Assessment and Treatment of Traumatic Brain Injury within the ECHCS Polytrauma System of Care

Estela Bogaert-Martinez, Ph.D. Director, Traumatic Brain Injury Team

Thanks to Rod Vanderploeg, PhD Neuropsychologist, Polytrauma Center Tampa VAMC , and to Michael Craine, Ph.D., CoDirector, VISN19 Polytrauma Network Site, for contributions to this material.

 Many

of those returning from current conflicts had experiences that put them at risk for TBI.  Mild symptoms of TBI may be difficult to recognize, or confused with other conditions.  Treatment of symptoms may be very different for TBI patients.

War Injuries: Explosive Blasts
Most common cause of injury • 64% of war injuries caused by blasts • 41% of blast injured at WRAMC had TBI (01/05 - 02/06)

Key Iraq wound: Brain trauma
By Gregg Zoroya, USA TODAY

“A growing number of U.S. troops whose body armor helped them survive bomb and rocket attacks are suffering brain damage as a result of the blasts. It's a type of injury some military doctors say has become the signature wound of the Iraq war.”

Traumatic Brain Injury
 Insult

to the brain caused by an external physical force  Produces a diminished or altered state of consciousness
• Dazed and confused for several minutes or • Knocked out / Rendered unconscious and/or • With memory gaps for some or all of the immediate period after the event
 Results

in impairments in physical, cognitive, behavioral, and/or emotional functioning

Consequences of TBI
 Cognitive

Memory deficits, poor concentration, thinking problems
 Emotional-Behavioral

Depression, anxiety, irritability, mood swings Impulsivity, apathy, agitation, aggression Impulsivity
 Physical

Headache, dizziness, fatigue, noise/light intolerance, insomnia/sleep disturbance

Levels of Severity
Mild • Complicated Mild • Moderate • Severe

C o g n i t i v e L e v e l

Preinjury Functioning

Brief PTA

Mild TBI Moderate TBI Severe TBI

Ongoing Cognitive Problems


Ongoing Cognitive Problems PTA



RetroGrade Amnesia






TBI Treatment Considerations
 Treatment varies based upon:

Severity of injury  Time since injury  Constellation of impairments

Continuum of Care for TBI / Polytrauma
Acute Rehab Post-Acute Rehab

Trauma Care

Subacute Rehab

Community Rehab

Long-Term Care

Outpatient Specialty Care

Interdisciplinary Traumatic Brain Injury Team - an Interdisciplinary Rehabilitation Approach
• • • • • • • •

Rehabilitation medicine physician Physical therapist Occupational therapist Speech Therapist Supported employment/Vocational rehabilitation specialist Social Worker Rehabilitation Psychology Neuropsychology

TBI Rehabilitation Interventions to Support Reintegration to Family, Community and Work
• TBI Education & Support • Cognitive Deficits:

Compensatory Training/Cognitive Remediation Stimulant Medications; physical activation

• • • •

Vocational Rehablitation/ Supported Employment Stress Management Training Social Skills Training Specialty Treatment for Secondary Conditions:
PTSD, Depression, Anxiety, Chronic Pain, HA, etc.

Follow-up Additional Specialized Assessments and Treatment
    

TBI: TBI Team PTSD: PTSD Program, Mental Health Chronic Pain: Pain Program, PM&RS Depression, Anxiety, Stress: Mental Health Seizures, Neurologic Conditions: Neurology

What to Know: Relevant Background
 Mild

TBI Symptoms

There is no symptom that is unique to or diagnostic of mild TBI Many postconcussion symptoms occur in normal healthy individuals All symptoms/problems overlap with one or more other conditions (PTSD, Depression, Anxiety, Chronic Pain, Somatoform Disorder, chronic health conditions)

Re-experiencing Avoidance Social withdrawal Memory gaps Apathy Arousal Sensitive to noise Concentration Insomnia Irritability


? Mild TBI Residual

Difficulty with decisions Mental slowness Concentration Headaches Dizzy Appetite changes Fatigue Sadness

+ Depression