symptom-based
approach.
The pharmacologic approach is based on the severity and acuity of the pre­
dominant symptoms. As with any medication, decision one should consider
balancing the risks and benefits. The use of a single agent for treatment of
multiple symptoms or conditions is preferred. Medication selection should take
into account other symptoms, other medical and/or psychiatric conditions,
presumed etiology of the symptom, compliance, and medication side effect
profiles. Table 2 adapted from Arciniegas, Topkoff, & Silver, (2000) provides
useful information about medications potentially useful in treating various symp­
tom profiles.
Common principles for prescribing medications for individuals with TBI include:
• Begin medications after non-pharmacologic interventions have been unsuc­
cessful • Obtain a detailed medication profile (including over the counter agents)
• Start low and go slow
• Make only one medication change at a time
• Provide an appropriate therapeutic drug trial
• Allow adequate time for one drug to clear out of the person’s system before
changing to another medication
• Be aware of confounding comorbidities (e.g. substance abuse, PTSD)
• Individuals with TBI are at higher risk for health illiteracy-related medication
issues
• Check for medication compliance in non-responders
• All providers and caregivers should be aware of current medications and any medication changes • Don’t prescribe what already hasn’t worked or has had negative effects
• The following classes of medication are not generally recommended in the
management of TBI-related symptoms: antihistamines, narcotics, benzodiaz­
epines
Acute Agitation/Aggression
This problem is seen most commonly during the early phase of recovery from
moderate to severe brain injury during the Rancho Level IV (see Chapter 2
for a review of Rancho Levels) and can severely affect the patient’s ability to
participate in therapy. Post-traumatic agitation is a diagnosis of exclusion. This
means that provoking or aggravating medical (infection, pain, drug withdrawal,
hypoxia), neurological (seizure, hydrocephalus, etc.), or pharmacological
factors should be investigated and treated before attributing agitation to posttraumatic causes.
74
Traumatic Brain Injury
Table 2: Medications and their Potential Usages for Emotional and Behavioral Problems following TBI
Medication
Nortriptyline
Desipramine
Amitriptyline
Protriptyline
Fluoxetine
Sertraline
Paroxetine
Citalopram
Lithium
Carbamazepine
Valproate
Benzodiazepines
Buspirone
Typical antipsychotics
Atypical antipsychotics
Methylphenidate
Dextroamphetamine
Amantadine
Bromocriptine
L-dopa/carbidopa
Beta blockers
Donepezil
Key Item
+
++
+++
0
--
Depression
++
++
++
++
++
+++
+++
++
+
+
+
+
0
0
+
+
+
0
0
0
Affective lability or Irritability
++
+
+
+
+++
+++
+++
+++
+
++
++
+
++
+
+
++
0
++
0
0
0
0
Key Description
Mild positive effects seen
Moderate positive effects seen
Marked positive effects seen
No effects seen
Mild negative effects seen
Moderate negative effects seen
Marked negative effects seen
Mania
0
0
0
0
0
0
0
0
++
++
+++
+
+
+
+
+
0
0
0
0
Psychosis
0
0
0
0
0
0
0
0
0
0
0
0
0
++
+++
0
0
Agitation or Aggression
++
+
++
+
++
++
++
++
++
+++
+++
++
+
+
++
+
+
++
0
0
+++
0
Anxiety
+
+
+
+
0
0
0
0
+
+
+
++
++
+
+
0
0
0
+
0
Apathy
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
0
++
+
0
Only medications for which there are reports in the literature are listed here. Additional adverse
events include increased likelihood of seizures (antidepressants), neurotoxicity (lithium), impaired
cognition (mood stabilizers and benzodiazepines), and psychosis (bromocriptine and
L-dopa/carbidopa).
Medications that should be used with caution in TBI patients include benzodi­
azepines, antispasticity drugs, typical antipsychotics, narcotics, H2 blockers,
certain anticonvulsants, anti-hypertensives, clonidine, and steroids, as they
can all contribute to agitation or restlessness. Nevertheless, benzodiazepines
and antipsychotic medications may be useful for the rapid resolution of acute
agitation. However, they should be used for the shortest period of time at the
lowest possible dose. Benzodiazepines are known to impair memory/attention,
prolong post-traumatic amnesia, and can result in a paradoxical reaction while
typical antipsychotics (haldol, thorazine) can lower the seizure threshold, delay
motor recovery, and impair cognitive recovery.
The following classes of medication may be used to manage acute agitation/
aggression: anti-epileptics (e.g., valproate, carbamazepine), beta blockers,
antipsychotics, antidepressants (e.g., SSRIs), sleep agents, and anxiolytics.
The following classes of medication are not recommended to manage acute
agitation/aggression: antihistamines, narcotics. Please refer to Table 2 on
pharmacology for further details.
Chronic Agitation/Aggression
To date there is no FDA approved drug for agitation or aggression. Most of
current treatment practice has been modified from psychiatric research with
non-TBI patients.
The following classes of medication may be used to manage chronic agitation/
aggression: anti-epileptics, beta blockers, atypical antipsychotics, antidepres­
sants, sleep agents, anxiolytics (Yudofsky & Hales, 2002). The following
classes of medication are not recommended to manage chronic agitation/
aggression: antihistamines, narcotics, benzodiazepines. Please refer to Table
2 on Pharmacology for further details.
Mood Disorders/Apathy
Depression occurs in 25-50% of TBI patients and risk factors include prior
psychiatric history, prolonged PCS, left hemisphere damage, and psychosocial
factors (loss of social support, work, etc.; Jorge, Robinson, Arndt, Starkstein,
Forrester, & Geisler, 1993). Studies report an increased risk of suicide fol­
lowing TBI (Yudofsky & Hales, 2002). Treatment for depression following TBI
includes supportive psychotherapy and pharmacologic treatment. Drug choice
is guided by side effect profiles but dictated by clinical presentation and his­
tory. SSRIs and SNRIs are most frequently used. Mania and emotional lability
are treated similarly. Mania occurs in 4-10% of TBI patients and risk factors
include right hemisphere damage and family history of mood disorders. The
treatment of choice for mania in the TBI population are the anticonvulsants.
Apathy presents as a lack of initiation, motivation, appropriate affect and plea­
sure. Depressed mood, feelings of hopelessness or worthlessness, identifiable
stressor, and changes in sleep are generally not present (Rao & Lyketsos,
2000). Treatment of choice is use of dopaminergic agents such as amanta­
dine and neurostimulants.
Traumatic Brain Injury
76
The following classes of medication may be used to manage depressive symp­
toms after TBI: traditional antidepressants (e.g., SSRIs and SNRIs), stimulants,
anti-epileptics, anti-psychotics. Please refer to Table 2 on Pharmacology for
further details.
Irritability
Irritability is one of the post prevalent neurobehavioral complaints following
TBI of any severity (Deb & Burns, 2007; Rapoport, 2002). Caregivers and
families of patients with prior TBI of all severities also often note that irritability
is a frequent issue. This can adversely affect many aspects of life including
interpersonal relationships and community re-entry. A thorough assessment of
psychosocial stressors should be investigated and psychological evaluation and
intervention should be initiated prior to considering pharmacologic treatment
options. Ensuring adequate sleep and stress control may decrease the overall
presentation of irritability. Counseling the patient to reduce exposure to known
irritants may be useful in limiting episodes.
The following classes of medication may be used to manage irritability: antiepileptics, beta blockers, antipsychotics, antidepressants, sleep agents,
anxiolytics. The following classes of medication are not recommended to
manage irritability: antihistamines or narcotics. Please refer to Table 2 on
Pharmacology for further details.
Anxiety Disorders
TBI often impairs the ability to understand or adapt to external and internal
stimuli. Approximately 29% of TBI patients have measurable levels of anxiety
(Yudofsky & Hales, 2002). This occurs most commonly with lesions involving
the right orbital-frontal region. Treatment should include a review of all factors
that might possibly play a role in provoking or maintaining symptomatology
such as work, family dynamics, and environment. Medications that can be
effective include SSRIs, buspar, SNRIs, and propranolol.
The following classes of medication may be used to manage anxiety: anti-epilep­
tics, beta blockers, antipsychotics, antidepressants, sleep agents, anxiolytics.
The following classes of medication are not recommended to manage anxiety:
antihistamines or narcotics. Please refer to Table 2 on Pharmacology for
further details.
Disinhibited Behavioral Control Disorders
Personality changes frequently occur following TBI and empirically we see this
as one of the most difficult adjustment issues. These are frequently a conse­
quence of frontal and temporal lobe damage and treatment depends on the
subtype of the personality change. DSM IV classifies the following personality
change subtypes: labile, disinhibited, aggressive, apathetic, paranoid, com­
bined, and unspecified. The disinhibited personality subtype may respond to
anticonvulsant or SSRI medications, whereas the apathetic type may respond
to psychostimulant medication.
77
Traumatic Brain Injury
The following classes of medication may be used to manage disinhibited
behavioral control disorders: anti-epileptics, beta blockers, antipsychotics,
antidepressants, sleep agents, anxiolytics. The following classes of medication
are not recommended to manage disinhibited behavioral control disorders:
antihistamines, narcotics. Please refer to Table 2 on Pharmacology for further
details.
Psychotic Disorders
The incidence of post-traumatic psychosis ranges for 0.7 to 20% (Ahmed &
Fujii, 1998). Risk factors include left hemisphere injury, specifically left tem­
poral lobe damage, and can occur early (during PTA) or after a long latency.
Interestingly, there is a higher incidence of head trauma in schizophrenic
patients. Treatment includes the use of atypical antipsychotics or anticonvul­
sants.
Points to Remember
• To effectively treat neuropsychiatric disorders following TBI, one must
be sure to rule out confounding medical and neurological factors as
well as alcohol or drug induced symptoms.
• Polypharmacy should be minimized. An attempt to minimize unneces­
sary medications should occur prior to initiating new medications to
treat symptoms.
• Familiarity with medication side effects is crucial, and helps guide medication selection.
• Family/Caregiver education and support are key for the effective
treatment and management of neuropsychiatric disturbances follow­
ing TBI.
Role of The Primary Care Physician
In the post-acute phase, TBI patients and their families are most likely to
present to their primary care physician with various emotional or behavioral
complaints. The family may well report problems with irritability, anger con­
trol, and disinhibition, while the patient is more likely to report general life
dissatisfaction, poor mood, or low self-esteem. Once the history of TBI has
been clarified and the onset of the reported symptoms dated to the TBI, the
primary care physician may well consider referrals to psychiatry, psychology, or
neuropsychology for further evaluations and treatment intervention. However,
the primary care physician is likely to remain the primary provider and is likely
to follow the patient on their medication regimen once an effective regimen is
determined by the specialists.
Traumatic Brain Injury
78
CHAPTER 8: TBI in the Elderly and Aging with TBI
Learning Objectives
• Identify unique aspects of traumatic brain injury (TBI) epidemiology in
the elderly
• List strategies to prevent falls (and TBI) in the elderly
• Explain the influence of age on outcome after TBI
• Identify indications for head CT after TBI in the elderly
• Describe the relationship between physiological changes in the elderly
and adverse cognitive medication side effects
• Describe the link between TBI and Neurodegenerative Disease
Epidemiology of TBI in the Elderly
Individuals 65 and older have among the highest annual incidence rates of TBI
at 524 per 100,000, exceeded only by 0-4 yrs and 15-25 yrs age groups
(Langlois et al., 2004.) Moreover, adults aged 75 years or older have the
highest rate of all age groups for hospitalization and death from TBI. Falls,
the leading cause of medically attended TBI overall, is by far the most com­
mon etiology in the elderly. Being struck as a pedestrian is a more common
etiology in the elderly compared with other adults. Men account for a higher
percentage of TBI in the young elderly group, whereas in those over 80 year
old, greater female longevity leads to a female preponderance (Englander et
al., 1999). People surviving TBI for 6 months have the same 10-year lifespan
as the general population; so regardless of age at onset they and their residual
impairments will age along with their noninjured peers (Brown et al., 2008).
Given current demographic and longevity trends in United States, the number
of older adults with TBI sequelae should continue to increase over the next
several decades.
Prevention of TBI in the Elderly
Despite the important connection between falls and TBI among the elderly,
relatively little research has been done on fall prevention. Approximately 30%
of persons over 65 fall each year and may sustain injuries requiring hospi­
talization (Englander et al., 1999). The cause is usually multifactorial, with
weakness, poor balance and medication side effects frequently contributing.
One study showed a reduction of falls and head trauma in subjects compared
Traumatic Brain Injury
80
with controls using gait training by physical therapist, assistive devices, and
balance and resistive exercises (Tinnetti et al., 1994). A recent comprehen­
sive critical analysis of the literature concluded that multifactorial programs
including patient evaluation and therapy home visits were best for those at
higher fall risk and that exercise by itself is effective for reducing falls among
the elderly; the exercise should include a comprehensive program combining
muscle strengthening, balance, and/or endurance training for a minimum of
12 weeks (Costello et al., 2008.). Physician input is a critical component of fall
prevention in the elderly as outlined in Table 1.
Table 1: Fall Prevention in the Elderly (Adpated from Brown et al., 2008)
Potential Problem
Intervention
Polypharmacy
Parsimony of medication prescription
Sedating medication
Avoiding both prescription and nonprespription sedating medi­
cations (e.g., tricyclics, sedative/hypnotics benzodiazepines,
neuroleptics, diphenhydramine, etc.)
Gait dysfunction
Physical therapy, prescription of appropriate assistive device
Visual disturbance
Addressing cataracts, refraction
Physical frailty
Strength training
Decreased balance
Physical therapy
Medical conditions that can
affect consciousness
Medical management of arrhythmia, seizures
Postural hypotension
Close medical monitoring, avoiding medications that lower
blood pressure, compressive hose, hydration
Environmental hazards
No throw rugs, proper footwear, grab bars, tub chairs, proper
lighting , avoiding slippery surfaces
Poor safety awareness
Education and supervision
Prognosis Following TBI in the Elderly
Age is an important factor in functional and cognitive outcomes after TBI. In
short, the probability of poor outcome increases with advanced age (Braak­
man et al., 1980; Jennet et al., 1979; Stablein et al., 1980; Chestnut et al.,
2000). Individuals sustaining a severe TBI after age 65 are unlikely (<10%
chance) to reach Good Recovery on the Glasgow Outcome Scale (Brown et al.,
2008). Possible explanations include reduced reserves with which to tolerate
brain injury and/or a more fragile physiologic status in the elderly resulting in
a more destructive injury (Rothweiler et al., 1998). Despite slower recovery
rates and longer lengths of stay, the majority of elderly TBI survivors undergo­
ing rehabilitation achieve functional improvement and community discharges
(Cifu et al., 1996).
81
Traumatic Brain Injury
When assessing the impact of TBI on the older adult, one must take into
account significant accumulated chronic comorbidities (e.g., arthritis, cardio­
pulmonary, diabetes, atherosclerosis, renal failure, cancer). In addition, one
needs to consider chronic premorbid conditions that could reduce cerebral
functional reserve at baseline (e.g., cerebrovascular disease, chronic alcohol­
ism, advanced liver or renal disease, dementia) and potentially impede or
prolong the recovery process. Another impediment to rehabilitation is higher
levels of psychosocial limitation seen with advanced age (Rothweiler et al.,
1998).
Assessment of TBI in the Elderly
Older individuals are more likely to have “complicated” mild TBI, a term used
for patients meeting clinical criteria for mild TBI (i.e. concussion), but who
also have abnormal findings on head CT. Thus, when an individual with mild
TBI presents to the clinic or emergency department (ED), age should be con­
sidered in the decision whether to obtain a head CT. Based on retrospective
review of 1448 patients seen in ED with mild TBI, Borczuk (1995) recom­
mends CT scan for patients after TBI when age is greater than 60 years, or if
any of the following is present: focal neurologic deficit, evidence of basilar skull
fracture, or cranial soft tissue injury. Major trauma in individuals over 70 is 6
times more likely to cause intracerebral lesions than severe chest, abdominal,
or pelvic injury. Many elderly are also on coumadin or other anticoagulation
therapy, further increasing the risk. The physician should order a cranial CT
and INR (International Normalized Ratio measuring clotting time) in all elderly
patients with suspected TBI after trauma (Callaway & Wolfe, 2007). Multiple
studies have supported the liberal use of cranial CT in the elderly with trauma
as cost effective and clinically appropriate.
For the elderly TBI survivor with significant functional limitations, a full medical
rehabilitation evaluation by a physiatrist is strongly recommended, when avail­
able. An estimation of physiological reserve allows more specific structuring of
the rehabilitation program, and is made possible by delineating preinjury activ­
ity level and pertinent acute and chronic medical issues. Impairments (e.g.,
hemiparesis, dysphagia, incontinence, and cognitive deficits) and functional
deficits (mobility status, activities of daily living) should likewise be fully delin­
eated. The evaluation should also seek to identify any of the potential medical
complications after TBI which will be discussed further below.
Management Behavioral and Cognitive Problems
in the Elderly
Due to the physiological and pathological changes that accompany aging, older
adults experience more frequent and more severe cognitive impairment when
compared to younger adults with similar severity of TBI (Rosenthal, Griffith,
Kreutzer, & Pentland, 1999). This is primarily due to lower cognitive reserve
capacity and a higher incidence of premorbid dementia. Significant premorbid
memory deficits are present in nearly 10% of community-dwelling older adults
(Beard et al., 1995), and greater than 20% of those over 85 (Skoog et al.,
1993).
Traumatic Brain Injury
82
Older individuals with TBI also have slower rates of drug metabolism and
excretion, which creates a greater propensity for cognitive side effects from
medications including agitation, somnolence, and increased confusion. To
complicate matters, most elderly are chronically on regular prescription
medications, with more than 90% of the entire population over age 65 tak­
ing at least one prescription medication daily, and most taking two or more
(Chutka et al., 1995). After TBI, thorough review of both prescription and
non-prescription medications is imperative; and all non-essential medications
should be stopped or tapered. General principles for TBI pharmacology should
be applied. For example, acetaminophen is the preferred medication for pain
syndromes; proton-pump inhibitors are favored over H2 blockers for peptic
ulcer disease or reflux; beta-blockers that cross the blood-brain barrier should
be avoided; benzodiazepines and metoclopromide should especially be avoided;
and low-dose trazodone is the preferred medication for insomnia.
Although major depression is less common, depressive symptoms are more
common in elderly TBI patients compared to younger adults (Rosenthal et al.,
1999). When pharmacological treatment of depression is indicated, selective
serotonin reuptake inhibitors (SSRIs) are the recommended first line in elderly
patients with TBI. Although generally safe, SSRI induced hyponatremia can
occur in older adults; so checking electrolytes soon after initiation is prudent
(Jacob & Spinler, 2006). In elderly patients with mild TBI, the development of a
significant post-traumatic dementia with transient psychotic symptoms at night
can be seen in association with increased nighttime agitation and disorienta­
tion (Goldberg, 2001). This can be viewed as stemming from a disorganized
circadian sleep-wake cycle and an exaggeration of the effects of aging on
circadian physiology. The use of low doses of risperidone, olanzapine, or que­
tiapine at bedtime can be helpful in reducing these disturbing symptoms and
re-establishing a normal circadian rhythm.
Common Comobidities
Common medical complications after TBI are discussed in Chapters 4 and 5.
As previously mentioned, polypharmacy should be avoided, and non-essential
medications should be eliminated. Compared to younger individuals with TBI,
the elderly have a higher risk for DVT and a higher risk for urinary retention
and incontinence especially while hospitalized. Those who remain sedentary will
continue to be at risk for complications of immobility such as decubitus ulcers,
DVT, pneumonia, and deconditioning weakness. Seizures can occur both early
and late. A recent large case-control study showed the risk of developing new
onset seizures in the elderly is doubled by a history of TBI (Pugh et al., 2009)
Motor and balance functions tend to recover more slowly in the older adult
with TBI because of premorbid limitations in cognition, sensation, strength
and balance, along with decreased tolerance for intensive therapy sessions,
and increased levels of joint and musculoskeletal pain. Special mobility con­
siderations in the older adult with TBI include alterations in vision, decreased
peripheral sensation, imbalance, decreased strength, and limited physical
83
Traumatic Brain Injury
endurance. Many elders have a difficult time comprehending and adjusting
to these limitations and therefore pose a significant risk in safety, judgment,
and fall propensity. Comprehensive caregiver education and training are para­
mount. A home evaluation by the rehabilitation team can optimize household
level mobility.
TBI and Neurodegenerative Disease Link
Evidence is accumulating that moderate or severe, but not mild TBI increases
the risk for neurodegenerative diseases in later life. Post-mortem evaluations
after severe TBI demonstrate beta-amyloid peptides, which are associated with
both Alzheimer’s disease (AD) and Parkinson’s disease (PD), and increased
amyloid precursor protein immunoreactivity, which represents plaque-like
formation and may be an early maker for axonal injury. In one large epidemio­
logic study, a history of documented TBI increased the risk of dementia of the
Alzheimer’s type for moderate TBI by a hazard ratio [HR] of 2.3; (CI = 1.04
to 5.17) and for severe TBI by a HR of 4.51 (CI = 1.77 to 11.47) (Plassman
et al., 2000). However specificity for AD pathophysiology was not established
as the authors reported only 53% specificity for AD on their prior autopsies
of those categorized as Alzheimer’s type dementia. Other potential causes for
dementia and the possible role of any residual dementia from the TBI itself are
confounding factors. Other studies have demonstrated an association between
moderate and severe TBI and Parkinson’s syndrome (Bower et al., 2003;
Goldman et al., 2006.). Of note, the presence of Apolipoprotein E gene with E
4 allele is associated with the onset of AD and has been studied in TBI. Earlier
studies suggested an association with poorer outcome in TBI, but more recent
studies have not replicated this finding. Further research is needed on genetic
predictors of prognosis before definitive conclusions can be made (Graham,
1999).
Points to Remember
• Falls are the leading cause of TBI in the elderly
• Gait training, the use of assistive devices, and balance and resistive
exercises can decrease the rate of falls and therefore prevent TBIs in
the elderly
• For the same type of injury, the elderly are more likely to have intrac­
ranial findings (e.g., bleeds) than younger individuals
• Elderly patients benefit from interdisciplinary rehabilitation but have
poorer outcomes than younger adults given similar injury severity
• Elderly patients are more susceptible to cognitive side effects of medi­
cations than younger adults
• In the elderly, a relatively mild TBI can disrupt the normal circadian
sleep-wake cycle and result in a reversible post-traumatic dementia
accompanied by transient psychotic symptoms at night
Traumatic Brain Injury
84
CHAPTER 9: The Impact of TBI on the Family System
Learning Objectives:
• Describe potential effects of TBI and related sequelae on the family system
• Assess how the family system is adapting to TBI
• Learn effective strategies to assist family adjustment to TBI
• Address FAQs from family members using a validation and education approach
Introduction
The effects that a traumatic brain injury (TBI) may have on family members
and caregivers have been well documented (Kreutzer et al., 1992; Sander et
al., 1997; Collins and Kennedy, 2008). The cognitive, emotional, and physical
changes in survivors of TBI can be quite significant, depending on the extent
and severity of injury. As such, living with a family member who has sustained
a TBI can be stressful and sometimes overwhelming for the family system as
a whole. In other cases, individuals with a history of TBI and their families may
find that the injury leads to new opportunities such as increased communica­
tion and understanding, and a rearrangement of family priorities.
Familiarity with common sequelae of TBI as well as common family concerns
regarding recovery and prognosis will prepare the provider to address the fam­
ily’s salient issues. Healthcare providers working in primary care settings, such
as physicians, nurse practitioners, and social workers, are well positioned
to assess the health of the Veteran’s family system, promote family wellness
to offer reassurance and support. Although a specialized system of care for
Veterans with TBI is available within the VA healthcare system (see Polytrauma
System of Care, Chapter 3), a large proportion of Veterans with TBI are seen
by VA providers in other settings (e.g., Primary Care, Mental Health or other
clinics).
It is important for healthcare providers to understand the effects of TBI within
the context of a pre-existing family structure. Family members vary significantly
in their ability to cope with life after TBI. Furthermore, the degree of physical
and cognitive disability of the individual with TBI does not entirely account for a
Traumatic Brain Injury
86
family member’s ability to effectively cope with the demands of providing care
and support. (Verhaeghe et al., 2005). Following injury to a loved one, premor­
bid stressors and tensions often become exacerbated and new problems or
challenges can emerge. Pre- and post-injury factors play an important role in
determining the psychological adjustment and quality of life of family members.
Pre-existing factors that place caregivers at higher risk for stress and mal­
adaptive coping include a history of psychiatric illness in the caregiver, fewer
socio-economic resources, lack of cultural or spiritual identity and support,
and the presence of several young children in the home. The latter risk factor
is especially salient in the new generation of Veterans, many of whom have
relatively young families for whom early identification and assistance is crucial.
In cases where the injured family member is a combat Veteran, the family’s
homeostasis may have already been disrupted by the stress related to multiple
deployments (Collins and Kennedy, 2008). Moreover, females in a caregiving
role typically report higher levels of stress and depression than their male
counterparts (Verhaeghe et al., 2005).
Relationship factors also contribute to the adjustment of caregivers. For
example, spouses who provide support or care report more health and psy­
chological problems than parents (Verhaeghe et al., 2005). Also, parental
stress is greatest when the injured adult must return home to live.
Post-injury factors affecting family adjustment to TBI include financial burden
associated with the injury (i.e., costs of treatment or the subsequent loss
of income for the patient and/or family member; McMordie et al., 1988).
In contrast, satisfaction with social support and the types of coping mecha­
nisms utilized contribute to the psychological health and adjustment of family
members who offer support or care (Sander et al., 1997). Lastly, in family
members of injured Service Members, separation from the military can be
associated with the loss of security and support specific to the military culture
(Collins and Kennedy, 2008).
Family Adjustment to TBI
Psychological distress is common in family members of individuals with TBI and
may persist for several years following the onset of the injury (Kreutzer et al.,
1994). Lezak (1986) and others have described a series of nonlinear, overlap­
ping stages of family adjustment to TBI that may span two to three years or
longer, depending on the severity of the injury. Each stage is defined by a series
of emotional reactions.
The range of emotional reactions characterizing each stage of family adjust­
ment to TBI is summarized in the following table.
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Traumatic Brain Injury
Table 1. Adapted from Lezak, 1986
Stage
Time Since Injury
Expectation
Family Reaction
I
0-1 to 3 months
Full recovery by one year
Relief, shock, denial, depression, avoidance
regarding the injury
II
1-3 months to 6-9
months
Full recovery if the
patient just tries harder
Bewildered, anxious, begin to realize the severity
of the situation, frustrated, loss, realize they lack
adequate knowledge about the injury or recovery
process
III
6 to 24 months or
can continue indefi­
nitely
Patient can become
independent if family
knows how to help
Impatient with survivor because they are not try­
ing hard enough, recognize the person is more
impaired than was first thought, feel discouraged,
guilty; seek additional information about living with
TBI
IV
9 months or later, can
continue indefinitely
Little or no change
Depressed, feel “trapped”, exhausted and need
respite, begin to realize the impact of the injury.
Experience emotions similar to bereavement,
patient’s disability or behaviors may bother family
immensely
V
12 months or later,
usually time-limited
Little or no change
Sadness and mourning, begin to understand
the full impact of the injury, begin the process of
accepting the losses
VI
18 months to 3 years
post injury
Little or no change
Reorganization and change in the family system,
become creative in helping injured family member,
begin to address the needs of the entire family
unit, become well-versed about TBI, invest time
and money on accommodations, become empow­
ered to advocate on behalf of patient
Although Lezak’s stage theory was initially meant to describe family reactions to changes
following moderate to severe TBI, this conceptualization may also prove useful in describing
the reactions of family members of Veterans whose recovery from mild TBI has been com­
plicated by significant comorbid mental health conditions such as PTSD or depression (Hoge
et al 2006, 2008). Family members of Veterans with a history of mild TBI may quickly pass
through the first few adjustment stages because mild TBI is less frequently associated with
life-threatening injuries. During all stages, family members tend to focus their energy and
care on the injured Veteran and may not attend to their own self care needs. While it can be
difficult to persuade family members to take time for themselves, healthcare providers are in
a unique position to encourage and support the importance of self care. Encouraging family
members to get adequate rest, nutrition, exercise and relaxation, helps to ensure that they
are able to provide assistance to their loved one, as needed.
Traumatic Brain Injury
88
Points to Remember:
• Psychological distress is common in family members of individuals
with TBI and may persist for several years following the onset of the
injury
• Family adjustment to TBI can be described as a series of nonlinear,
overlapping stages. Each stage is defined by a series of emotional
reactions which call for different types of intervention by healthcare
providers
Assessing the Wellness of the Family System
Given the importance of family involvement and support in the outcome of
Veterans with a history of TBI, periodically assessing the health and adjustment
of the family system is good practice and strongly recommended, as studies
suggest that caregiver distress may remain at elevated levels for 10-15 years
post-injury (Verhaeghe et al., 2005). A brief assessment will allow the healthcare provider to make an informed decision about the level of support that may
be required to assist the Veteran and their family. Establishing the well being
and adjustment of the family requires the healthcare provider to determine
if the support system is coping effectively and able to meet the needs of the
Veteran. This information can be obtained from the patient or, preferably col­
laterally from a family member.
Veterans with a history of TBI may draw support from a range of individuals
including spouses, parents, grown children, friends and various healthcare
providers. The ability of the support system to meet the needs of the Veteran
is determined by a multitude of factors, including the depth of the support
system, the level of investment in providing support, financial resources, and
competing family responsibilities (e.g., child rearing responsibilities, careers,
etc.). The healthcare provider can elicit information about the how well the
family is coping and meeting the needs of the individual with TBI by asking
questions such as:
Questions for the Veteran:
1. Who provides you with the most support?
2. Do you feel that you are receiving enough support?
Questions for the Family Member:
1. Are you and your family able to manage all of the needs of loved one with TBI?
2. Do you have needs or concerns for which you need help or guidance?”
Being able to provide support to an individual with TBI does not mean, however,
that every member of the support system is coping well. If left unchecked,
poor coping could lead to a break down in the provision of essential support for
the Veteran who experienced TBI. Determining how effectively the family is
coping is best accomplished by asking questions such as:
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Traumatic Brain Injury
1. How are you managing these days as a family?
2. How have changes in your family affected you?
Points to Remember:
• The best way to determine how a family system is functioning after a
TBI is to ask direct questions of the family members and/or Veteran
• It is important to assess both the family’s ability to manage the needs
of the Veteran post-TBI and how well family members are coping with
changes in the family system
Helping the Family Adjust to Changes After TBI
Successful reintegration of a person with a history of TBI into their previ­
ously existing family structure is essential to maximize the quality of life and
independence of these individuals (Sander et al., 2002). Family members and
friends provide a host of psychosocial and physical supports throughout the
recovery process and serve as extremely important collaborators with the
injured person’s treatment team. As the individual with TBI transitions from
an acute inpatient setting to post-acute outpatient care, family members often
assume a range of care and/or support activities that can include assistance
with rehabilitation tasks (i.e., instrumental activities of daily living, cognitive
remediation). Changes in the behavior and personality of an individual following
TBI, including low frustration tolerance, poor social judgment, disorganization
and apathy can be especially distressing for family members. Unrealistic expec­
tations about recovery by the patient, family or both serve to compound this
distress (Lezak, 1986). New responsibilities frequently overlap with emerging
family adjustment issues related to changes in family structure and functioning.
Family members of TBI patients require both emotional support and education
to help them meet the many challenges they face as a result of the injury to
their loved one.
When the Veteran or family shares information about the health of the support
system, the following steps can be used as a guide to assess the situation and
offer assistance:
1. Validate and Normalize. Family members will benefit from someone
listening to their concerns and feelings and validating their experience.
This can be as simple as listening carefully, reflecting what they say, and
normalizing the family’s reaction to common TBI sequelae.
2. Educate. Psychoeducation regarding the typical course of recovery often
serves to reduce distress and anxiety. Information about how to adjust
to post-injury changes in the person with TBI has been identified as one
of the most commonly expressed needs by caregivers (Sinnakaruppan &
Williams, 2001). It has been noted that the majority of family members
and caregivers of Veterans with TBI demonstrate remarkable resilience in
the face of adversity. For these individuals accurate information and psyTraumatic Brain Injury
90
choeducation appear to be the most appropriate interventions (Sammons
& Batten, 2008).
3. Collaborate and Refer. Consulting with other healthcare professionals
is an important step in determining what services might be needed and
available. The needs of individuals with TBI and their family can be com­
plex and may possibly require more specialized intervention. Should that
be necessary, referral to providers with specialized knowledge of TBI may
be warranted to assist with issues related to recovery (e.g., adjustment,
logistical needs, community re-integration, training).
Points to Remember
• The role of the VA provider when presented with issues related to
family adjustment after TBI is to assess the situation and,
• Validate and normalize the family’s concerns and their reactions
• Educate the family about TBI and the recovery process
• Collaborate with TBI specialists and other providers within the
system
• Refer for specialized intervention, when necessary
Responses to Frequently Asked Questions (FAQs)
by Families
The following are frequently asked questions that may be encountered when
working with Veterans with a history of TBI and their family members. Many
questions are related to certain themes that commonly concern family mem­
bers. These themes include: 1) course of recovery, 2) etiology, or the cause
of problems and symptoms, 3) changes in personality, 4) changes in relation­
ships, and 5) how to best help and support the individual who experienced the
TBI.
For each theme, a prototypical question is provided followed by a response
that demonstrates the application of the strategies described above (i.e. vali­
date/normalize, educate, collaborate/refer).
1. Course of Recovery. “When is our life going to get back to normal?”
• Validate and Normalize - Acknowledge that the ambiguity of not
knowing the definite course of recovery can be stressful for family
members and others supporting a patient who experienced a TBI.
Express that it is normal to feel anxious and scared when family life
is disrupted by an injury, especially when the timeline of recovery is
unclear. Reassure the family member that his/her reaction is under­
standable given the nature of the circumstances.
• Educate – Provide the family with information regarding the expected
recovery course following TBI (see Chapter 2). Explain that the course
of recovery is different for each individual depending on the nature and
severity of the injury. Although recovery is most rapid and noticeable in
the first 12 months post injury, reassure the family that improvements
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Traumatic Brain Injury
in cognition, mood, behavior, and independence typically occur with
time and appropriate treatment (Christensen et al., 2008; Millis et
al., 2001).
• Collaborate / Refer – Collaborate with other healthcare providers
to help determine the best course of intervention for the injured
Veteran or his family. Make appropriate referrals to providers within
the VA system who can assist with complicated diagnostic problems
or with family support needs (i.e., family education or psychotherapy,
respite care, etc). Consider a referral to a community partner if other
resources are needed to meet the needs of the family member or
injured Veteran.
2. Etiology. “Did the TBI cause all of these problems (depression,
anger, memory problems, headaches)?”
Family members of Veterans with a history of TBI may want to know to
what extent the Veteran’s problems are related to the TBI. This can be a
complicated question to answer as past and present physical and psycho­
social problems also contribute to the Veteran’s current clinical picture.
• Validate and Normalize - Acknowledge that it can feel overwhelming
when someone seems to have a host of problems that are not clearly
explained. Listen to the family’s concerns and convey that their feelings
are important and can be managed. Share with the family that it is
common for people who experience a TBI to have numerous changes
directly and indirectly related to the TBI.
• Educate – Provide the family with information about the common
comorbidities in Veterans recovering from TBI and the frequency of
symptom overlap. For example, co-occurring physical problems and
significant emotional distress are not uncommon in Veteran’s recover­
ing from TBI (Hoge et al., 2006; Sayer et al., 2008). Further, indicate
that symptoms associated with conditions such as TBI, PTSD, and
chronic pain can be very similar and that current environmental condi­
tions such as job-related stress or parenting responsibilities cause
symptom exacerbation. Although it is not always possible to establish
a single “source” for each symptom, an empirical and collaborative
approach to treatment usually results in successful reduction in symp­
toms.
• Collaborate / Refer – As necessary, collaborate with other healthcare providers within your facility, and consider an interfacility consult
to a TBI specialist if necessary. This may include a physiatrist or a
neuropsychologist with experience treating patients with a history of
TBI. If the Veteran is experiencing chronic pain such as headache or
neck pain, referral to a pain clinic may be warranted. If the Veteran is
struggling with psychological issues such as acute stress or depres­
sion, referral to a mental health provider may be useful. Similarly, a
referral to a substance abuse trained counselor or a substance abuse
treatment program may be important for a Veteran who discloses
problems with alcohol or drugs.
Traumatic Brain Injury
92
3. Changes in Mood or Personality. “Why does she overreact to little
things now and say things that are embarrassing?” ”Why does he
just want to stay in his room all the time?”
Family members are especially sensitive to the changes in the mood and
personality of their loved one following TBI (Ponsford et al., 2003). Prob­
lems such as isolating oneself from others, irritability or inappropriate
behavior can be misinterpreted as intentional by family members, causing
feelings of resentment. In an attempt to avoid embarrassing social situ­
ations resulting from inappropriate behavior, family members may opt to
bypass community activities available to them and the Veteran. Individuals
with a history of TBI may also show a lack of initiation for formerly enjoyed
activities or lack of interest in interpersonal interaction, which also can
result in decreased social opportunities.
• Validate and Normalize – Acknowledge the frustration and hurt
feelings family members may express. They may feel that mood or
personality changes are directed at them personally or feel angry
that they are not being treated the same way as they were before
the injury. In addition, family members may feel a loss of the preinjury person they knew. Share with the family that changes in mood,
personality, and social skills are commonly reported following TBI and
that these changes, depending on the severity of the injury, may be
temporary or long-standing.
• Educate – It is often helpful for the family to hear that the frontal
lobes of the brain help to inhibit impulsive responses (i.e., anger, inap­
propriate verbalizations), select appropriate behaviors, and engage
in social endeavors. Simple strategies such as distracting the injured
Veteran or ignoring inappropriate behavior (i.e., avoiding reinforce­
ment) are typically effective in reducing unwanted behaviors. If family is
concerned about lack of initiation it may be helpful to suggest that they
engage the Veteran in planning social activities.
• Collaborate / Refer – In addition to seeking collaboration with other
providers, a referral to a mental health professional may be especially
helpful for mood and personality related concerns. Such a referral
may include training in anger management strategies and other
cognitive behavioral-based therapies for depression and anxiety. Addi­
tionally, referral to vocational rehabilitation may be useful in promoting
community re-integration. For family members who are struggling to
understand changes in their injured loved one, a referral to a support
group for caregivers and supporters of individuals with a history of TBI
may be helpful.
4. Relationship Issues / Intimacy – “Why is he less interested in sex?”
“ Why is she so impatient with the children?”
Spouses typically report more distress related to caregiving than parents
(Verheaghe et al., 2005). This is likely due in part to the significant role
change experienced by the spouse. A spouse may begin to feel more
like a parent, should they need to take on responsibilities for providing
93
Traumatic Brain Injury
physical and psychological care and support to the injured individual.
Furthermore, TBI-related changes in the injured individual’s personality
and libido may have a significant impact on the relationship. The stress of
caring for a spouse with brain injury can be further magnified by the pres­
ence of young children in the household and other competing demands
such as work and elder care.
• Validate and Normalize – Listen to the spouse or family members’
concerns and acknowledge feelings expressed, such as confusion,
frustration, and anger. The spouse may feel offended or rejected if
they do not understand the distressing behavior is a result of the TBI
and not purposeful nor intentional. Acknowledge that providing care
and support while maintaining a romantic relationship with an injured
partner can be difficult. Share with the spouse that these changes
may be temporary, especially in the case of mild TBI, but can be chal­
lenging even in the short term.
• Educate – Acknowledge that providing care and ongoing support
can be a tremendous burden, especially when the spouse has other
responsibilities. Encourage the spouse to participate in activities out­
side the home as a way to reduce stress and maintain social support.
Stress the importance of self care (Kreutzer et al., 2002).
• Collaborate / Refer - For more severe TBI, consider referral for
respite or adult day care services to allow the spouse time to engage
in other activities outside the home. Referral to community based TBI
family support groups may provide an important source of caring and
insight for spouses and family members. Referral for couples and fam­
ily counseling may be helpful, especially for individuals with a history of
mild TBI who retain strong cognitive abilities and primary partner and
parenting roles in the family system.
5. Helping and Supporting. “What can I do to help?”
Many family members and other supportive persons are extremely
invested in the recovery of their injured loved one and derive considerable
satisfaction from working collaboratively with healthcare providers. These
family members may ask to assist in helping the Veteran with a history of
TBI to overcome problems such as forgetfulness, poor organization/plan
ning, sleep disturbance, and irritability. In addition to providing validation
and education regarding the frequency of these problems following TBI, a
few suggestions regarding modifications to the Veteran’s environment and
daily routine may help to build a stronger collaborative relationship with
the family member and may lead to improvement in the Veteran’s daily
functioning.
• Forgetfulness and Organization / Planning. Regardless of the
initial severity of the TBI or the current stage of recovery, reducing dis­
tractions in the environment and developing compensatory strategies
may help improve the functioning of the individual recovering from TBI
(Cicerone et al, 2005). Reducing distractions and clutter can help the
injured person focus more easily on relevant stimuli or information.
Traumatic Brain Injury
94
Use of a memory notebook is helpful to keep track of appointments,
notes, phone numbers, etc. Family members can play an instrumen­
tal role in encouraging the person with a history of TBI to use their
memory notebook throughout the day. Initial referral to a rehabilitation
professional (e.g., neuropsychologist, speech pathologist, occupational
therapist) for training in the use of such compensatory strategies is
encouraged. Routine use of these strategies fosters independence in
a person recovering from TBI, thus reducing the burden on family and
others to provide these supports.
• Sleep Disturbance – Developing a consistent sleep hygiene routine
and creating an environment that is conducive to sleep can improve
the sleep disturbances (Bootzin & Perlis, 1992). Referral to a reha­
bilitation professional or sleep specialist may initially be necessary
to develop an appropriate sleep routine. Regardless of who initially
develops this plan with the injured individual, a family member or other
supportive person can be instrumental in monitoring and encouraging
the injured person’s adherence to the sleep hygiene plan.
• Irritability – Irritability may be the manifestation of one or more
conditions related to a history of TBI including lowered frustration
tolerance, disturbed sleep, and confusion. Family members should be
encouraged to set boundaries with the person, ignore inappropriate or
disruptive behaviors and avoid escalating stressful situations.
Internet Resources for Families and Caregivers
The following is a list of internet resources that caregivers and persons with a
history of TBI may find helpful:
Brain Injury Association, Inc – www.biausa.org
Brain Injury Resource Center – www.headinjury.com
The Perspective Network – www.tbi.org
Recovery Awareness Foundation – www.tbinet.org/raf
Family Caregiver Alliance – www.caregiver.org
Rosalynn Carter Institute for Caregiving – www.rosalynncarter.org
Defense and Veterans Brain Injury Center – www.dvbic.org
95
Traumatic Brain Injury
CHAPTER 10:
Community Integration and Extended
Care: Services and Resources
Learning Objectives
• Recognize the life long issues that may impact the Veteran with brain injury.
• Identify resources to meet community and extended care needs
Introduction
Community integration refers to resumption of appropriate roles in the family,
community and workplace. Survivors of TBI may require support well beyond
the initial course of rehabilitation, in order to maximize function, reduce barri­
ers and assist the Veteran to live in the community of his/her choice.
Observations of individuals who sustained a TBI and returned to their respec­
tive communities without adequate transitional preparation reveal progressive
isolation due to inappropriate social skills, poor impulse control, disturbed
sleep patterns that exacerbate inadequate decision making and problem solv­
ing, difficulties to form and maintain meaningful relationships, and pervasive
inability to cope effectively. (Dikmen at al., 2003; Lew et al., 2006) Injured per­
sons may fail to thrive in communities without interventions to facilitate skills
development.
Statements like the following should be recognized as expressions of difficulties
with community reintegration: “I got kicked out of my apartment”; “ I have no
friends, I can’t get along with my family”; “ I don’t have anything to do with my
time”; “I can’t get to the grocery store”; and, “ I ran out of my medications
two weeks ago.” More often than not, appropriate action from the person’s
healthcare team is required to remedy these situations and to prevent further
problems.
At the same time, community participation has been shown to promote con­
tinued gains in functional recovery and quality of life in individuals with TBI, and
to reduce family/caregiver stress (Inzaghi et al., 2005). Education and rein­
forcement of the benefits of community reintegration may facilitate functional
improvements through adaptation to environment overtime. Referral should be
considered to a specialty team within the Polytrauma/TBI System of Care for
Traumatic Brain Injury
96
evaluation and recommendations regarding:
• Independent living skills (ability to care for personal needs as well as main­
tain the household)
• Community access (driving, transportation)
• Vocational and leisure activities (work, school, recreation)
• Social networks and connections (community activities, support groups)
• Safety
• Health and wellness
• Individual and family supports
Recreation/Leisure, Driving, and Vocational Issues
Recreation and Leisure
Participation in recreation and leisure activities is an important part of the
recovery from TBI. Recreation and creative arts therapy can be especially
meaningful for persons with brain injury who are unable to continue with
work activities. Without adequate interventions that integrate Veterans who
have TBI into their home communities, they are likely to become isolated from
others avoiding many or all activities within or outside the home.
Referral to recreation therapy should be considered in order to promote
community participation, life satisfaction and overall health and well-being of
individuals with TBI. Clinical practice in recreational and creative arts therapies
involves the deliberate and purposeful use of specifically designed interventions
that contribute to quality of life of Veteran in his or her community. The inter­
ventions are activity-based and require the development, strengthening, and
maintenance of physical and cognitive skills that transfer readily to “real world”
experiences.
Activities included in recreational and creative arts therapy interventions affect
change, a process that begins with the Veteran’s desire to participate - a
critical pre-requisite to therapeutic engagement. Activities are crafted around
Veteran’s interests and desires with adaptations that support existing skills and
abilities. These activities serve as strong motivators for enduring participation
in interventions that are designed to facilitate skill strengthening and new skill
development that transfer readily to family and community life. Furthermore,
these activities are delivered in supportive environments in which therapeutic
relationships with professionally trained practitioners help Veterans learn,
adapt, and develop in ways that contribute to their well-being.
Driving after TBI
Driving is an essential activity of daily living for most individuals and is one
determinant of level of independence. Driving requires a complex set of skills
and abilities including vision, visual-motor coordination, memory, appropri­
ate reactivity, and planning, many of which may be impaired following TBI.
Guidelines to determine fitness to drive in patients with TBI have not yet been
established, leaving physicians with the difficult task of deciding how to ascer97
Traumatic Brain Injury
tain driving capacity. However, it is the physician’s responsibility to determine
when and how to return the individual to driving. Appendix G provides further
detail about driving following TBI, and driving assessment and rehabilitation in
the VA.
Vocational Rehabilitation
Vocational rehabilitation services prepare individuals to achieve a lifestyle of
independence and integration within their workplace, family and local commu­
nity. This transition is accomplished through work evaluation and job readiness
services, job counseling services, education, and training. Medical and
therapeutic services are sometimes necessary to support the achievement of
vocational goals. Vocational services may include, but are not limited to:
• Vocational evaluation
• Vocational training
• Functional capacity evaluation
• Work hardening
• Job site evaluation
• Job coach
• Supported employment
Vocational rehabilitation services may be provided through VA or through other
state and government agencies, as presented below.
VA’s Vocational Rehabilitation and Employment (VR&E) Services assists Veter­
ans with service-connected disabilities to become suitably employed, maintain
employment, or achieve independence in daily living. Eligible Veterans may
receive rehabilitation services, independent living services, educational or
vocational training, employment services, or a combination of theses. Ser­
vices provided vary depending on the needs of the Veteran. A comprehensive
vocational evaluation assists in determining the Veteran’s skills, aptitudes, and
abilities and forms the basis for vocational planning. This may include training
in a college or university, technical school, on-the-job training or in a specialized
rehabilitation program (for individuals with severe disabilities). For more infor­
mation go to: http://www.vba.va.gov/bln/vre/vrs.htm
Each state offers vocational rehabilitation services for individuals with disabili­
ties that meet their eligibility requirements. Vocational rehabilitation is a joint
federal-state program administered by each state; therefore services vary
from state to state. Services may include evaluation, job training, assistance
with job placement, supported employment and independent living services.
In some states, vocational rehabilitation agencies may also pay for therapies,
technical/vocational training and post-secondary education. The following is a
link to vocational services by state. https://secure.ssa.gov/apps10/oesp/
providers.nsf/bystate
Traumatic Brain Injury
98
Neurobehavioral Programs
Severe and persistent neurobehavioral problems following TBI sometimes
require admission to a specialized neurobehavioral program. Such programs
are tailored to manage the needs of patients with behavioral excesses that
cannot be managed safely in a traditional rehabilitation setting. (Uomoto &
McLean, 1988) Neurobehavioral problems are common in acute rehabilitation
of patients with TBI at Rancho Levels IV and V (Arciniegas & McAllister, 2008).
Problems such as agitation, disinhibition, and even aggression can generally
be managed competently by a trained team using appropriate environmental
and therapeutic modifications. However, persistent behavioral excesses may
become an obstacle for the person with TBI to be engaged in rehabilitation
therapies. Specialized programs are sometimes required that target the reduc­
tion of behavioral excesses, improve behavioral deficits, and facilitate social
functioning.
Neurobehavioral programs are designed for patients with significant mal­
adaptive behaviors or for those who are unsafe due to suicidal, homicidal,
or violent behavior and cannot be treated in less restrictive environments
(Trudel, Nidiffer, & Barth, 2007). Such programs can be physically located
in secured hospital units, or community-based programs. They generally use
an interdisciplinary approach that may include interventions such as behavior
modification, medication management, socialization skills training, substance
abuse treatment, family therapy, and physical management programs, in
addition to traditional interdisciplinary treatment. Length of stay can greatly
vary depending on etiology and severity of the behavioral disorders; it typi­
cally ranges from 1-6 months (Malec & Ponsford, 2000). Patients can be
discharged from neurobehavioral programs to a variety of settings including
inpatient acute rehabilitation, post-acute residential programs, outpatient pro­
grams, supported living programs, or home and community-based programs.
Use of psychiatric hospitals that are not experienced in brain injury rehabilita­
tion is not recommended for the treatment of neurobehavioral sequelae of TBI.
Neurobehavioral programs are also appropriate for severe behavioral prob­
lems due to other concomitant diagnoses, such as alcohol or substance abuse
(Trudel, Nidiffer, & Barth, 2007).
Extended Care
VA offers a spectrum of extended care services in institutional and non-institu­
tional settings, with the goal of maintaining the maximum level of independence
in the least restrictive setting.
OEF/OIF Veterans with polytrauma and TBI are significantly younger than the
current cohort of Veterans in VA’s extended care programs. Younger Veterans
and their loved ones typically wish to receive care near their homes, and often
prefer community based services to institutional settings. If an institutional
setting is needed, the environment of care should be age appropriate and pro­
viders should be familiar with the complexities of brain injury.
99
Traumatic Brain Injury
In order to ensure a comprehensive array of services, VA may purchase care
that cannot be provided within the VA system from community agencies. In
addition to purchased care for Veterans, VA lends family support through infor­
mation and referral services. These resources are particularly important in
rural areas or areas that are geographically distant from a VA medical center.
VA Extended Care Programs
Home Based Primary Care (HBPC). HBPC provides services for persons
with complex chronic disabling conditions. These include comprehensive, longi­
tudinal primary care by an interdisciplinary team in the homes of Veterans. The
HBPC team addresses medical, functional, social and behavioral aspects of
chronic disabling conditions. They may also facilitate structural adaptations in
the home and provide training to the Veteran and family caregivers to promote
maximal independence and maintain the Veteran in his or her home.
Purchased Skilled Home Care (PSHC). PSHC is for Veterans who are
homebound and require intermittent, short-term, or long-term skilled nursing
services, transitional rehabilitation services, or transitional social work ser­
vices. Homemaker/Home Health Aid services are provided when necessary
to assist the Veteran to live at home. Homemaker services include assistance
with daily living needs such as light housekeeping, meal preparation, launder­
ing, grocery shopping, etc. On the other hand, Home Health Aid services
typically address basic needs such as bathing, dressing, eating, toileting, and
mobility.
Respite Care. Respite care is a distinct VA program with the unique purpose
of providing temporary relief for unpaid caregivers from routine caregiving
tasks, thus supporting caregivers in maintaining the chronically ill Veteran in
the home. Respite care services may include various VA and non-VA programs
or contracts. The focus and purpose of respite care is providing relief for the
caregiver. Eligible Veterans/caregivers are entitled to 30 days of respite per
calendar year. Respite care may be provided through VA programs (e.g., Com­
munity Living Centers or VA Adult Day Health Care). VA may also purchase
respite in the community using home respite services, Homemaker/Home
Health Aid, Community Nursing Homes, or Assisted Living facilities.
Adult Day Health Care (ADHC). VA ADHC services are located near medical
centers and community based outpatient clinics. Day care services can also be
purchased from other community providers. ADHC is a therapeutically oriented
outpatient day program that provides health maintenance and rehabilitative
services to persons in a protective, congregate setting. ADHC is less than
24-hour care. Health professionals and support staff deliver individualized pro­
grams of care, with an emphasis on helping participants and their caregivers
to develop the knowledge and skills necessary to manage care requirements
in the home. The primary goal of ADHC is to maintain or improve the health
of participants so they may remain in the community, enabling families and
other caregivers to continue home care for an impaired family member. NOTE:
Traumatic Brain Injury
100
VA ADHC is typically provided to an elderly population; however some non-VA
programs may serve special populations such as TBI.
Community Residential Care (CRC). CRC is a form of enriched housing
which provides health care supervision to eligible Veterans who do not require
hospital or nursing home care, but are not able to live independently and
have no suitable family or significant others to provide the necessary level of
supervision and supportive care. Individuals qualify for CRC placement if it is
determined (through a statement of needed care) that they have significant
medical, psychiatric and/or psychosocial limitations to living independently.
Examples of CRC’s enriched housing may include, but are not limited to: Medi­
cal Foster Homes, Assisted Living Homes, Group Living Homes, Family Care
Homes, and psychiatric CRC Homes. Care must consist of room, board,
assistance with activities of daily living (ADL), and supervision, as determined,
on an individual basis. The cost of residential care is financed by the Veteran’s
own resources. Veterans may be eligible to receive enhanced VBA benefits
to assist with the cost of this level of care. Placement is made in residential
settings inspected and approved by the appropriate VA facility, but chosen by
the Veteran (VHA Handbook 1140.01, Community Residential Care Program,
March 29, 2007).
Medical Foster Home (MFH). MFH is a non-institutional long-term care
option for Veterans with chronic disabling conditions who are unable to safely
live in their own homes. A MFH caregiver is a person or family in the com­
munity who is willing to take a Veteran into their private homes and provide
personal assistance and supervision, with medical and rehabilitation support
from a specialized VA HBPC team. This is an alternative to nursing home care,
allowing the Veteran to remain safely in a home environment within his or her
community while working toward maximally independent living.
Community Living Centers (CLC). VA operates its own nursing home care
units, which have been re-designated as CLCs to emphasize the transformation
to a more home-like environment. VA also funds Veteran costs for State Vet­
erans Homes, and contracts with nursing homes in the community to provide
care for Veterans. Both VA and community nursing homes, as well as other
locations such as assisted living facilities, provide inpatient respite care (VHA
Handbook 1142.01, Criteria And Standards For VA Community Living Centers
(CLC), August 13, 2008).
Medicaid’s Home and Community-Based Services (HCBS) TBI Waiver.
The HCBS TBI Waiver program is for individuals with traumatic or acquired
brain injury having a cognitive or behavioral condition that requires specialized
TBI treatment in a nursing home or neurobehavioral facility. Twenty-five states
currently offer this program as an alternative to institutional care. Services
may vary from state to state and may range from behavioral interventions to
independent living skills training and from respite care to extended home care
services.
101
Traumatic Brain Injury
Financial Management and Life Care Planning Issues
In addition to medical care for a brain injury, Veterans and their caregivers
may need assistance with a variety of non-medical issues that can significantly
impact their ability to function in the community setting. These may include but
are not limited to:
• Guardianship
• Fiduciary
• Representative Payee
• Advanced Directives
Typically, a referral to Social Work service can initiate addressing these issues,
if needed. Brief description of each service follows.
Guardianship
If a Veteran is felt to lack the capacity and/or judgment to make decisions
regarding themselves or personal affairs, the state may assign a guardian.
The guardian can be a family member, other interested party or professional
chosen by the family or state. States differ on mechanisms of determination
and assignment. Court fees may apply.
Fiduciary
If a Veteran lacks the capacity or judgment to manage their VA monies, a fidu­
ciary may be assigned through the local VA Regional Office. The fiduciary may
be a family member or professional. The fiduciary manages only VA monies
such as compensation or pension benefits.
Representative Payee
If a Veteran lacks the capacity to manage their Social Security benefits, the
Social Security Administration (SSA) may assign someone as their representa­
tive payee. This can be a family member, other interested party or a guardian.
For further information visit the SSA website at www.ssa.gov
Additional Resources
The Brain Injury Association (BIA)
BIA partners with many federal, state, and other agencies to promote aware­
ness, education, prevention, public policy, and research related to brain injury.
BIA is an excellent resource for healthcare providers, families and survivors.
Their website (http://www.biausa.org/aboutus.htm) contains educational
materials, links to state chapters, support groups, and many other resources.
They also maintain a toll-free Family Help line (800) 444-6443.
TBI State Grant Programs
The Health Resources and Services Administration (HRSA), an agency of
the U.S. Department of Health and Human Services, is the primary Federal
agency for improving access to health care services for people who are uninTraumatic Brain Injury
102
sured, isolated or medically vulnerable. HRSA in conjunction with the Traumatic
Brain Injury Act (1996) provides grant funding to states to develop community
based programs and services for TBI survivors and families. The following web
address contains information about programs and services available by state;
http://www.nashia.org/programs/states/index.html
103
Traumatic Brain Injury
CHAPTER 11:
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Appendix A:
AMA and ANCC Continuing
Education Credits
Accreditation:
Accreditation Council for Continuing Medical Education (ACCME)
The VA Employee Education System is accredited by the Accreditation Council
for Continuing Medical Education to provide continuing medical education for
physicians.
American Nurses Credentialing Center (ANCC)
VA Employee Education System is accredited as a provider of continuing nurs­
ing education by the American Nurses Credentialing Center’s Commission on
Accreditation.
American Psychological Association (APA)
The VA Employee Education System (EES) is approved by the American Psy­
chological Association to sponsor continuing education for psychologists. The
Employee Education System maintains responsibility for this program and its
contents.
Association of Social Works Board (ASWB)
VA Employee Education System, Provider Number 1040, is approved as a
provider for continuing education by the Association of Social Works Boards
400 South Ridge Parkway, Suite B, Culpeper, VA 22701. www.aswb.
org. ASWB Approval Period: 4/7/10 – 4/7/13. Social workers should
contact their regulatory board to determine course approval. Social workers
will receive 4.0 continuing education clock hours in participating in this course.
Continuing Education Credit:
Accreditation Council for Continuing Medical Education (ACCME)
The VA Employee Education System designates this educational activity for a
maximum of 4.0 AMA PRA Category 1 Credit(s) TM. Physicians should only
claim credit commensurate with the extent of their participation in the activity.
Traumatic Brain Injury
124
American Nurses Credentialing Center (ANCC)
VA Employee Education System designates this educational activity for 4.0
contact hours in continuing nursing education.
Association of Social Work Boards (ASWB)
VA Employee Education System, Provider Number 1040, is approved as a
provider for social work continuing education by the Association of Social Work
Boards (ASWB), (1-800-225-6880) through the Approved Continuing Educa­
tion (ACE) program. VA Employee Education System maintains responsibility for
the program. Social workers will receive 4.0 continuing education clock hours
in participating in this course.
American Psychological Association (APA)
As an organization approved by the American Psychological Association, the
VA Employee Education System is sponsoring this activity for 4.0 hours of
continuing education credit. The Employee Education System maintains respon­
sibility for this program and its content.
The Employee Education System maintains responsibility for this educational
activity. A certificate of attendance will be awarded to participants and
accreditation records will be on file at the Employee Education System.
Report of Training:
It is the participant’s responsibility to ensure that this training is documented in
the appropriate location according to his/her locally prescribed process.
125
Traumatic Brain Injury
Appendix B:
Polytrauma System of Care Referral
Regions and Facility Designation
Polytrauma System of Care Referral Regions and Facility Designation
Regional
Polytrauma/TBI
Rehab Center (PRC)
Richmond
VISN
VISN 1
Polytrauma/TBI
Network Site
(PNS)
Polytrauma/TBI Support
Clinic Teams (PSCT)
Polytrauma/TBI Point of
Contact (PPOC)
Boston
West Haven
Bedford
Togus
Manchester
White River
Providence
North Hampton
VISN 2
Syracuse
Albany
Buffalo
Bath
Canandaigua
VISN 3
Bronx
Hudson Valley HCS/Montrose
Hudson Valley HCS/CastlePoint
NJHCS/East Orange
NJHCS/Lyons
NY Harbor HCS/New York
NY Harbor HCS/Brooklyn
NY Harbor HCS/St Albans
Northport VAMC
VISN 4
Philadelphia
Pittsburgh
Clarksburg
Wilmington
Erie
Lebanon
Coatesville
Altoona
Butler
Wilkes-Barre
Traumatic Brain Injury
126
Regional
Polytrauma/TBI
Rehab Center (PRC)
Richmond
VISN
VISN 5
Polytrauma/TBI
Network Site
(PNS)
Polytrauma/TBI Support
Clinic Teams (PSCT)
Washington DC
Baltimore
Polytrauma/TBI Point of
Contact (PPOC)
Martinsburg
VISN 6
Richmond
Hampton
Ashville
Salisbury
Beckley
Durham
Fayetteville
Salem
Regional Polytrauma/TBI Rehab
Center (PRC)
Tampa
VISN
Polytrauma/TBI
Network Site
(PNS)
VISN 7
Augusta
Polytrauma/TBI Support
Clinic Teams (PSCT)
Polytrauma/TBI Point of
Contact (PPOC)
Tuscaloosa
Dublin
Columbia
Tuskegee
Charleston
Atlant
Birmingham
VISN 8
Tampa
Bay Pines
San Juan
Gainesville
Orlando
Miami
West Palm
VISN 9
Lexington
Huntington
Louisville
Memphis
TVHC-Nashville
TVHC-Murfreesboro
TVHC-Mountain Home
VISN 16
Houston
Alexandria
New Orleans
Jackson
Central Arkansas-Little Rock
Gulf Coast (Biloxi)
Fayetteville AR
Oklahoma City
Muskogee
Shreveport
VISN 17
127
Dallas
Temple
Waco
San Antonio
Kerrville
Traumatic Brain Injury
Regional
Polytrauma/TBI
Rehab Center
(PRC)
Palo Alto
VISN
Polytrauma/TBI
Network Site
(PNS)
VISN 18
Southern Arizona
HCS (Tucson)
Polytrauma/TBI Support
Clinic Teams (PSCT)
Polytrauma/TBI Point of
Contact (PPOC)
New Mexico HCS-Albuquerque
Amarillo
Phoenix
West Texas HCS (Big Spring)
El Paso
Northern Arizona HCS
(Prescott)
VISN 19
Denver
Salt Lake
Cheyenne
Grand Junction
Montana HCS- Ft. Harrison
Sheridan
VISN 20
Seattle
Portland
Alaska
Boise
American Lake
Roseburg
Spokane
Walla Walla
White City
VISN 21
Palo Alto
Sacramento
Sierra Nevada HCS
San Francisco
Honolulu
Manila
Central California HCS
(Fresno)
VISN 22
West LA
Long Beach
Southern Nevada HCS
San Diego
Sepulveda
Loma Linda
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128
Regional
Polytrauma/TBI
Rehab Center
(PRC)
Minneapolis
Minneapolis
VISN
Polytrauma/TBI
Network Site
(PNS)
VISN 10 Cleveland
VISN 11 Indianapolis
VISN 12 Hines
Polytrauma/TBI Support
Clinic Teams (PSCT)
Polytrauma/TBI Point of
Contact (PPOC)
Cincinnati
Columbus
Dayton
Chillicothe
Detroit
Battle Creek
Danville (Iliana)
NICHS-Marion
Ann Arbor
Saginaw
Milwaukee
Iron Mountain
North Chicago
Tomah
Madison
Chicago HCS (Jesse Brown)
VISN 15 St. Louis
Kansas City
Poplar Bluff
Wichita
Columbia MO
Eastern Kansas/Topeka
Marion
VISN 23 Minneapolis
Sioux Falls
Fargo
Black Hills
129
Iowa City
Greater Nebraska-Grand Island
Central Iowa - Des Moines
Greater Nebraska-Lincoln
St Cloud
Omaha
Traumatic Brain Injury
Appendix C: Recovering From Mild Brain Injury: A Guide For Patients
Recovering From Mild Brain Injury: A Guide For Patients
What happens in a mild brain injury?
A mild traumatic brain injury (mild TBI) or concussion may result from a blow
or jolt to the head that briefly knocks you out (loss of consciousness) or makes
you confused or “see stars” (change in consciousness, getting your “bell rung”).
A blow to the head can occur in a motor vehicle accident, a fall, when the skull
is struck by a blunt or heavy object, in combat injuries, or in other ways. In
most cases, there are no lasting symptoms or ill effects from an injury to the
head. This is because the brain is surrounded by shock absorbing liquid and
covered by the skull. Often these are enough to protect the brain from damage.
Sometimes the force of impact is severe. Some impacts cause the skull to
break or fracture. Some impacts penetrate the brain, for example, a gun shot
to the head. Some lead to long periods of loss of consciousness or periods of
amnesia (failure to lay down new memories). These would be considered more
severe brain injuries, not a mild TBI/concussion.
When the head is hit, the brain may be shaken around inside the skull, lead­
ing to bruising of the brain. The brain may swell inside the skull. The brain is
made of many thousands of long, thin nerve fibers. Some of these nerves can
stretch or become damaged following injury. Like any other part of the body
the brain has blood vessels in it. Some of these blood vessels can tear and
bleed soon after injury. The bleeding often stops on its own and the blood ves­
sels heal as in any cuts. Bruises, swelling, snapped and stretched nerve cells,
and broken blood vessels are the causes of symptoms after a more serious
brain injury. Again, these types of injuries do not occur in mild TBI/concussion.
Your doctors have examined you for any signs of injury to the brain and pre­
scribed treatment if you need it. Initial symptoms are common after mild TBI/
concussion, but most individuals who suffer mild TBI/concussion recover com­
pletely within a few days to a couple of weeks. This guide primarily addresses
mild TBI/concussion. Research has shown that individuals with mild TBI
recover faster and more completely if they understand the usual course and
recovery of symptoms after concussion.
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130
How serious was the brain injury?
One way to tell if a brain injury is serious is the amount of time the individual
is unconscious afterwards. Another sign of more serious brain injury is if the
patient has a long period of time where he or she cannot recall things that just
happened. If you were not knocked out at all or if you were unconscious for
less than half an hour, or if the time it took for you to be able to recall ongoing
events after the injury was less than a day, then the injury was most likely mild.
Although you may have some symptoms, there was probably little injury to the
brain and complete recovery is expected. Most people who have a brain
injury fall into this category.
If you had loss of memory for more than 24 hours, or loss of consciousness
longer than half an hour, your injuries were most likely in the moderate or
severe range. Recovery may take longer. Even patients who suffered a severe
injury are likely to make a good recovery, although symptoms can last a long
time, and ability to function can be affected. Treatment at a rehabilitation hos­
pital by TBI specialists is usually recommended and can help recovery.
How long will the symptoms last?
If you had a mild TBI/concussion, you have probably gotten a lot better over
the last few days. Most patients will be back to normal by a couple of weeks.
If you still have symptoms after 6 months, these still are likely to disappear
altogether or be greatly improved by a year after the injury. Not everyone
recovers at the same rate. People who are under 40 recover faster and have
fewer symptoms as they are recovering. If you are over 40 or have had more
than one brain injury, you may take longer to recover and you may have more
symptoms at first.
Most doctors who treat mild TBI/concussion agree that recovery is faster
when the patient gets enough rest during the weeks after their injury. Work,
exercise, social activities, and family responsibilities should be started gradu­
ally, not all at once.
What symptoms can I expect?
The most common symptoms after a mild TBI/concussion are known as
postconcussive symptoms. Eight out of 10 patients with a mild brain injury
report one or more of these symptoms after their injury. These symptoms are
typical, and usually resolve within weeks after the injury. They are not signs of
permanent brain damage or medical complications. Some patients develop
symptoms a few days after their accident, but typically, symptoms begin soon
after the injury.
A list of symptoms you may have after mild TBI/concussion are shown in Table
1, along with the percent of mild TBI patients who experience each symptom
after their injury.
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Traumatic Brain Injury
Table 1: Symptoms of Postconcussive Syndrome
Symptom
Percent of Patients
Poor concentration
71%
Irritability
66%
Tired a lot more
64%
Depression
63%
Memory problems
59%
Headaches
59%
Anxiety
58%
Trouble thinking
57%
Dizziness
52%
Blurry or double vision
45%
Sensitivity to bright light
40%
What Can I Do About the Symptoms?
Postconcussive symptoms should be expected. Most patients will be back to
normal by 2-3 weeks after their injury without special treatment. Symptoms
are not a sign of relapse or permanent brain damage. Few patients will
experience all the symptoms, but even one or two of the symptoms can be
unpleasant.
Some patients find that at first, postconcussive symptoms make it hard to
work, get along with family members, or relax. The best way to deal with this
is to resume activities and responsibilities gradually, a little at a time. The time
you spend at work, getting together with friends, with your family, or exercising
is determined by what you are comfortable with. You should pace yourself
and be sure to get all the rest you need. If your symptoms get worse, or if
you notice new symptoms, this may be a sign that you are pushing yourself too
hard.
Treatments are available. If your symptoms are interfering with your usual
activities or are not improving within several weeks of your injury, consult with
your care provider. He or she may be able to provide guidance as to self care
that will get you back on the track to recovery. Or, he or she may decide that
care provided by TBI specialists is needed.
Ignoring your symptoms and trying to “tough it out” often make the symptoms
worse. Symptoms are your body’s way of giving you information. A broken bone
or a torn muscle hurts so that you won’t use it and it has time to heal. PostTraumatic Brain Injury
132
concussive symptoms are your brain’s way of telling you that you need to rest.
Most doctors who treat brain injuries agree that recovery is faster when the
patient gets enough rest and resumes responsibilities gradually.
Thinking and worrying about your symptoms can make them seem worse. It is
important to remember that the symptoms are normal after mild TBI/concus­
sion and usually go away on their own. Of course, we all have some of these
symptoms once in a while, anyway. After a concussion it can be easy to forget
that we were sometimes irritable, tired, had headaches, couldn’t concentrate,
or forgot things before the accident. Try to deal with these symptoms the
same way you did before.
Some symptoms may actually have nothing to do with your mild TBI/concus­
sion. Ordinary day to day stress can cause many of the same symptoms or
worsen symptoms typical after mild brain injury. A list of postconcussion symp­
toms is shown in Table 2, along with the percent of people who experience
each symptom even though they didn’t have a mild TBI.
Having a mild TBI/concussion adds more stress to your life, and symptoms
may result from a combination of the added stress as well as mild and
temporary disruption of normal brain functioning. The accident itself, being
hospitalized, going back to work or school after injury are all things that add
stress to most patients’ lives. Bills can pile up, time is lost from work or
school, and there may be injuries to other parts of your body. You may have
some trouble with work or school at first, and this is stressful also, even
though it is normal. Trying to do your regular work right after a brain injury is
something like trying to play baseball or swim with a pulled muscle. You can’t
see the injury, it isn’t permanent, but it takes some time to get better.
Table 2: Symptoms in people without mild TBI/Concussion
Symptom
Percent of People
Poor concentration
14%
Irritability
16%
Tired a lot more
13%
Depression
20%
Memory problems
20%
Headaches
13%
Anxiety
24%
Trouble thinking
6%
Dizziness
7%
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Traumatic Brain Injury
Symptom
Percent of People
Blurry or double vision
8%
Sensitivity to bright light
14%
Talking to your doctor about your symptoms is also important. Your doctor can
prescribe medication that can help you, if you need it. You can also talk about
your problems to the person who gave you this booklet.
More about specific symptoms
Headaches
Headaches are common after brain injury, but that does not make them less
troublesome. Headaches can be a cause of irritability and concentration prob­
lems after mild TBI/concussion. This guide cannot replace the medical advice
that you should get if you are bothered by headaches. Headaches can have
many causes, and your doctor will want to diagnose the problem and prescribe
medication that can help, if you need it.
One of the most common causes of headaches after a head injury is stress or
tension. This is usually the cause when the headaches start for the first time
a week or two after the injury. If this is the cause, these headaches may mean
you are trying to do too much. They will probably disappear if you take a break
and relax. Your work day, class schedule, or daily routine should be temporarily
shortened if you continue to have headaches.
Stress or worry cause tension headaches by increasing muscle tension in your
neck or forehead. These muscles become tense and can stay tight without you
realizing it. They can become even tighter once a headache starts, because
muscles automatically tense in reaction to pain. This muscle tension makes the
headaches worse.
Occasionally, medication may be needed to treat your headache. Take the
medicines exactly as prescribed. Avoid taking over the counter medications
frequently as this can lead to worse, more frequent headaches.
Fatigue
It is normal to be more tired after a injury. The only sensible treatment for
being tired is rest. Avoid wearing yourself out. Gradually increase your activity
level. Be patient with your recovery, and give yourself the rest that you need.
Most patients have more energy in the morning than later in the day. You may
benefit from scheduled work breaks or daytime naps. If your symptoms get
worse, this means that you are pushing yourself too hard. You may be tempted
to use energy drinks to overcome your fatigue, however, this may only worsen
your symptoms. If fatigue continues to be a problem and interferes with your
daily activities, discuss solutions with your primary care provider.
Traumatic Brain Injury
134
Poor Concentration
The main cause of poor concentration is tiredness. When it becomes difficult
to concentrate on what you are doing, take a break and relax. Between 15
to 30 minutes should be enough. If you continue to have problems, your work
day, class schedule, or daily routine should be temporarily shortened. Trying to
“stick to it” won’t help, and usually makes things worse.
Reducing distractions can help. Turn off the radio or try to work where it’s
quiet. Don’t try to do too many things at once. Watching TV while doing home­
work is an example of multi-tasking or doing more than one thing at a time. It
may be difficult to concentrate on more than one thing at first. You will be able
to concentrate better when you have had enough rest.
Irritability
A frequent cause of irritability is fatigue. People lose their tempers more easily
when they are tired or over worked. Adjust your schedule and get more rest if
you notice yourself becoming irritable.
Everyone gets angry from time to time, often with good reason. Being irritable
only becomes a problem when it interferes with your ability to get along with
people from day to day. If you find yourself getting into arguments that cause
trouble at home or at work, try to change the way you think about things.
When something makes you angry, ask yourself what caused this situation.
Family, friends, or co-workers can do things that bother us at times. Try to
think of why they did whatever it was that irritated you. What would they say
the reason was? Thinking about what caused a problem is the first step to
solving it.
Problems can usually be solved better if you stay calm and explain your point
of view. The steps you need to solve a problem will be the same when you are
calm as they would be if you were irritated. Try to remind yourself of this when
you find yourself becoming irritable. You can usually come up with several ways
to solve a problem. Try to think of at least 3 different ways, and then decide on
which is best. Just realizing that there are several things you can do to solve
a problem will make it a lot less irritating. Sometimes, you may find it best to
walk away from the situation and re-address it later, after you have had time to
cool down.
If you find that irritability continues to be more of a problem for you than before
your injury, and the steps listed above to do not help you, discuss your irritabil­
ity with your primary care provider.
Depression
People become depressed when unpleasant things happen to them, and a
brain injury is unpleasant. We feel good when good things happen to us. An
effective way to treat depression is to make sure that good things happen. One
way to do this is to plan to do something enjoyable for yourself each day. Make
135
Traumatic Brain Injury
your plan specific, and then be sure to stick to it. Decide on something you
like and exactly when you’re going to do it. That way you can look forward to it.
Anticipating and doing enjoyable things each day will improve your mood.
Thinking that things are bad or terrible can make us more depressed. Bad
situations are often not as terrible as they may seem at first. Think back to an
unpleasant moment in your own life, and you will see that this is so. Thinking
that the situation is terrible, that there is no end to it in sight, that you aren’t
able to do anything about it, and that it is your fault are all depressing things to
tell yourself. Thinking this way can become a bad habit if you do it enough.
Usually, when people tell themselves unpleasant things all the time, it is out
of habit, not because those things are really true. If you find yourself thinking
depressing thoughts, stop and replace it with a good thought. Simply stopping
a depressing thought can make you feel better. See if what you are telling
yourself is really true. Depression usually gets better over time. If depression
continues to be a problem for you, or interferes with your daily activities, dis­
cuss it with your primary care provider.
Memory Problems
Memory difficulties have several causes. Most memory problems patients
notice after a mild TBI/concussion are caused by poor concentration and
being tired. In order to remember something, you have to pay attention to it
first. If you don’t concentrate long enough, the information is not stored in your
memory. Concentration problems are a normal part of recovering from mild
TBI/concussion, and some memory trouble is a side effect of this.
You will probably be able to concentrate and remember better when you get
enough rest. Memory problems can be a sign that you are pushing yourself
too hard. Writing things down or using a pocket tape recorder, or hand held
communication devices are other excellent ways of coping with temporary
memory difficulties. These devices will help recovery.
Of course, no one has perfect memory. After a brain injury it can be easy to
forget that we sometimes had trouble remembering things even before the
accident. Some of the symptoms you notice may actually have nothing to do
with your mild TBI/concussion. A list of common memory problems reported
by people without TBI is shown in Table 3.
Traumatic Brain Injury
136
Table 3: Things We Normally Forget
Symptom
Percent of People
Forgets telephone numbers
58%
Forgets people’s names
48%
Forgets where car was parked
32%
Loses car keys
31%
Forgets groceries
28%
Forgets why they entered a room
27%
Forgets directions
24%
Forgets appointment dates
20%
Forgets store locations
20%
Loses items around the house
17%
Loses wallet or pocketbook
17%
Forgets content of daily conversations
17%
Worrying about remembering things can make your memory seem worse to
you. People with serious memory difficulties are usually not upset by these
symptoms since they don’t remember that they have memory problems.
If you are concerned about your memory, have it tested. Your doctor can send
you for these tests if you need them. You can also ask the person who gave
you this booklet, or your case manager.
Anxiety
Worry about symptoms and problems at work are the main cause of anxiety
for most patients. Anxiety should not be a problem for you if you understand
that symptoms after mild brain injury will resolve with time, if you get enough
rest, and increase your responsibilities at work gradually.
If you are anxious, chances are you are telling yourself things that are making
you that way. Usually when people worry all the time it is out of habit, and not
because the things they are telling themselves are really true. The steps you
need to solve a problem will be the same whether you are calm or anxious. If
you find yourself thinking anxious thoughts, stop. Stopping an anxious thought
can make you feel better. See if what you are telling yourself is really true. If
your anxieties cannot be reduced with these strategies, talk to your health
care provider about additional ways to reduce your anxieties.
137
Traumatic Brain Injury
Trouble Thinking
This problem is usually a side effect of other symptoms. Concentration prob­
lems, being tired, headaches, and anxiety can all make it hard to think clearly.
As with these other symptoms, trouble thinking is probably a sign that you are
doing too much too soon.
Dizziness, Visual Difficulties, and Light Sensitivity
Dizziness and visual difficulties should be checked by your doctor. These symp­
toms usually go away by themselves in several weeks in most patients. If you
find these symptoms troublesome, your doctor may prescribe exercises or
eyeglasses to help improve dizziness or vision problems. Work with your doctor
on finding treatments that work for you.
You may notice some increased sensitivity to bright light or loud noise, particu­
larly if you have headaches. Some increased sensitivity is normal after a mild
TBI/concussion. Adjusting the level of indoor lighting and wearing sunglasses
when outside may help make light sensitivity more tolerable. Paying attention
to these symptoms can make them seem worse. The less you think and worry
about your symptoms, the faster they will usually go away.
Summary
The most common symptoms after a mild brain injury are known as postcon­
cussive symptoms. These symptoms get better as part of the normal recovery
process and are not signs of permanent brain damage or medical complica­
tions. They are not cause for concern or worry.
Most patients have one or more of these symptoms, but very few will experi­
ence all of them. Symptoms are often present immediately following the injury
but sometimes develop several days after the accident, especially if the body is
over-stressed. Most patients will be back to normal in 2 - 3 weeks without any
special treatment. However, if your symptoms are interfering with your daily life
and/or are not getting better, discuss them with your health care provider. He
or she will discuss strategies and treatments that will help your recovery.
Most doctors who treat mild TBI/concussion agree that recovery is faster
when the patient gets enough rest and resumes responsibilities gradually. If
your symptoms get worse, or you notice new postconcussion symptoms, this
is probably a sign that you are under too much stress. Your work day, class
schedule, or daily routine may need to be modified in order to reduce stress,
get sufficient rest, and help your recovery.
About This Guide
This guide was adapted by The Defense and Veterans Brain Injury Center at
Wilford Hall Medical Center, Lackland AFB, Texas, from: Mittenberg, Zielinski
& Fichera, (1993). Psychotherapy in Private Practice, 12, 37-52.
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138
Appendix D:
Interdisciplinary TBI Specialists for
Possible Consultation
Interdisciplinary TBI Specialists for Possible Consultation
Physiatrist is the rehabilitation physician who treats physical, cognitive, and
behavioral sequelae of TBI and provides leadership for the interdisciplinary
rehabilitation team. The physiatrist coordinates treatment to maximize the level
of function and is responsible for medical evaluations and plans of care most
suitable for the individual and his/her family. Physiatrists are actively involved
with planning the patient’s rehabilitation program, including team meetings and
family conferences.
Neurologist assesses and treats neurological sequelae of TBI, with emphasis
on physical, such as movement disorders, seizures, and pain, as well as neu­
robehavioral sequelae, such as mood problems and memory complaints. The
primary goal of the neurological evaluation is to rule out the presence of condi­
tions requiring neurosurgical attention (hematomas, skull fractures, elevated
intracranial pressure, etc.) and to consider differential diagnosis of mild TBI
and other neurogenic disorders with similar symptoms.
Psychiatrist can prescribe pharmacological and behavioral interventions for
the treatment of psychiatric disturbances occurring as a result of brain injury.
The range of psychiatric disturbances which may follow brain injury is extensive
and embraces most of what can be found in psychiatric symptomatology.
Premorbid personality, pre-existing psychiatric disturbance and genetic predis­
position also play a part in psychiatric complications after brain injury, but the
contribution of the physical and neurochemical disruption to the brain should
not be underestimated.
Neuro-ophthalmologist may address double vision, blurry vision and/or
other visual deficits following brain injury. Deficits in the visual system are often
overlooked in the mild TBI patient. A common visual deficit found after mild TBI
is convergence insufficiency, which is often described by the person as “blurry”
vision. The neuro-ophthalmology evaluation should rule out potential eye dam­
age involving the cornea, retina, vitreous fluids, as well as occipital lobe (visual
cortex) and optic nerve functioning. Therapeutic intervention may involve prism
glasses and/or eye exercises.
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140
Audiologist evaluates hearing deficits and defines the type of hearing loss.
Hearing changes after TBI may be include tinnitus or loss of acuity especially
in noisy environments. Hearing aids may or may not be prescribed, depending
upon the nature and severity of the problem. Audiologists may also be involved
in diagnosing vestibular deficits that may lead to balance problems.
Neuropsychologist (psychologist) is the key player in diagnosing cognitive
impairments and emotional and behavioral sequelae of TBI. The neuropsycho­
logical assessment evaluates the areas of intellectual functioning: attention and
concentration; problem solving and judgment; memory and learning; flexibility
of thought and speed of information processing. Evaluations of disorders in
these areas are provided to help patients and families understand the nature
and severity of deficits and to assist other team members when planning
patient treatment programs. Treatment services provided by neuropsycholo­
gist (psychologist) are designed to help patients achieve maximum benefit from
the rehabilitation program and to help them manage adjustment related prob­
lems. Counseling may be offered to patients and family members who wish
to know more about brain injury and who may be having difficulty coping with
family and/or work related stress.
Speech and Language Pathologist will evaluate and treat communica­
tion and cognitive deficits that may impact a person’s everyday functioning.
Speech pathologists assist patients who have speech, language, and cognitive
problems to gain optimal communication skills. Communication problems may
include difficulty understanding complex and abstract written or verbal informa­
tion, difficulty finding words and expressing coherent ideas, and problems with
the use of language in interpersonal relations. Cognitive problems, such as
difficulty paying attention, learning and remembering information, organizing
ideas, reasoning, and solving problems also interfere with communication
skills. Academic skills may also be assessed to rule out potential deficits that
may have an impact upon the person’s return to community participation,
including work and school. Training using memory strategies and memory aids
may be recommended to improve daily function and community reintegration.
Physical therapist provides assessment and treatment for balance disorders,
dizziness, functional mobility, physical problems, and pain. Physical therapists
can evaluate and address peripheral nerve and musculo-skeletal injuries
related to brain trauma, along with balance issues that may be centrally
caused. Treatment goals include improving mobility, increasing strength,
decreasing joint stiffness, improving static and dynamic balance, decreasing
vertigo and dizziness, and managing pain and discomfort. The physical thera­
pist also evaluates a patient’s needs for equipment, such as, canes or braces
to improve safety and endurance of ambulation.
Kinesiotherapist can recommend a cardiovascular conditioning program that
promotes wellness and reduces the risk of injury or further disability. Fitness
can have a positive impact upon the person’s mental and physical stamina,
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Traumatic Brain Injury
reduce pain, and elevate his/her feeling of well-being. The physical conditioning
program should be initiated in the health care facility and gradually transferred
to a community gym as the person becomes more independent.
Occupational therapist is the function expert who works with the braininjured person to improve everyday function in daily routines. A thorough
occupational therapy evaluation can provide a window into the ways that TBI
impacts an individual’s daily life. The occupational therapist will assess the
patient’s skills, which include visual, cognitive and perceptual abilities to per­
form tasks in complex and multi-stimuli environments. Treatment goal is to
enable patients to best manage their daily tasks, including self-care (feeding
and dressing) and managing tasks in the community (shopping, driving, school
and work activities). To be able to do these tasks, patients may need to use
special techniques, modify their physical environment or use equipment rang­
ing from simple memory aids to more advanced technology such as computers
and environmental controls.
Recreation Therapist assists persons with brain injury to resume community
life by helping them participate in play and leisure activities, which enrich life.
Through leisure counseling, leisure education, leisure skills development,
aquatic education, adaptive sports, resocialization programs and community
readjustment outings, the person with brain injury learns how to participate in
community life.
Social Worker (counselor) helps patients and their families respond to social,
emotional or financial problems resulting from physical disability or chronic
illness. Treatment modalities include individual and group psychotherapy, crisis
intervention, family counseling and family support groups. The social worker
explores community resources and entitlement programs that are available to
the patient and family.
Vocational Rehabilitation Counselor may act as a treatment coordinator
for patients who are having difficulty returning to work after a brain injury.
This specialist may be asked to provide assistance in returning to work, col­
laborating with employer, patient and co-workers to build a successful working
relationship.
Case Manager provides effective coordination of patient care and appropriate
utilization of resources. Whenever possible, one may consider bringing in a
case manager who specializes in brain injury, to assist in coordinating medical
care and keeping open lines of communication between the various specialists
and the patient and family. The case manager is an advocate for, and an active
participant in, the treatment process.
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142
Appendix E:
Pharmacotheray and Associated
Treatments for Physical/Somatic
Symptoms following TBI
Table 1. Pharmacotheray and Associated Treatments for Physical/Somatic Symptoms following
TBI (Adapted from the VA/DoD Mild TBI Clinical Practice Guidelines)
Common Symptoms
post-concussion/mild TBI
Pharmacologic Treatment
Non-Pharmacologic
Treatment
Referral after failed re­
sponse to initial treatment
Headaches
• Non narcotic pain meds
• NSAIDs
• Triptans (migraine type)
• Sleep hygiene education
• Physical therapy
• Relaxation
• Neurology
• Pain clinic
Feeling dizzy
• Antibiotics, deconges­
tants for infections and
fluid
Loss of balance Poor
coordination
Nausea
• Antiemetics
• Dizzy: ENT/Neurology
after ENT interventions
• Physical therapy
• Balance: PT, PM&R
• Coordination: PT, Neu­
rology
• Sleep hygiene education
• GI
Change in appetite
Sleep disturbances
• Consider Mental Health
• Sleep Meds
• Sleep hygiene education
• Mental health
• PM&R
• Neurology
• Sleep hygiene education
• Light desensitization
• Sunglasses
• Optometry
• Ophthalmology**
• Difficulty falling or stay­
ing a sleep (insomnia)
Vision problems
• Blurring
• Trouble seeing
• Sensitivity to light
Hearing difficulty
• Audiology
• ENT
• Sensitivity to noise
** Depends upon the local resources, impaired vision may be referred in some facilities to neuro-ophthalmologists.
Note that such may be due to problems with oculomotility as well as due to disorders of the retina and visual path­
ways.
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144
Table 2. Pharmacotherapy in Concussion/mTBI – List of Selected First Line Agents
Potential side effects
Contraindications/
Comments
Common issues in
concussion/mTBI
Non-benzodiazepine Sleep Agents
First line agent: Zolpidem 5 mg
at night, if poor results after 3
nights of therapy increase to 10
mg nightly
Prazosin initiate therapy with 1
mg at bedtime for three days.
May increase to 2 mg at bedtime
through day 7. If patients con­
tinued to have nightmares, the
dosage may be increased to 4
mg at bedtime through day 14.
The dosage could be increased to
6 mg at bedtime through day 21
and to 10 mg at bedtime through
day 28.The maximum daily dose
is 10 mg at bedtime.
• Orthostatic hypotension
For patients with
nightmares and/or
violent or outburst or
agitation during sleep
• GI upset
• Dizziness
• Vertigo
• Potential renal
NSAIDS for headache
ibuprofen 400-600 mg TID-QID
Naproxen 500 mg BID
145
impairment with
long term use
• Rebound headache
may occur with
continuous use
Traumatic Brain Injury
Potential side effects
Contraindications/
Comments
Common issues in
concussion/mTBI
Abortive agents for mirgraine/migraine-like headaches
Zolmitriptan oral 5-10 mg at
onset of headache, may repeat
once if headache is not resolved
in 2 hours
• unusual taste (nasal
Zolmitriptan nasal one spray of
5 mg for the treatment of acute
migraine. If the headache returns
the dose may be repeated after
2 hours. The maximum daily dose
should not exceed 10 mg in any
24-hour period
• Dizziness, vertigo,
Serious cardiac
events, including
myocardial infarc­
tion, have occurred
following the use
of zolmitriptan and
sumatriptan tablets
and nasal spray. These
events are extremely
rare and most have
been reported in pati­
ents with risk factors
predictive of CAD
formulation), paresthe­
sia, hyperesthesia,
dizziness, chest tight­
ness
tingling, hypertension,
injection site reactions
Sumatriptan oral 50-100 mg at
onset of headache, may repeat
once if headache is not resolved
in 2 hours
Sumatriptan nasal 10 mg spray
in one nostril, may repeat in 2 hrs
not to exceed 40 mg/day
Sumatriptan injectable 6 mg
injected subcutaneously may
repeat in 1 hour. Not to exceed
12 mg/day
Prophylactic headache agents
First line agents:
Divalproex sodium extended
release 250 mg twice daily,
increase by 250 mg/day every
week to a maximum of 1000
mg/day
Topiramate 25-100 mg twice
daily
• Asthenia, dizziness,
somnolence, tremor,
nausea, diplopia
Hepatic failure result­
ing in fatalities has
occurred in patients
receiving valproic acid
and its derivatives
• May take up to 3
•
• Anorexia, sedation,
ataxia, dizziness
months to receive
the full benefit from
any of the prophylac­
tic medications
Association with
teratogenecity,
neural tube effects.
Caution in women
of childbearing
potential
• May worsen cogni­
tive dysfunction
• May cause renal
stones
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146
Potential side effects
Contraindications/
Comments
Common issues in
concussion/mTBI
• Somnolence
• Cold extremities
• bradycardia
There are two for
mulations- tartrate is
immediate release,
dosed 2 times daily
and succinate is sus­
tained release, dosed
one time daily.
• Use with caution
Meclizine 12.5-50 mg every 4-6
hours
• Hallucinations, blurred
Scopolamine 0.5 mg patch every
3 days
• Dry mouth
• Topical Allergy
• Tachyarrhythmia
All of the agents may
cause sedation and
require caution when
driving or operating
machinery
Dimenhydrinate 50 mg every
4-6 hours orally
• Dry mouth
Lorazepam 0.5 mg twice a day
orally
• Drug dependence
• Respiratory depressant
Metoprolol initiate with 25 mg
twice daily, increase dose up to
100 mg twice daily if needed,
wait 3-4 weeks between dose
increases
in asthmatic and
diabetic patients
Vestibular Suppressants
vision
• Avoid use of benzo­
diazapines in mTBI if
at all possible
Clonazepam 0.25 -0.5 mg twice
a day orally
Diazepam 2-10 mg orally, IM,
or IV
(Adapted from the VA/DoD Mild TBI Clinical Practice Guidelines)
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Traumatic Brain Injury
Appendix F:
Pharmacotherapy in Concussion/mTB
– List of Selected First line Agents
Pharmacotherapy in Concussion/mTBI – List of Selected First line Agents
Potential side effects
Contraindications/
Common issues in
concussion/mTBI
Comments
Stimulants (In specialty care after ruling out sleep disorder.)
First line agents:
Methylphenidate 5 mg q (every)
8 am and 1 pm, increasing total
daily dose by 5 mg every 2 weeks
to a maximum of 20 mg twice
daily
• Insomnia
• Decreased appetite
• GI upset
• Headaches
• Dizziness
• Motor tics
• Irritability
• Anxiousness
• Tearfulness
Modafanil start with 100 mg q
am (morning). Increase in 100
mg amounts, using split daily
dosing up to maximum of 400
mg/day
• Headache, asthesia
Amantadine 100-400 mg daily
• Nausea
• Dizziness
• Dry mouth
Ongoing substance
abuse.
• Possible addiction
potential
• Requires additional
prescription regula­
tion under federal/
state law.
• Cannot be refilled,
only one month of
therapy at a time
may be written for
Antidepressants
First line agents:
Citalopram 10 mg QD (daily) for
1 week, then 20 mg QD if toler
ated (up to 80 mg QD if needed)
Sertraline 25 mg QD increasing
weekly in 25 mg increments to
maximum dose of 200 mg/day
• Nausea
• Insomnia
• Agitation
• Asthesia
• Nausea
• Insomnia
• Dry mouth
• Headache
Do not initiate con­
comitant therapy with
a benzodiazepine
May cause sexual
dysfunction
(Adapted from the VA/DoD Mild TBI Clinical Practice Guidelines)
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148
Appendix G: Driving Issues after TBI
Learning Objectives
• Describe the effects of physical, cognitive, and neurobehavioral TBI
sequelae on driving abilities.
• State how medications can affect driving abilities.
• Describe the components of a pre-driving assessment.
Introduction
Driving is an essential activity of daily living for many individuals and is one
determinant of level of independence. Individuals lacking this mobility have
decreased opportunity to receive healthcare and reduced ability to participate
in educational, vocational, recreational, social, cultural, and community events.
Driving is a key component of self-sufficiency in American culture. Further­
more, loss of driving skills is also a major obstacle to continued rehabilitation
(Lew et al., 2009).
Driving requires a complex set of skills and abilities including mobility, vision,
and visual-motor coordination, as well as multiple cognitive and neurobehavioral
abilities and functions. It is well known that individuals with traumatic brain
injury (TBI) have varying degrees of physical impairments, cognitive dysfunction,
and neurobehavioral problems that can impede the integrated operation of
neuropsychological and physical capacities necessary for safe driving. However,
disabled Veterans, including those undergoing rehabilitation, are entitled by
Public Law 93-538 to have the opportunity to pursue a return to driving.
An unprecedented number of Operation Enduring Freedom/ Operation Iraqi
Freedom (OEF/OIF) Veterans are seeking DOD and VA medical and rehabilita­
tive care for TBI suffered during wartime (Lew et al., 2007), and many will
attempt to resume driving. In fact, it has been estimated that 38% to 78% of
individuals with TBI seek and obtain driving privileges after their injury (Katz,
1990; Oliver, 1996; Priddy, 1990). A history of TBI does not always necessi­
tate a permanent loss of driving privileges. One study suggests that individuals
with TBI who successfully pass a driving evaluation and complete a comprehen­
sive driving program are able to reintegrate into the driving community with
minimal difficulty (Schultheis, 2002). Importantly, it is the physician’s responsiTraumatic Brain Injury
150
bility to determine when and how to return the individual to driving.
Unfortunately, guidelines to determine fitness to drive in patients with TBI have
not yet been established, leaving physicians with the difficult task of deciding
how to measure driving safety. Even in the more studied area of driving and
aging/dementia, a survey of Canadian primary care physicians found that 55%
of physicians felt unqualified to determine driving safety and 88% felt that they
would benefit from additional training in this area (Jang et al., 2006). In terms
of TBI, it is clear that developing a plan for training and treatment requires
understanding of the impact of the individual’s physical, cognitive, and neurobe­
havioral factors on driving.
Effects of Physical Impairments
Deficits in basic visual skills are common following TBI and can directly impact
driving capabilities. For instance, in a sample of 50 OIF/OEF Veterans with a
history of TBI approximately 24% had visual field deficits, 20% had pursuit/
saccade impairments, 22% accommodation dysfunction, and 30% conver­
gence dysfunction (Goodrich et al., 2007). Overall, approximately 25% of TBI
participants had visual impairments that could negatively affect driving safety.
Underscoring the importance of visual acuity and visual field integrity for driv­
ing, the American Medical Association’s (AMA) recommended Assessment of
Driving Related Skills (ADReS) identified acuity and visual field integrity as the
two primary areas for visual screening in older adults (Wang, 2003). There­
fore, visual screening prior to TBI patients’ return to driving is necessary and
should include a visual acuity test and visual field evaluation.
Another important visual skill for driving is contrast sensitivity (CS), which is
defined as the difference in luminance needed to detect a target from its back­
ground. Many driving situations involve low contrast conditions such as fog,
rain, and dusk/nighttime driving. CS has been found to be a strong predictor
of driving skills in several neurological conditions (for a review, see Uc & Rizzo,
2008). Although CS has not been well examined in patients with TBI, these
patients are at risk for CS deficits, which can result from injury at many differ­
ent points along the retinocalcarine pathway. Measurement of CS should also
be considered as an adjunct to standard visual acuity and visual field evaluation
prior to TBI patients return to driving.
Following TBI, some individuals are also known to have auditory and/or vestibu­
lar dysfunction, causing hearing impairment and/or vertigo/dizziness, which
may also interfere with driving performance. For example, Lew and colleagues
(2007) report that 44% of OIF/OEF Veterans with non-blast related TBI and
62% of OIF Veterans with blast-related TBI had hearing impairments primarily
of the sensorineural type. Refer to Chapter 5 for more detail about visual and
vestibular dysfunction.
Motor disturbances, such as paresis of the limbs, neuropathy, spasticity, and
ataxia can obviously interfere with the visual-motor coordination and motor
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Traumatic Brain Injury
skills requisite for driving. It is thus essential to evaluate motor strength, range
of motion, sensation, and proprioception prior to a driving evaluation. For
interested readers, the ADReS describes how to measure the motor functions
necessary for driving in the primary care setting. It should be noted that the
guidelines for interpreting impairment may not be applicable for younger TBI
patients.
Primary care physicians may wish to consult ophthalmology, audiology, otolar­
yngologists, or physical medicine and rehabilitation to assist with evaluation
of these physical dysfunctions. For a more detailed description of physical
changes following TBI, refer to Chapter 5.
Effects of Cognitive Impairments
Because driving places high demands on the brain’s ability to rapidly integrate
a number of cognitive functions simultaneously with incoming sensory infor­
mation, possession of driving knowledge and driving skills are insufficient to
guarantee safe driving performance. Cognitive impairments commonly seen
after TBI can influence driving performance in several ways.
Arousal and Attention
Following TBI, individuals often suffer from impairments in arousal, sustained
and divided attention, as well as slowed information processing speed, all of
which can impair driving abilities.
Executive Abilities
Changes in executive abilities as a result of TBI were presented in Chapter
6. Dysfunction in mental flexibility, sequencing ability, monitoring and alloca
tion of cognitive resources, and problem solving can impede the individual’s
driving performance. These dysfunctions may be expressed as difficulties in
navigation planning, the ability to handle unexpected road conditions, the ability
to consider multiple decision alternatives and their consequences, the ability
to suppress distracting non-driving related stimuli, and the ability to perform
multiple simultaneous tasks.
Visuospatial Perception and Skilled Motor Abilities
The ability to see accurately, to judge depths and speed, and to perceive
changes in the environment are important for safe driving. Impairments in
visuospatial perception, visual scanning ability, perception of focus, spatial rela­
tions, color perception, and perceiving figure-ground relationships can obviously
interfere with driving performance and safety.
In sum, cognitive abilities such as attention, executive function, and visual
spatial ability are essential for driving safety, but more research is necessary
to demonstrate their relative contribution to safe driving, specifically in patients
with TBI. Emphasizing the importance of these cognitive skills, studies involv­
ing patients with other neurological conditions (such as Alzheimer’s disease
and Parkinson’s disease) have found that executive functions and visual spatial
Traumatic Brain Injury
152
abilities are the best predictors of driving safety (for reviews see Amick et al.,
2007; Uc & Rizzo, 2008). Therefore, as part of assessing and developing a
remediation plan for driving safety, primary care providers may want to refer
their patients with suspected or known cognitive impairments for more thor­
ough neuropsychological assessment.
Effects of Neurobehavioral Dysfunction
Neurobehavioral changes frequently include impulsivity, aggression, lack of
insight, and substance abuse as detailed in Chapter 7. These behaviors can
lead to risky driving behaviors, which may endanger the safety of the driver,
passengers, pedestrians, and other vehicles and property.
Other Factors Affecting Driving Capabilities
Seizures
A seizure occurring during driving can impose a great threat to public safety.
Some investigators have shown a 40% increased risk in serious injuries due
to automobile accidents in patients with seizure disorder (Taylor, 1996). How­
ever, there is no common nation-wide law that restricts driving for patients
with epilepsy. Most states require people with epilepsy to be seizure-free for a
certain period, ranging from 3 to 12 months. Other states have more flexible
restrictions, basing the required seizure-free period on clinical factors (Krauss,
2001). Thus, it is the responsibility of the physician to help determine when
their patients may drive, the intent being to protect the public and patient
safety optimally while permitting patients with controlled seizures to drive.
Medications
Psychotropic medications, commonly prescribed for individuals who have
sustained a TBI, include benzodiazepines, neuroleptics, narcotics, hypnotic
sedatives and barbiturates, and antidepressant medications such as SSRIs
and tricyclics (see Chapters 5, 6, and 7 for more details on pharmacologi­
cal treatments). Psychotropic medications can influence driving capabilities
by affecting visual abilities; causing fatigue, drowsiness, and slowed reaction
time; and decreasing attention and multitasking abilities (Hopewell, 2002).
Other agents, frequently prescribed in the TBI population to treat general medi­
cal problems, may also affect the above driving abilities (e.g. beta-blockers,
anti-convulsants, sedating antihistamines, etc.) or interact with the primarily
“psychotropic” medications. As always, physicians should be aware of potential
interactions and the effects of multiple prescribed medications and monitor or
assess side effects.
Pre-Driving Assessment
There is no universally accepted standardized driving evaluation for individuals
who have sustained a TBI. Current pre-driving assessment methods typically
include neuropsychological evaluation, behind-the-wheel evaluations, reaction
time measures, and assessment of visual abilities including acuity, night vision,
and depth perception (Schultheis, 2000). The Department of Veteran’s Affairs
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Traumatic Brain Injury
offers a Driver Rehabilitation for Veterans with Disabilities Program, which
provides both assessment and rehabilitation of driving skills. See final page of
this Appendix for a list of VA Driver Rehabilitation Programs and the website
listed in the references (VA, 2010). To determine driving safety and inform
remediation, the program recommends review of: physical health (medica­
tions, fatigue), driving history, driver’s license status, motor functioning (range
of motion, strength, balance, coordination, and spasticity), and perception and
sensation screening (vision, hearing, and proprioception).
For a physician not geographically near or able to refer to a VA Drivers
Rehabilitation Center, the AMA has published a guide for physicians to assess
and counsel older drivers (AMA, 2003), some of which may be applicable
to assessing patients with TBI. The recommended office-based assessment
battery (ADReS) includes methods for measurement of vision, cognition, and
motor functioning. Unfortunately, the ADReS has not been uniformly accepted
due to limited measurement validation (Molnar et al., 2006). Although, the
older driver literature indicates a lack of consensus for how to determine
driving safety, existing guidelines suggest that driving safety should not be
determined by performance on a single measure, but rather based on the con­
sideration of many patient characteristics. Importantly, compared to physical
examinations or neuropsychological tests, a road test conducted by a profes­
sional driving instructor or other certified occupational therapist is considered
the gold standard for determining driving safety.
Computer-based driving simulators are emerging as a valid alternative to road
testing. Performance on simulated driving courses has been found to be corre­
lated with actual road test assessment and driving simulators can discriminate
safe and unsafe drivers across a range of physical/cognitive disorders (for a
review, see Lew et al., 2009). Most importantly, simulator performance has
been found to have predictive utility for determining long-term driving outcome.
A recent pilot study reported that pass/failure on the driving simulator cor­
rectly classified 82% of moderate to severe TBI drivers’ performance when
assessed ten months later, via standardized observer-rating by a passenger
(Lew, et al., 2005).
A significant strength of driving simulator assessment is that it offers a safe
means of replicating actual driving conditions including hazardous situations
(emergency vehicles, surprise pedestrians) and poor weather and lighting
conditions (rain, glare) that would be difficult, if not unethical, to test with
a live road test. Furthermore, the computer-administered assessment can
precisely and simultaneously measure multiple aspects of driving performance
(speed, positioning, and obeying rules of the road), which cannot be as care­
fully monitored during most road tests (for a review, see Lew et al., 2009).
Unlike traditional paper and pencil cognitive assessments, simulators can also
evaluate the dynamic cognitive abilities necessary for safe driving such as spa­
tial orientation updating, sustained and divided attention, planning, and route
learning, which are often impaired following TBI (Bieliauskas, 2005). Driving
Traumatic Brain Injury
154
simulators are now widely being used and it is expected that research will soon
be available to verify driving simulator’s reliability and validity in predicting driv­
ing capabilities.
Driver Rehabilitation Programs
Changes in sensory, motor, or cognitive functioning do not always mean that
the TBI patients should cease driving. Evaluation and training can help many
TBI patients return to safe driving. A driver rehabilitation program for individu­
als who have cognitive and/or physical deficits secondary to brain injury should
include a pre-driving assessment, a behind-the-wheel assessment, education,
and training. These components are necessary to ensure that they are safe
to operate a motor vehicle on public roads. This multi-faceted rehabilitation
approach is initiated by referral from a physician, who has determined that the
patient is medically stable and able to receive this comprehensive evaluation.
The Driver Rehabilitation for Veterans with Disabilities Program provides four
phases of in-car instruction. The first phase focuses on helping the Veteran
develop skills to transfer in and out of the car, adapting the car for the Vet­
eran’s physical limitations, and practicing basic rules of the road/driving skills.
Phases two through four involves supervised driving in increasingly more com­
plex settings (e.g., residential neighborhood, downtown area, and freeway).
Completion of the in-car training is recognized by a certificate. Other services
offered include assistance with appropriate vehicle selection and documenta­
tion of the assessment and training program in the patient’s medical chart
(VA, 2010).
Simulators are also being used as training devices that allow patients to
rehearse driving skills in challenging situations such as merging with heavy
traffic, negotiating left hand turns, poor weather conditions, and unexpected
events (such as being cut off) without the potential risk to safety. It has
also been proposed that practice with the driving simulator may “treat” the
cognitive deficits that frequently accompany TBI. That is, repeated practiced
driving could potentially improve sustained attention, planning, route learning,
and affect regulation as these cognitive skills are engaged during safe driv­
ing (Lew et al., 2009). Another potential benefit of simulator training is the
opportunity for immediate review of critical driving mistakes through the replay
feature (Stern & Schold, 2006). Anasognosia (lack of awareness of deficits)
is frequent following TBI, and can be a significant impediment to rehabilitation.
Immediate confrontation with actual driving mistakes may increase selfawareness and improve compliance with driving safety recommendations (for a
review, see Lew et al, 2009).
Though simulator training has been found to improve rate of return to driving
in stroke patients (Akinwuntan et al., 2005), driving intervention research
has yet to be conducted in patients with TBI. Kua and colleagues (2007)
performed a systematic review of the older driver rehabilitation literature and
found that only eight studies demonstrated sufficient internal validity to be
155
Traumatic Brain Injury
included in the review. Limited benefits of physical (range of motion exercises
or at home physical therapy exercises) and vision interventions (speed of
information processing training or visual perception exercises) were reported.
Driver education programs were associated with increased driving avoidance
and greater self-regulatory behaviors but not reduced crash risk.
Until these programs are empirically validated it is difficult to judge the rela­
tive benefit of the intervention as well as which elements of the treatment are
associated with the best remediation of driving skills. The limited research on
rehabilitation programs, however should not dissuade clinicians from recom­
mending these services as clinical experience has shown these programs can
be helpful to individual drivers.
VA Driver Rehabilitation Centers
1. VA Upstate New York, Albany, NY
2. VA New Mexico HCS, Albuquerque, NM
3. VA Medical Center Ann Arbor, MI
4. VA Medical Center Atl., GA (Decatur)
5. VA Medical Center Augusta, GA
6. VA Gulf Coast HCS, Biloxi, MS
7. VA Medical Center Bronx, NY
8. VA Hudson Valley, Castle Point, NY
9. VA Medical Center Cleveland, OH
10. VA Medical Center Columbia, SC
11. VA North Texas HCS, Dallas, TX
12. 12. VA Medical Center Denver, CO
13. VA New Jersey HCS, East Orange, NJ
14. VA Baltimore HCS, MD
15. VA Medical Center Hampton, VA
16. VA Medical Center Hines, IL
17. VA Medical Center Houston, TX
18. VA Medical Center Indianapolis, IN
19. VA Central Iowa, Knoxville, IA
20. VA Medical Center Long Beach, CA
21. VA Medical Center Butler, PA
22. VA Medical Center Little Rock, AR
23. VA Medical Center Philadelphia, PA
24. VA Medical Center Syracuse, NY
25. VA Medical Center Washington, DC
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
VA Medical Center Memphis, TN
VA Medical Center Miami, FL
VA Medical Center Milwaukee, WI
VA Medical Center Minneapolis, MN
VA Medical Center Palo Alto, CA
VA Medical Center Phoenix, AZ
VA Medical Center Portland, OR
VA Medical Center Richmond, VA
VA Medical Center Salisbury, NC
VA Medical Center Salt Lake City, UT
VA South Texas HCS, San Antonio, TX
VA Medical Center San Juan, PR
VA Puget Sound HCS, Seattle, WA
VA Greater L.A. HCS, Sepulveda, CA
VA Medical Center St. Louis, MO
VA Medical Center Tampa, FL
VA Medical Center Topeka, KS
VA Boston HCS, Brockton, MA
VA Medical Center
West Palm Beach, FL
45. VA Medical Center Lexington, KY
46. VA Medical Center Oklahoma City, OK
47. VA Medical Center Sheridan, WY
48. VA Medical Center Tucson, AZ
VHA Handbook 1173.16: Driver Rehabilitation for Veterans with Disabilities Program
Procedures: http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2148
Traumatic Brain Injury
156
APPENDIX H: Disclosure[s]
The VA Employee Education System (EES) must insure balance, independence,
objectivity, and scientific rigor in all its individually sponsored or jointly EES
sponsored educational activities. All prospective faculty & planning committee
members participating in an EES activity must disclose any relevant financial
interest or other relationship with: (a) the manufacturer(s) of any commercial
product(s) and/or provider(s) of commercial services discussed in an educa­
tional presentation, and (b) any commercial supporters of the activity. Relevant
financial interest or other relationship includes but is not limited to such things
as personal receipt of grants or research support, employee or consultant
status, stock holder, member of speakers’ bureau, within the prior 12 months.
EES is responsible for collecting such information from prospective planners
and faculty, evaluating the disclosed information to determine if a conflict of
interest is present and, if a conflict of interest is present, to resolve such
conflict. Information regarding such disclosures and the resolution of the con­
flicts for planners and faculty shall be provided to activity participants. When
an unlabeled use of a commercial product or an investigational use not yet
approved by the FDA for any purpose is discussed during an educational activ­
ity, EES shall require the speaker to disclose that the product is not labeled for
the use under discussion or that the product is still investigational.
Each faculty and planning committee member (author, facilitator, moderator)
reported having no relevant* financial relationships with any commercial inter­
est. This activity includes no discussion of uses of FDA regulated drugs or
medical devices which are experimental or off-label.
*The ACCME defines “relevant financial relationships” as financial relationships in any
amount occurring within the past 12 months that create a conflict of interest.
American with Disability Act Policy
The Employee Education system wishes to ensure no individual with a disability
is excluded, denied service , segregates, or otherwise treated with a differ­
ently from other individuals participating in this independent study because of
the absence of auxiliary aids and services. If you request any special arrange­
ments to fully participate in this independent study, please contact Constance
L. Singleton, MHR, Program Manager, at 205-731-1812 extension 317, or
email [email protected]
Traumatic Brain Injury
158
CME Test
01. Severity of TBI means:
a.Severity of injury at the time of injury
b.Severity of outcomes and symptoms after injury
c.A combination of (a) and (b)
d.A Glasgow Coma score of 6 or less
02. Which of the following is Not a defining characteristic of mild TBI?
a.Some alteration in mental state at the time of the accident
b.Glasgow Coma Scale score of 13-15
c.Indication that a physically traumatic event occurred
d.Positive CT or MRI findings
03. The single most common cause of civilian TBI is:
a.Falls
b.Firearms
c.Motor vehicle accidents
d.Sports injuries
04. One of the most commonly used scale to quantify initial severity of
brain injury is the:
a. American Academy of Neurology guidelines for grading level of
concussion
b.Glasgow Coma Scale (GCS)
c.Post-concussion Symptom Checklist
d.Rancho Los Amigos Scales of Functioning
05. TBI occurs most frequently among:
a.Babies/toddlers, teenagers, and the elderly
b.Men in their 40s and 50s
c.Middle aged women who are stressed from multiple roles and have
higher than average rates of motor vehicle accidents
d.Women of all ages compared to men
Traumatic Brain Injury
160
06. Which if the following is not a component of the VA’s Polytrauma/TBI
system of care?
a.Polytrauma Rehabilitation Centers (PRCs)
b.Polytrauma Support Clinical Teams (PSCTs)
c.Polytrauma Mental Health Centers (PMHCs)
d.Polytrauma Network Sites (PNSs)
07. Which of the following statements is false?
a.The VA has a program to screen all patients for possible TBI
b. The VA has a program to screen for possible TBI only for OEF/OEF
Veterans presenting for medical care
c. Polytrauma Network Sites (PNSs) should complete a comprehensive
TBI evaluation following a positive TBI Clinical Reminder (i.e., following
a positive TBI screen)
d. Polytrauma Network Sites (PNS) have an interdisciplinary team of TBI
providers
08. The CPRS note entitled “TBI/Polytrauma Individualized Rehabilitation
Plan of Care” should contain:
a.Contact information for the TBI patient’s parents
b.The patient’s responses to the TBI Clinical Reminder
c.Contact information for a patient’s TBI physician and case manager
d.The number of the VHA Directive mandating this care plan
09. Initial medical assessment in the post-acute of chronic phase of TBI
should include all of the following except:
a.A CT or MRI scan of the head
b. An assessment of what education the patient has received about TBI
and recovery
c. An understanding of the patient’s beliefs about brain injury and their
beliefs about their long-term prognosis
d. Whether or not the patient has pending litigation related to TBI Trau­
matic Brain Injury
10. Which of the following is Not a common medical symptom or problem
in the individual with an acute mild TBI?
a.Dizziness and balance problems
b.Headache is the most common pain complaint
c.Post-injury fatigue, which can have several contributing factors, includ­
ing depression and environmental demands
d.Spasticity usually emerges in the acute phase of mild TBI
161
Traumatic Brain Injury
11. Most individuals with a moderate to severe traumatic brain injury
require a period of inpatient rehabilitation. Which of the following is
true regarding this rehabilitation:
a. These services are best provided in an established interdisciplinary
program
b. To be eligible for admission to most inpatient brain injury program, the
individual should be medically stable and able to participate in rehabili­
tation therapies
c.There should be a reasonable expectation for functional improvement
d.All of the above are true
12. Which of the following is Not True about post-TBI Spasticity?
a.Spasticity can lead to pain syndromes and skin breakdown
b. Spasticity is best treated on an outpatient basis through primary care
clinics
c. Spasticity must be distinguished from other causes of resistance to
passive movement including anxiety, joint pain, heterotopic ossification,
and contractures
d. Whenever spasticity develops, a stretching, positioning, and range-of
motion program should be instituted
13. Which of the following is Not True about hydrocephalus following mod­
erate to severe TBI:
a. The usual cause of post-TBI hydrocephalus is disruption of the absorp­
tive capability of the arachnoid villae
b. Post-TBI hydrocephalus is characterized by the classic clinical signs
(imbalance, incontinence, and dementia)
c.True post-TBI hydrocephalus must be distinguished from hydrocepha­
lus ex vacuo
d.All of the above are true
14. Which of the following is Not a general rule of thumb when prescribing
medical treatments following TBI?
a. The relationship between initial injury severity and current symptom
presentation should guide the general approach A CT or MRI scan of
the head
b. One should investigate prior treatments to avoid repeating ineffective
strategies
c.Start fresh with treatment approaches from a new perspective unbi­
ased by what has happened before
d. If the patient does not responded to initial interventions, a referral to
an experienced TBI- physiatrist should be considered
Traumatic Brain Injury
162
15. Which of the following is Not True regarding post-traumatic head­
aches (PTHA)?
a. Post-Traumatic Headaches (PTHA) can be present in a large percent­
age of patients following TBI and can be very challenging to manage
b. Psychological interventions such as “habit reversal” involving detection,
interruption, and reversal of maladaptive habits are not effective in
headache treatment
c. Botulinum toxin may be effective for both PTHA tension and migraine
headaches if other treatment approaches have not been successful
d. Post-Traumatic Headaches (PTHA) can be of the tension or migraine
headache type
16. Which of the following is Not True about regarding sleep disturbance
following TBI?
a. Sleep disturbance rarely occurs following TBI
b. If sleep problems are present they can result in fatigue and increased
levels of irritability
c. Treatment for sleep problems should begin with removal when feasible
of all medications with stimulant properties, both prescription and non­
prescription
d. Both sleep agents and antidepressants may be effective in treating
insomnia
17. All of the following statements are false except:
a. Visual impairments and dysfunctions rarely go undetected following
brain
injury because they are obvious to both patients and family members
b. Although problems with visual field cuts and accommodative dysfunc­
tion may occur following TBI, binocular dysfunction is extremely rare
c. Oculomotor dysfunction following TBI can result in difficulty with fixa­
tion, saccades and pursuits, and consequent functional problems with
scanning, tracking, and nystagmus
d. Visual impairment rarely have a negatively impact a person’s mobility
or ability to engage in education, employment, and activities of daily
living
18. Which of the following is the least common cognitive problem following
moderate to severe TBI?
a. Attention and concentration problems
b. New learning and memory problems
c. Problems with visuospatial abilities such as drawing
d. Problems with executive functioning such as self-control and problem-solving
163
Traumatic Brain Injury
19. Which of the following statements is false?
a. Cognitive effects similar to those of TBI may occur as a result of other
organic and mental health conditions
b. Neuropsychological evaluations definitively determine whether or not a
brain injury occurred
c. Neuropsychological evaluations assess current cognitive and psycho­
logical functioning
d. Emotional responses (e.g., irritability or emotional reactivity) can
amplify the functional limitations of cognitive impairments
20. Which of the following statements is false regarding effective interven­
tions for cognitive deficits?
a. Cognitive enhancing medication should be tried only after medical and
behavioral factors have been mitigated (e.g., poor sleep hygiene or the
adverse side effects of other centrally-acting medications)
b. Strategy training for severe memory problems is a practice standard
after brain injury
c. Direct attention training in conjunction with metacognitive training (i.e.,
feedback, self-monitoring, and strategy training) is a practice guideline
for attention problems after TBI
d. Problem-solving strategy training is helpful for the treatment of
executive dysfunctions such as problems with problem-solving and selfmonitoring
21. Which of the following statements is false?
a. In the days and weeks following TBI, many aspects of cognition
improve, some quite rapidly
b. Cognitive symptoms of mild TBI typically resolve within a few weeks
after the injury
c. Preliminary evidence from the research literature indicates that the
cognitive effects of blast-related TBI are substantially different from
those from non-blast TBI, such as motor vehicle accidents
d. A sizable proportion of individuals who sustain a severe TBI have dif­
ficulty returning to work or independent living because of persistent
cognitive problems
22. Which of the following statements is false?
a. Damage to the frontal lobes is common in serious motor vehicle
accidents and can cause specific behavioral problems or changes in
personality
b. Behavioral and emotional problems may be long-lasting and take a
tremendous toll on the family
c. The relationship between original severity of injury and long-term out­
comes is not one-to-one
d. Following a brain injury, pre-injury personality characteristics no longer
play a significant role because of the TBI behavioral changes
Traumatic Brain Injury
164
23. Which of the following psychological issues is less likely in a combatrelated TBI compared to a civilian-related TBI?
a. PTSD
b. Depression
c. Anxiety
d. Actually all of these conditions are more likely in combat-related TBI
24. Which of the following statements is Not an important general prin­
ciple in the management of psychological and behavioral sequelae
following TBI?
a. Patient and caregiver education and support is not important
b. Interdisciplinary approach is very useful due to the complexities in this
patient population
c. Psychotherapy/behavioral management play important roles in treat­
ment
d. Appropriate pharmacotherapy may provide significant benefits
25. Which of the following in Not an important principle for prescribing
medications for individuals with TBI?
a. Make only one medication change at a time
b. Allow adequate time for one drug to clear out of the person’s system
before changing to another medication
c. Be aware of confounding comorbidities (e.g. substance abuse, PTSD)
d. Medication compliance is not an important factor to consider in nonresponders
26. All of the following are True except:
a. Falls are the leading cause of TBI in the elderly
b. Men generally account for a higher percentage of TBI than women,
except in individuals over the age of 65
c. A TBI secondary to being struck as a pedestrian is more common in
the elderly than in younger adults
d. Motor vehicle accidents continue to account for a high proportion of
TBIs in the elderly
27. In terms of prognosis or outcomes, all the following are True for the
elderly except:
a. The probability of poor outcome increases with advanced age
b. The elderly have a more fragile physiologic status which can result in a
more destructive injury
c. The elderly have slower recovery rates and longer lengths of stay than
younger adults
d. The majority of elderly TBI survivors undergoing rehabilitation do not
achieve functional improvements
165
Traumatic Brain Injury
28. Which of the following statement is not True:
a. Older adults experience more frequent and more severe cognitive im­
pairment when compared to younger adults with similar severity of TBI
b. Older individuals with TBI have slower rates of drug metabolism and
excretion, which creates a greater propensity for cognitive side effects
from medications
c. Acetaminophen is the preferred medication for pain syndromes in the
elderly with TBI
d.All of the above statements are true
29. Compared to younger adults, the following statements are true for
elderly individual with TBI the except:
a.The elderly have a higher risk for DVT
b.The elderly have a higher risk for urinary retention and incontinence
c.Special mobility considerations in the older adult with TBI include alter­
ations in vision, decreased peripheral sensation, imbalance, decreased
strength, and limited physical endurance
d.All of the above statements are true
30. All of the following are True except:
a. Psychological distress is common in family members of individuals with
TBI
b. Family adjustment to living with a loved who had a TBI is usually back
to normal after a few months
c. Family adjustment to TBI can be described as a series of nonlinear,
overlapping stages
d. Each stage is defined by a series of typical emotional reactions by fam­
ily members
31. All of the following are questions that may be useful in evaluating how
well a family is coping and meeting the needs of the individual with TBI,
except:
a. Are you and your family able to manage all of the needs of loved one
with TBI?
b.Do you have needs or concerns for which you need help or guidance?”
c.Do you have friends or a support system for yourself when you feel
overwhelmed?
d.All of these are useful questions to assess family coping.
32. Which of the following is Not a useful step/intervention to use with
family members of individuals with TBI?
a.Validate and normalize the family’s concerns and their reactions
b.Educate the family about TBI and the recovery process
c. Collaborate with and Refer when necessary to TBI specialists and
other providers within the VA system of care
d. Instruct the family that there is always one best way to handle every
situation
Traumatic Brain Injury
166
33. Which of the following is Not an example of community reintegration:
a. Resumption of parental role
b. Receiving physical therapy
c. Volunteering at the animal shelter
d. Taking classes at the local community college
34. The following types of interventions may be considered to support
community integration of individuals with TBI:
a. Vocational rehabilitation
b. a, c, and d
c. Driving rehabilitation
d. Cognitive rehabilitation
35. All
a.
b.
c.
d.
167
the following are True about extended care except:
Environment of care should be age appropriate
Extended care is always provided in institutionalized settings
VA may purchase community extended care service
Community Living Centers emphasize care in a home-type environment
Traumatic Brain Injury
Long Description Figure 3: Hypothetical recovery paths of cognitive functioning
This graph shows typical recovery of cognitive function following mild, moderate, and
severe TBI. Those who have sustained a mild TBI typically return to baseline within 3
months while those with more severe injuries show gradual recovery but no return to
baseline. As shown, recovery is the rule rather than the exception and extent of
recovery depends on injury severity. However, it is important to note that recovery is
highly individualized and depends on many other factors.
Long Description Polytrauma/TBI System of Care (PSC) Components
A generic organizational chart depicting the Polytrauma/TBI System of Care Components, the chart
reads as follows:
1)
2)
3)
4)
One Polytrauma Rehabilitation Center block centered as the top tier.
Three Polytrauma Network Site blocks branch off the Polytrauma Rehabilitation Center block.
Two Polytrauma Support Clinic blocks branch off the third Polytrauma Network Site to the right.
Two Polytrauma Point of Contact blocks branch from the Polytrauma Support Clinic on the right.

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