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Traumatic Brain Injury: An Overview DRAFT


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Title: Traumatic Brain Injury: An Overview DRAFT

Traumatic Brain InjuryAn OverviewDRAFT
  • Anastasia B. Edmonston MS CRC
  • MD TBI Projects Director
  • MD Mental Hygiene Administration
  • The Mental Health Management Agency of Frederick
    County, Inc. the Howard County Mental Health

Training Agenda
  • The incidence and prevalence of TBI
  • What is brain injury?
  • What are the types of brain injury?
  • Common cognitive, behavioral and physical sequela
    of TBI

Training Agenda
  • Why screening for a history of TBI is important
    in the human service setting
  • Ideal rehabilitation pathways for mild, moderate
    and severe TBI
  • The TBI, mental health and substance abuse
  • What are the state and national resources
    available to individuals with TBI, their families
    and professionals

Definitions How brain injury may be defined in
the Medical Record
Traumatic Brain Injury is an insult to the brain
caused by an external physical force Acquired
Brain Injury is an insult to the brain that has
occurred after birth, for example TBI, stroke,
near suffocation, infections in the brain, anoxia
Incidence of TBI CDC 2004
  • In the United States, at least
  • 1.6 million sustain a TBI each year

Incidence of TBI CDC 2004Of those 1.6 million..
  • 51,000 die
  • 290,000 are hospitalized and
  • 1,224,000 million are treated an released from an
    emergency department

Annual Incidence of TBI with DisabilityAN
ESTIMATED 124,000 American civilians
  • Cited by Jean Langlois ScD,MPH NASHIA Conference
  • Preliminary findings as analyzed by Selassie, et.

Traumatic Brain Injury and Returning Vets
  • According to a Army mental health report in
    February, 11 of 2,195 soldiers surveyed in Iraq
    and Afghanistan showed signs of mild BI, but
    fewer then half were identified and evaluated in
    the field. USA Today March 17, 2008 Greg Zoroya
  • As of 11.07 VA officials reported that of 61,285
    veterans screened since April 14, 2007 19
    screened positive Honolulu Star-Bulletin Nov. 4,
  • Pentagon reported as of September 20, 2007, 4,471
    of 30,327 wounded troops sustained brain
  • A September 2007 article in USA Today by Gregg
    Zoroya looked at data from a variety of military
    sources put the number as at least 5 times that
    much. (20,000)

TBI- Signature Wound of War USA TODAY 9.07
  • Blast, and multiple blast exposures
  • Wave of compressed air traveling thru the brain
  • Injury to brain cells/cell death
  • Road side bombs cause 80 of all wounds

Mild Traumatic Brain Injury in U.S. Soldiers
Returning from IraqHoge, McGurk, Thomas,
NEJM Volume 358453-463 January 31, 2008
  • 1 in 6 returning troops have had at least one
  • 4.9 reported injuries with LOC of those, 43.9
    met criteria for PTSD (3xs the rate found in
    those with other injuries)
  • 10.3 reported altered mental status, of those,
    27.3 met criteria for PTSD
  • TBI with LOC also associated with major depression

Causes of TBI CDC 2006
Who is at the Highest Risk of TBI? 2005
  • Males 1.5 times as likely as females to sustain a
  • Two age groups most at risk are 0-4 year olds and
    15-19 year olds
  • The elderly, 75 and older from falls
  • African Americans have the highest death rate
    from TBI

Incidence of TBI Maryland 2000 CDC Surveillance
  • 5,229 Marylanders sustained a moderate to severe
  • 13 people a day
  • 5 of all hospitalizations TBI related

The Scope of the Problem
  • Distribution of Severity
  • Mild injuries 80(LOC lt 30 min, PTA ,1 hour)
  • Moderate 10 - 13(LOC 30 min-24 hours, PTA
    1-24 hours)
  • Severe 7 - 10(LOC gt24 hours, PTA gt24 hours)

The Importance of Post Traumatic Amnesia
  • PTA is the period of time after injury when a
    person is unable to lay down new memoriesfor

That first morning, wow, I didnt want to move,
I was thankful that nothings broken, but my
brain was all scrambled Ryan Church, NYT 3/10/08
  • All he remembers from the collision with
    Anderson is the aftermath, being helped off the
    field by two people, although he said he did not
    know who they were until he saw a photograph
    later Ben Shpigel NYT reporter

2000 Epidemiological Study of Mild TBI J. Silver
of NYU, cited in WSJ by Thomas Burton 1.29.08
  • 5,000 interviewed
  • 7.2 recalled a blow to the head
    w/unconsciousness or period of confusion
  • Follow up testing found 2x rate of depression,
    drug and alcohol abuse
  • Elevated rates of panic and and
    obsessive-compulsive DO

MHAs TBI Resource Coordination Project
  • Three resource coordinators served 147 consumers
    in 6 counties 7/03-8/07
  • More men than women (60)
  • Average time since injury for consumers served is
    12 years
  • Unemployment among consumers range at any given
    time between 67-87. The majority of those
    employed are working part-time

Co-occurring Conditions among Consumers Served
  • Drug and Alcohol use and abuse 28.5
  • Mental Health 27
  • Homelessness/danger of homelessness 20

Simplified Brain Behavior Relationships BIAA 2000
BI 101
Frontal Lobe Initiation Problem solving
Judgment Inhibition of behavior
Planning/anticipation Self-monitoring Motor
planning Personality/emotions Awareness of
abilities/limitations Organization
Attention/concentration Mental flexibility
Speaking (expressive language)
Parietal Lobe Sense of touch
Differentiation size, shape, color Spatial
perception Visual perception
Occipital Lobe Vision
Cerebellum Balance Coordination Skilled
motor activity
Temporal Lobe Memory Hearing Understanding
language (receptive language) Organization
and sequencing
Brain Stem Breathing Heart rate
Arousal/consciousness Sleep/wake functions
What happens in a TBI?
  • Mechanism Acceleration/Deceleration
  • Differential movement of partially tethered brain
    within the skull
  • Results in
  • Bruising of the brain surface
  • against rough areas of the skull
  • Stretching and twisting of nerve axons

Primary Injuries
Coup-Contra Coup
BIAA 2000
Primary Injuries
Diffuse Axonal Injuries
Rotational forces on the brain cause the
stretching, snapping and shearing of axons
BIAA 2000
Primary Injuries
Epidural Hematoma
Hematoma or Blood Clot forms on top of the dura
BIAA 2000
Primary Injuries
Subdural Hematoma
Hematoma or blood clot forms under the dura
BIAA 2000
Secondary Injuries
Intracerebral Hemorrhage
Hydrocephalus (enlarged ventricles
Edema (swollen brain tissue)
BIAA 2000
Possible Changes-Physical
  • Motor skills/Balance
  • Hearing
  • Vision
  • Spasticity/Tremors
  • Speech
  • Fatigue/Weakness
  • Seizures
  • Taste/Smell

Possible Changes-Thinking
  • Memory
  • Attention
  • Concentration
  • Processing
  • Aphasia/receptive and expressive language
  • Executive skills
  • Problem solving
  • Organization
  • Self-Perception
  • Perception
  • Inflexibility
  • Persistence

Possible Changes-Personality and Behavioral
  • Depression
  • Social skills problems
  • Mood swings
  • Problems with emotional control
  • Inappropriate behavior
  • Inability to inhibit remarks
  • Inability to recognize social cues

Personality and Behavioral cont..
  • Problems with initiation
  • Reduced self-esteem
  • Difficulty relating to others
  • Difficulty maintaining relationships
  • Difficulty forming new relationships
  • Stress/anxiety/frustration and reduced
    frustration tolerance

Lack of Awareness
  • A common and difficult to remediate hallmark of a
    brain injury

Sequelae of TBI
  • What often underlies the challenges in return to
    work, school and major role are problems in
  • cognition (including memory and judgement)
  • impulse control
  • modulation of affect
  • regulation of mood. These areas are often
    referred to as the neurobehavioral cluster.

The Relationship Between Brain Injury and Mental
  • Depression is the most common Axis I psychiatric
    disorder after TBI followed by alcohol abuse,
    panic disorder, specific phobia and psychotic
    disorders (Gordon et. al 2004)
  • Major depressive episodes occur in 20-30 of TBI
    patients in the first year. Depressive symptoms
    occur even more commonly.

Other Mental Health Disorders Related to TBI
  • Anxiety, seems to go hand in hand with
    depression. Those with depression or anxiety
    perceive their injury and cognitive impairment as
    more severe then nondepressed individuals with
    TBI (Fann 1995)
  • Oquendo and colleagues (2004) found that males
    with mild TBI with a hx of substance abuse
    coupled problems of aggression and hostility were
    more likely to attempt suicide then non injured

Other Mental Health Disorders Related to TBI
  • PTSD is noted in some individuals following TBI
    even if there is no memory of the incidence
    (Klein, Caspi 2003)
  • Rapid cycling bipolar is rare but noted in the
    literature for individuals with temporal lobe
    damage (Murai, Fujimoto 2003)
  • Psychotic syndromes occur more frequently in
    individuals who have had a TBI than in the
    general population (McAllister, Ferrell 2002)

TBI Suicide
  • The risk of attempted or completed suicide in
    neurological illness is strongly related to
    depression, feelings of hopelessness or
    helplessness, and social isolation (Arciniegas
    Anderson, 2002)
  • Simpson and Tate (2002) screened 172 individuals
    for suicidal ideation and hopelessness. Findings
    using the Beck Suicide Ideation and Hopelessness
    Scales found 35felt hopeless and 23expressed
    suicide ideation. 18 had attempted suicide post

Alcohol Use TBI-IncidenceAnalysis of the
Literature (Corrigan 1995)
  • Alcohol, the drug of choice-Corrigan and his
    colleagues report that for 70 of the
    individuals they work with who use substances,
    alcohol is the preferred substance
  • Intoxication at time of injury-7 studies looked
    at incidence of intoxication (BAL equal or
    exceeding 100mg.dL)at time of injury.
    Intoxication ranged from 36 to 50
  • History of Substance Abuse-Findings suggest that
    for adolescents and adults in rehabilitation
    following a TBI, as much as 60 of this
    population have histories of alcohol use or

Why Screen?What other TBI Screening efforts have
Findings from the LiteratureCriminal Justice
  • Researchers at Indiana State University found
    that 83 of felons studied reported a head injury
    that predated their first encounter with the law
  • Adults who had frontal lobe damage prior to age 8
    exhibited recurrent impulsive and aggressive
  • 14 of the subjects in the Vietnam Head Injury
    Project with frontal lobe lesions engaged in
    fights or damaged property compared to 4 of
    controls without TBI

Domestic Violence TBI Findings
  • Batterers fared worse on three neuropsychological
    indicators of cognitive functioning then a
    nonbatterer control group (Cohen et. Al 1999)
  • Corrigan, (2003) found that of 167
    individuals treated for domestic violence related
    health issues, 30 experienced a loss of
    consciousness on at least one occasion, 67
    reported residual problems that were potentially
    TBI related
  • Valera and Berenbaum, (2003) assessed 99 battered
    women. Of these, 57 had brain injured related

TBI Among Individuals with Persistent Mental
  • Kathleen Torsney (2004) found in one mental
    health treatment setting 13 of individuals
    served had a history of TBI
  • These same individuals had been treated in
    various mental health settings but not received
    specific brain injury treatment

Homelessness Brain InjuryA little studied
population, however..
  • A University of Miami study found that 80 of 60
    homeless individuals had high incidence of
    neuropsychological impairment
  • Researchers in Milwaukee found possible cognitive
    impairment in 80 of 90 homeless men evaluated.
  • Dr. LaVecchia of the MA Statewide Head Injury
    Program reported in 2006 that of 140 homeless
    individuals evaluated, 83.6 of males and 16.4
    of females had an acquired brain injury
  • Other studies in the UK and Australia show
    similar rates of brain injury among homeless

In Maryland- Screening Results from the MD TBI
Post Demo II Project-2005
  • Summary of TBI Incidence Among all Screened at 7
    public mental health agencies in Frederick and
    Anne Arundel counties
  • N190
  • 39 no reported history of TBI (78)
  • 58.94 of individuals with a history of TBI
  • 35.78 of individuals with a history of a single
    incidence of TBI (68)
  • 23 of individuals with a history of 2 or more
    TBIs (44)

TBI Screening, Adapted From
  • Ohio Valley Center for Brain Injury Prevention
    and Rehabilitation
  • John Corrigan Ph.D

Have you ever been injured following a blow to
the head?
  • As a child?
  • Playing sports?
  • From a fall?

Have you ever been hospitalized or treated in an
emergency room following an injury?
  • Treated and released?
  • Evaluated by a neurologist?
  • Had a CAT scan, MRI or EEG done while in the
    emergency room?

Have you ever been unconscious following an
accident or injury?
  • Have no memory for the event?
  • Felt dazed or confused?
  • Experienced a head ache, fatigue, dizziness, or
    changes in vision?

Have you ever been injured in a fight?
  • Taken a direct blow to the head
  • Experienced a violent shaking of the head and

Have you ever been injured by a spouse or family
  • Pushed
  • Punched
  • Shaken
  • Choked

Have you ever had any major surgeries?
  • Heart Bypass
  • Transplant
  • Brain surgery to treat a tumor, aneurysm, stroke

  • Toxic Shock Syndrome
  • Meningitis
  • Encephalitis
  • Hydrocephalous
  • Seizure disorder
  • Lead poisoning

Additional comments and observations of the
  • Any visible scars?
  • Walks with a limp?
  • Uses a cane or walker?
  • Has a foot brace?
  • Limited use of one hand?
  • Appears to have difficulty focusing vision?
  • Difficulty answering questions?
  • Answers are unorganized and/or rambling
  • Becomes easily distracted, agitated or is
    emotionally labile

What you are looking for..And Why
  • Any reported or suspected functional difficulties
    that are interfering with home, work or community
  • With the identification a history of brain
    injury, professionals can better support the
    individuals served and make informed referrals to
    brain injury specialists when appropriate

Clues to the Presence of Brain Injury in the
Medical Record/History
Has there been a Mild TBI?
  • Look for history of ER visits after MVAs or
    fights/sports/ accidents
  • Was the individual treated and released for a
  • Does the individual suffer from whiplash or
    complain of chronic pain?

Ideal Rehabilitation Pathway for Mild TBI
  • Diagnosed after injury and provided with
    education and follow-up
  • If they are of the approximately 10 of mild TBI
    sufferers who continue to experience difficulty
    functioning, is there evidence of any
    rehabilitation treatment, neurological/neuropsychi
    atric/neuropsychol-ogical treatment or

Common and Less than Ideal Pathway-Mild TBI
  • Discharged and released from ER or not even seen
    in ER
  • Memory, emotional lability, visual, vertigo,
    headaches and or fatigue symptoms do not resolve
    after the first few weeks following injury
  • If subsequently seen by GP or in the ER often
    told to justtake it easy

Common and Less than Ideal Pathway-Mild TBI,
  • Cant function at work or home
  • Spiral into depression and anxiety
  • Family, friends and co-workers loose patience
  • If seen by a GP or neurologist may be viewed as
    having a psychosomatic reaction or be labeled a
    malinger-inappropriately medicated

Common and Less than Ideal Pathway-Mild TBI,
  • Job loss
  • Mental Health Problems
  • Relationships and supports erode
  • At risk for Substance Abuse
  • At risk for entry into the criminal justice

Ideal Medical/Rehabilitation Pathway-Moderate to
Severe TBI
  • Acute care delivered at a trauma center (Shock
    Trauma, Johns Hopkins)
  • Inpatient rehabilitation at a CARF accredited
    brain injury rehabilitation hospital(Sinai,
    Kernan, Maryland General)
  • Outpatient rehabilitation at a CARF accredited
    brain injury rehabilitation center offering a
    community re-entry program and individual
    therapies (Sinai, Kernan, Humanim, Total Rehab
    Care, Sky Neurorehabilitation)

Moderate to Severe TBI Pathway cont.....
  • Referral to a state vocational services
    counselor with a TBI caseload
  • Vocational services as appropriate can include
    vocational evaluation, work adjustment training,
    vocational training, job placement and job
  • Support services in the community-case management
    and individual/family therapy

Common and Less than Ideal Pathway-Mod to Severe
  • Scenario I
  • Discharged from Trauma or Acute due to good
    physical recovery
  • Referrals not made for continuing rehabilitation
    (cognitive therapy)
  • Impulse control, memory problems affect home,
    community, work and school
  • Family is strained
  • At risk for mental health problems, substance
    abuse, criminal behavior, entry into a state

Common and Less than Ideal Pathway-Mod to Severe
  • Scenario II
  • Injured as a child
  • Go through ideal pathway thru outpatient
  • Return to school, behind peers
  • Struggle academically
  • Act out behaviorally, if the injury several
    grades back, not recognized as TBI related

Common and Less than Ideal Pathway-Mod to Severe
  • Scenario II continued
  • Trouble making the transition to post graduation
    roles and responsibilities
  • Get in with the wrong crowd
  • At risk for mental health issues, substance
    abuse, criminal activity, burn out families and

There are limits to what can be changed-Staff can
accommodate the injury related behaviors by
modifying the individuals environment, and their
own interpersonal interactions with the individual
  • Biological Limits to Behavioral Recovery
  • Farrell Hooper (1995)

Strategies for Remediation and Compensation
  • Use of a journal/calendar
  • Create a daily schedule
  • To do lists and shopping lists
  • Labeling items
  • Learning to break tasks into small manageable
  • Use of a tape recorder

Strategies cont..
  • Encourage use of rest and low activity periods
  • Work on accepting feedback or coaching from
  • Work on generalizing strategies to new situations
  • Use of a high lighter
  • Alarm watch

Strategies cont..
  • Review schedule each day
  • Post signs on the wall etc.
  • Try to routinize the day as much as possible

Teach a variety of strategies for individuals to
incorporate into their daily routines
  • Safety checklist (e.g. for use of
    stove)reinforces attention
  • Checklists- things to do before leaving the
    house (turn off all the appliances?, lock all
    the doors?, did I take my morning medications?
    turn down the heat/turn off the air conditioner?,
    do I have money or keys?, where am I going?, how
    will I get there? What time should I leave?
    Etc.) Very good for routine tasks, reinforces
  • Place visual cues in the environment (cupboard
    labels, written directions, calendars, list of
    emergency phone numbers) reinforces memory

Even for individuals with poor new learning
capacity, the three Rs ReviewRehearseRepeat
Can lead to mastery of tasks as they eventually
enter into memory
Resource Coordination Services in Maryland
  • Charlotte Wisner, Resource Coordinator for
    Frederick Washington Counties, call
  • Lauren Dorsey, Resource Coordinator for Baltimore
    Howard Counties, call 301-529-1508
  • Catherine Reinhart Mello, Resource Coordinator
    for Montgomery County, call 301-586-0900
  • Any questions regarding resource coordinator or
    free training on brain injury related topics,
    call Anastasia Edmonston, Project Director

  • Brain Injury Association of America 703-236-6000,
  • Brain Injury Association of Maryland
  • Ohio Valley Center For Brain Injury Prevention
    and Rehabilitation, 614-293-3802,
  • Good resource for memory
    aides and tips

  • Http//
    The Job Accomodation Network offers useful
    articles about working with individuals with
    brain injury on the job, and simple
    accommodations that can be used to maximize
    success on the job
  • Http// National Resource
    Center for Traumatic Brain Injury, developed by
    the Medical College of Virginia and Virginia
    Commonwealth University. Offers useful articles
    that are very user friendly, and a catalogue of
    nicely priced resources for working with people
    with brain injury

  • The University of Alabama Traumatic Brain Injury
    Model System has created the UAB Home Stimulation
    Program. This program offers many activities for
    use by individuals with brain injuries, their
    families and the professionals who work with
    them. The activities are designed to help
    support cognitive skills and can be done in the
    home setting. The Home Stimulation Program can
    be accessed from the Internet at
    htt// For
    further information contact Research Services,
    Dept. of Physical Medicine and Rehabilitation,
    University of Alabama at Birmingham, 619 19th St.
    S SRC 529, Birmingham, AL 35249-7330/

Resources staff training.
  • As of April 2004, the Defense and Veterans Brain
    Injury Center at Walter Reed Army Medical Center
    is offering an online learning course on
    traumatic brain injury through the Veterans
    Health Initiative. For more information
  • http// -
    this is a site that can be used in staff
    training. It is a simulation of the effects of
    cognitive disabilities. You will be asked to
    complete simple tasks, but other tasks will get
    in the way.
  • http//
    - links to many online articles, written not for
    professionals in the field, but for people
    learning about brain injury. The y cover all
    types of topics, from substance abuse and brain
    injury to cognition and brain injury. Written by
    various experts in the brain injury field.
  • Certified Brain Injury Specialist (CBIS) Training
    offered through the American Academy for the
    Certification of Brain Injury Specialists,

Acknowlegements...This presentation is a product
of the Maryland TBI Post Demonstration Project
II, a collaboration of the MD Mental Hygiene
Administration the Mental Health Management
Agency of Frederick CountySupport is provided
in part by project H21MC06759 from the Maternal
and Child Health Bureau (Title V, Social Security
Act), Health Resources and Services
Administration, Department of Health and Human
ServicesSpecial thanks to New Hampshires
Project Response and the participating
consultants of the Maryland TBI Post
Demonstration II Project
Anastasia Edmonston MS CRCaedmonston_at_dhmh.stat
  • Stefani ODea MS
  • 410-402-8476
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