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The Rural Veterans Health Access Project presents Dr. Amy Murphy Certified Brain Injury Specialist

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Traumatic Brain Injuries are a risk for Veterans who are the primary focus of the RVHAP and rural ... Diagnosis and Treatment of Brain Injurywith a focus on Mild TBI. – PowerPoint PPT presentation

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Title: The Rural Veterans Health Access Project presents Dr. Amy Murphy Certified Brain Injury Specialist


1
The Rural Veterans Health Access Project presents
Dr. Amy Murphy Certified Brain Injury Specialist
  • Assessment, Diagnosis and Treatment of Brain
    Injury with a focus on Mild TBI

2
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3
RVHAP Sponsored TBI Webinar
  • Traumatic Brain Injuries are a risk for Veterans
    who are the primary focus of the RVHAP and rural
    veterans have less access to services
  • Alaska has a higher rate of TBI than the national
    average among the general community which is the
    secondary focus for the RVHAPs telehealth
    services

4
  • Training medical and behavioral practitioners in
    the diagnosis, assessment and treatment of TBI
    enhances the health care provided for Alaskans
    with TBI, in particular rural residents.

5
Polling Question
  • Do you (or your organization) serve Veterans?

6
For more information on the Rural Veterans Health
Access Program contact the Program
Director Susan Maley, MPH, Ph.D.
susan.maley_at_alaska.gov, 907-269-2084 http//dhss.a
laska.gov/dph/HealthPlanning/Pages/veterans/defaul
t.aspx Funding provided by the Health Resources
and Services Administrations Office of Rural
Health Policy Office for the Advancement of
Telehealth Grant number H3GRH26369
7
Assessment, Diagnosis and Treatment of Brain
Injury with a focus on Mild TBI
  • Amy L. Murphy, DO
  • Brain Injury Medicine Specialist
  • Providence Medical Group Brain Injury Services
  • Providence Alaska Medical Center

8
Objectives
  • Assessment
  • Common issues
  • Treatment
  • Referrals
  • Discuss case

9
Assessment
  • Misdiagnosed, misunderstood, mismanaged
  • Lack of education, increased psychosocial
    stressors
  • Screening tools
  • OSU screening tool
  • Rivermead
  • Sports versus non-sports concussion
  • Return to play versus return to school/work

10
Assessment
  • Complete history- especially risk factors,
    previous treatments
  • Full exam- focused neurologic and musculoskeletal
    assessment, eye movements
  • Gait evaluation
  • Balance evaluation (BESS)
  • Overview of laboratory studies, prior radiologic
    studies, any other notes

11
Common Issues
  • Headache
  • 1 complaint
  • Post-traumatic headache
  • Treat as primary headache dx
  • No great studies for PTH subtypes

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16
Common Issues
  • Fatigue/Sleep

17
Common Issues
  • Cognition

18
Treatment
  • Fatigue and Cognition
  • Medication list should be completed prior to
    initiating pharmacologic therapy, also any drug
    or alcohol use
  • Stopping sedating meds may remove the need for
    medication, significantly decrease dose
  • Weaning benzodiazepines or alcohol, slowly
  • Work in combination with therapies- SLP,
    neuropsychology, psychology
  • Check for mood!

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20
Treatment- Sleep
  • Non-pharmacologic management should be used as
    much as possible after a brain injury.
  • Environment- adequate exposure to sunlight,
    reduced noise and distractions at night.
  • Cognitive behavioral-cognitive therapies- later
    in course
  • Ensure that activating medications are reduced or
    given early
  • If environmental and behavioral interventions are
    maximized and need for pharmacologic intervention
    is necessary, melatonin supplementation/agonists
    or trazodone should be considered for first line
    management to avoid cognitive sequelae

21
Common Issues
  • Mood
  • PTSD
  • Depression
  • Anxiety
  • Mania
  • Frustration
  • Anger
  • Overwhelmed

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24
Treatment
  • Mood
  • Therapy, neurofeedback, sleep, pain
  • Adjunct if medications are needed
  • Benzodiazepines- decreased functional recovery in
    animals and extends post-traumatic amnesia
  • Maximize treatment with multi-use medicines
  • Potential side effects should be considered
    carefully
  • Assess any recreational drug use and refer
    accordingly for services
  • Drug use, alcohol, supplements- many can
    interfere with medications- get an adequate
    history

25
Common Issues
  • Musculoskeletal/Cervicogenic

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27
Treatment
  • Musculoskeletal/Cervicogenic
  • Assess for injuries, imaging as needed
  • Referrals
  • Orthopedics, Pain management
  • PT, OT
  • Naturopath, Osteopath, Acupuncturist
  • Non-pharmaceutical management
  • Trigger point management
  • Nerve blocks
  • Appropriate stretching and exercise

28
Common Issues
  • Vestibular/Ocular

29
Treatment
  • Vestibular/Ocular
  • Referrals
  • Optometry- specializing in vision rehab
  • PT- specializing in vestibular therapy
  • Medications
  • Meclizine- hallucinations, blurred vision,
    drowsiness
  • Scopolamine- dizziness, dry mouth/eyes,
    restlessness
  • Dimehydrinate- dizziness, drowsiness, dry mouth

30
Treatment planning
  • Further work-up
  • Imaging
  • Laboratory Studies
  • Referrals
  • PT, OT, SLP
  • Optometry
  • Behavioral health- counseling, neurofeedback
  • Other medical specialty- pain, sleep, primary
    care, orthopedics

31
Summary
  • Education and Prevention are KEY!
  • Working as an interdisciplinary team-
    communication!
  • Initially schedule close follow-up care
  • Return to play
  • Return to school
  • Return to work
  • Work on most debilitating symptoms first-
    headache, sleep, mood

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33
References
  • Watanabe, T.K. et al. Systematic Review of
    Interventions for Post-traumatic Headache. PM R.
    4, 129-140. (2012).
  • Hou, L. et al. Risk Factors Associated with Sleep
    Disturbance following Traumatic Brain Injury
    Clinical Findings and Questionnaire Based Study.
    PLoS One. 8(10), e76087. (2013)
  • Thiagarajan, P Ciuffreda, K. Effect of
    oculomotor rehabilitation on vergence
    responsivity in mild traumatic brain injury.
    JRRD. 50(9), 1223-1240. (2013)
  • Giacino J, Whyte J, Bagiella E et al.
    Placebo-Controlled Trial of Amantadine for Severe
    Traumatic Brain Injury. N Eng J Med. 366(9),
    819-826 (2012).
  • Jha A, Weintraub A, Allshouse A et al. A
    Randomized Trial of Modafinil for the Treatment
    of Fatigue and Excessive Daytime Sleepiness in
    Individuals with Chronic Traumatic Brain Injury.
    J Head Trauma Rehabil. 23(1), 52-63 (2008).
  • Ponsford J, Ziino C, Parcell D et al. Fatigue and
    Sleep Disturbance Following Traumatic Brain
    Injury- Their Nature, Causes and Potential
    Treatments. J Head Trauma Rehabil. 27(3), 224-233
    (2012).
  • Shekleton JA, Parcell DL, Redman JR et al. Sleep
    disturbance and melatonin levels following
    traumatic brain injury. Neurology. 74, 1732-1738
    (2010).
  • Larson E, Zollman F. The Effect of Sleep
    Medications on Cognitive Recovery From Traumatic
    Brain Injury. J Head Trauma Rehabil. 25(1), 61-67
    (2010).

34
References
  • Perna R. Brain Injury Benzodiazepines,
    Antipsychotics, and Functional Recovery. J Head
    Trauma Rehabil. 21(1), 82-84 (2006).
  • Mysiw WJ, Bogner J, Corrigan J et al. The impact
    of acute care medications on rehabilitation
    outcome after traumatic brain injury. Brain
    Injury. 20(9), 905-911 (2006).
  • Willmott C, Ponsford J. Efficacy of
    methylphenidate in the rehabilitation of
    attention following traumatic brain injury a
    randomised, crossover, double blind, placebo
    controlled inpatient trial. J Neurol Neurosurg
    Psychiatry. 80, 552-557 (2009).
  • Erickson JC, Neely ET, Theeler BJ. Posttraumatic
    Headache. Continuum Lifelong Learning Neurol.
    16(6), 55-78 (2010).
  • Rizzoli P. Acute and Preventive Treatment of
    Migraine. Continuum Lifelong Learning Neurol.
    18(4), 764-782 (2012).
  • Kaniecki R. Tension-type headache. Continuum
    Lifelong Learning Neurol. 18(4), 823-834 (2012).
  • Simon O, Yelnik AP. Managing spasticity with
    drugs. Eur J Phys Rehabil Med. 46, 401-410
    (2010).
  • Petraglia, A.L. et al. From the Field of Play to
    the Field of Combat A Review of the
    Pharmacological Management of Concussion.
    Neurosurgery. 701520-1533 (2012).

35
Assessment, Diagnosis and Treatment of Brain
Injury with a focus on Mild TBI
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