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Diagnosis and Treatment of Traumatic Brain Injury
Angela Colantonio, PhD, OT Reg. (Ont.)
Carolyn Lemsky, PhD, C. Psych.
Catherine Wiseman Hakes, PhD Candidate, Reg. CASLPO
Diagnosis & Treatment of Traumatic Brain Injury
March is National Brain Injury Awareness Month
Traumatic Brain Injury (TBI) is a serious public health problem
TBI: It’s not just an injury
Presenters
Saunderson Family Chair in Acquired Brain Injury (ABI) Research, Professor at University of Toronto
Leads an internationally recognized program of research on ABI
Angela Colantonio, PhD, OT Carolyn Lemsky, PhD, Catherine Wiseman-Hakes,Reg. C. Psych. M.Sc. Reg. CASLPO
Clinical Director at Community Head Injury Resource Services of Toronto
Director of the Substance Use and Brain Injury (SUBI) Bridging Project
Registered Speech Pathologist and a doctoral candidate, University of Toronto
Specializes in the assessment and treatment of children & adults with cognitive communication impairments secondary to TBI
Goals of the Session
1. Prevalence and history of TBI among the homeless population
2. Clinical manifestations of TBI
3. Screening tools for TBI
4. Treating TBI and co-morbidities (e.g., substance abuse)
5. Communicating with someone with TBI
Improvement in Quality of Life in Adults with ABI
Collaborative links:- Local- Provincial- National- International
Consumers / Caregivers
Students, Trainees,Visiting scholars
Knowledge Transfer
Gender Issues
ABI in the Population
InterventionStudies
Aging with TBI
Providers
Acquired Brain Injury
NON-TRAUMATIC
Anoxia Aneurysms Brain Tumors Encephalitis Meningitis Metabolic
Encephalopathy Stroke with
Cognitive Disabilities
TRAUMATIC
Open
Closed
Brain Injury is the leading cause of death and disability worldwide.
Injuries to the brain are among the most likely to result in death and permanent disability
International Brain Injury Association
Brain Injury is a leading cause of death and disability worldwide.
Injuries to the brain are among the most likely to result in death and permanent disability
International Brain Injury Association
Extent of TBI
TBI is more common than breast cancer, spinal cord injury, HIV/AIDS and multiple sclerosis combined
Estimated prevalence, 2% of population
Definition of TBI
An alteration in brain function, or other evidence of brain pathology, caused by an external force…”
Brain Injury Association of America
The effect of TBI on the health of the homeless(Hwang, Colantonio et al, 2008)
Have you ever had an injury to the head which knocked you out or at least left you dazed, confused, or disoriented?
Yes: 53% (of 904 participants)
0
10
20
30
40
% of All* Respondents
(N=475)
1 2 3 4 5+
Number of Injuries
Number of Injuries over Lifetime
010203040506070
% of All* Respondents
Mild Mod-Severe
Unknown
Severity of Injury
Severity of Worst TBI
TBI in the Homeless Population
Age at Time of First TBI (Any Severity): Mean (SD): 18 years (13 Years)
70% prior to first episode of homelessness
Persons with a history of TBI compared to persons without a history had significantly higher levels of:
– Seizures– Mental health problems– Alcohol problems– Drug abuse problems
The risk of these conditions increased significantly with severity of injury
Diagnosis
History of TBI Length of unconsciousness, post
traumatic amnesia Physical examination Imaging: CT, MRI Neuropsychology
Measuring Severity/Level of Consciousness
Glasgow Coma Scale: Eye Opening (1-4) Best Motor Response (1-6) Verbal Response (1-5)
Scoring: Mild 13-15 Moderate 9-12 Severe <12
American Congress of Rehabilitation Medicine definition of mTBI
A traumatically induced physiological disruption of brain function, as manifested by at least one of the following:
1. Any loss of consciousness;
2. Any loss of memory for events immediately before or after the accident;
3. Any alteration in mental state at the time of the accident (e.g. feeling dazed, disoriented, or confused); and
4. Focal neurological deficit(s) that may or may not be transient; but where the severity of the injury does not exceed the following:
Loss of consciousness of approximately 30 min or less;
After 30 minutes, an initial Glasgow Coma Scale (GCS) of 13-15; and
Posttraumatic amnesia (PTA) not greater than 24 hrs.
Katy, et al. (1993)
Consequences of TBI
Cognition: concentration, memory, judgment, communication, sleep.
Movement abilities: strength, coordination, balance, fatigue.
Sensation: tactile sensation, vision, hearing, headaches.
Emotion: instability, impulsivity, mood.
Communityintegration: impacts family, work, economic/
social wellbeing
Clinical Sequelae
Highly variable presentation depending on area of the brain affected
TBI survivors described like “snowflakes” e.g., frontal lobe damage can affect social
behaviour Occipital lobe damage may affect vision
Impact on reproductive health, women with TBI vs. women without TBI:
Women and TBI
68% of women 5-10 years post TBI reported their cycles were irregular after injury
46% experienced amenorrhea
No significant differences in conception but more post partum difficulties
Significantly more mental health issues
Colantonio et al., 2010
SCREENING TOOLS
Survey Questions to Identify Traumatic Brain Injuries
Background of Surveys to Identify TBI
Many surveys exist. Some examples are:
Ohio State University TBI Identification Method
Brain Injury Screening Questionnaire HELPS Brain Injury Screening Tool
Bogner J, Corrigan JD. (2009). Reliability and predictive validity of the Ohio State University TBI identification method with prisoners. J Head Trauma Rehabil, 24:279-291.
Corrigan JD, Bogner J. (2007). Initial reliability and validity of the Ohio State University TBI identification method. J Head Trauma Rehabil, 22:318-329.
Inter-rater reliability and predictive validity have both proved acceptable when tested in a substance abuse population:
– IR (r=0.849-0.951) – Intra-class correlation coefficient all above
0.80, with 6/7 above 0.90
Ohio State University TBI Identification Method (OSU TBI-ID)
Definition of Brain Injury in Context of the Survey
Self-identification of an injury to the head (Questions 1-5)
PLUS
An Affirmative Answer to one of 6-8
Confirmation of head injury and loss of consciousness or episode of blacking out
Neuropsychological Evaluation
Typically involves many hours of testing Repeatable Battery for Assessment of
Cognition (RBANS) is a short test
Treatment
Referral for further evaluation and treatment
Multidisciplinary rehabilitation Wide range of treatments with emerging
evidence Follow up for disability support
services/payments
CMHA Kelowna and Brain Trust Canada partnership: ABI Outreach Services
Aims to secure residential settlement
ABI Outreach Worker provides the knowledge required to maintain a productive lifestyle, including budgeting, dealing with mental health problems, drug addiction and other physical issues.
ABI Tenant Support Worker assists in providing access to non-emergency medical support, basic needs such as nutritious food, and support with coping skills, personal health practices, etc.
Research Based Theatre
Based on focus groups with consumers, family members and health care providers
Translated key elements on experience of TBI and experiences with providers
AFTER THE CRASH www.ruckusensemble.com
Models of ABI Intervention
Carolyn Lemsky, PhD, C. Psych.
Overview
Models of community-based care for ABI Cognitive compensation (adapting
substance use/mental health interventions)
Principles for working with people living with acquired brain injury
Integration of substance use and mental health intervention in the continuum of
Rehabilitation care
ER Acute Care ----or----Follow-upClinic
Acute Rehab
Post-Acute Rehab
Community-Based Supports
Education of Staff/Patient/FamilyPsycho-educational materialsReferral to appropriate programming
Active treatmentEducationHarm ReductionCase management
Time of Injury
mildmoderate
Severe
Supporting people with ABI in the community
Whatever it Takes
1. No two people with brain injury are alike
2. Skills are more likely to generalize when taught in the environment where they will be used.
3. Environments are easier to change than people.
4. Community integration should be holistic.
5. Life is a place-and-train venture.
Willer and Corrigan (1994)
6. Natural supports last longer than professionals.
7. Interventions must not do more harm than good.
8. Service delivery systems present many of the barriers to community integration
9. Respect for the individual is paramount.
10. Needs of the individuals last a lifetime, so should their resources.
…Cont’d
Case Example
Tom’s goal: Get a jobProblems Observed:
Poor hygiene Limited compensation for memory
impairment Socially inappropriate behaviour
Learn and then Place…
Get aJob
Place and Learn
Keep JobMaintainChange
Good morning, Tom.Your shower is getting warm…
Hey Tom, Good morning, your shower is
getting warm…
“In the absence of meaningful, chosen life activities, all interventions are doomed to failure” Ylvisaker, 1998
Restorative
Compensatory
Environmental
Behavioural
Restorative
Therapy activities designed to promote return of function:
Attention training Aphasia therapies
Compensatory
Learning a way to get around the existing impairment:
Memory books, notes, alarms Meta-cognitive strategies (planning) Routines
Environmental
Reminder signs Locks Staff member provides a cue Routine that is driven by others in the
environment
Behavioural
Using behavioural strategies to train a skill: Modeling Rehearsal Chaining Errorless learning
Program Modifications
Smaller sessions Simplified materials Flexible programming
(breaks/shortened sessions) Integrating rehabilitation workers into
treatment
Why some clients don’t compensate
Lack of awareness Feeling that compensating means
‘giving up’ on progress Stigma and shame Impaired cognition
What does the literature say about treatment of substance abuse
after ABI?
Simplified Program Model
Mild
Severe
Mild Severe
Brain injury
Community Based
Psycho-educational Approach
CAMH – Based
CHIRS Support
CHIRS - Based
Psycho-educational
Case Management
CHIRS –Based CAMH support
Harm reduction
Intensive Case Management
Adapted from Corrigan (2004)
From the literature…ABI-Specific Treatment Models
Common Characteristics:
Engagement in meaningful activity (incompatible with substance use and addresses mood/behaviour)
Skills training Treatment may begin before insight/readiness
to change
Case Management Models
Access to substance abuse services/mental Health Services
ABI consultation Explain Neuro-cognitive Impairment Adapt treatment plans Trouble-shoot
Assist with access to other support services
Case Management Outcomes(Heinemann, Corrigan, & Moore, 2004)
Compares 2 intensive Case management programs with typical care offered at a major rehab centre:
No changes in substance use at 9 months follow-up
Earlier referral was associated with better outcomes
No differences in community integration
Small changes in health-related QOL
Life satisfaction /family satisfaction improved
Motivational Interviewing
Main Goal: To produce an internal drive to change, using non-confrontational techniques
Main Method: Evidence of the negative consequences of the behaviour are elicited from the client, so that the client sees and accepts the advantages of change
Structured Motivational Interviewing
Cox, Heinemann et al. (2003):
Outcome after 12 sessions of Motivational Interviewing – follow-up (mean = 9 months)
Improved Motivational Structure Reduced negative affect Reduced substance use
Consumer and professional education Intensive Case Management Consultation to Substance Abuse
Services
www.ohiovalley.org
Ohio Valley TBI Network Model
Corrigan Review (2005)
Treatment is likely to be protracted Successful programs will address
engagement in treatment Early intervention is important
Findings
N=195 (138, male; 57 female)
Mean age = 36.6 (range = 18 to 72)
Mean time since injury = 8.0 (range = 3 weeks to 55 years)
45% 45%
74%
83%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Attn. Control
MotivationalInterviewBarrierReductionFinancialIncentive
% Complete ISP In 30 days
6-Month Follow-up Data
By 6-months over 30% had terminated therapy
50% improvement over control for Barrier Reduction and Financial Incentives
Brief phone intervention makes a big difference
53%
66%
84%79%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Attn. Control
MotivationalInterviewBarrierReduction
FinancialIncentive
Still in treatment or successfully terminated
Why did these interventions work?
Financial incentive participants stated that the reward was not what made a difference in attending appointments
Reminders to address memory issues Transportation support to address
planning/financial issues Learning by ‘rule’ not by consequence
Barriers to Care
Behaviour resulting from the cognitive impairment that appears uncooperative or unmotivated
Difficulty recalling information learned Difficulty generalizing Difficulty predicting and managing
behaviour
5 Principles for Working with ABI clients
Pace communications (one concept at a time) Repeat important concepts Illustrate using concrete examples Memory Aids for use in session and outside Environmental modifications (including the
involvement of caregivers) Re-direction sometimes necessary to move
client to problem-solve or address tangential speech
A Guide for Working with Homeless Persons
Catherine Wiseman-Hakes
Ph.D. Candidate, Reg. CASLPO
Speech Language Pathologist
Communication Problems Associated with
Traumatic Brain Injury
Communication After Brain Injury
• Communication difficulties are common
• Some more obvious, and some are not!
• Subtle (but highly debilitating) communication issues can be misconstrued by a communication partner reflection of poor attitude, disinterest, disrespect, or even substance use.
Communication: Why all the Hype???
• What exactly is communication?
• We know when we’ve been involved in a successful communication interaction
• AND we all know what it is like to be part of an unsuccessful communication interaction
• SO, what exactly is involved?
Components of Communication: Expression
• Successful communication involves an exchange by 2 or more individuals where a message or intent by 1 person is expressed clearly, and received and understood successfully by the communication partner(s)
• This involves speech (or other non-verbal alternative system) which is the motor act of forming sounds
• The content is the language• This is augmented by the equally important non
verbal communication behaviours such as body language, eye contact and tone of voice, known as pragmatics
Pragmatic Communication
Personality changes following TBI involving egocentric thinking with loss of social sensitivity may result in a self-centered style of communication that is lacking empathic interaction with a conversational partner.
Pragmatic Communication
• Personality changes following TBI involving egocentric thinking with loss of social sensitivity may result in a self-centered style of communication that is lacking empathic interaction with a conversational partner
• Behavioral changes may also affect communication. Decreased initiation may result in sparse, uninformative interactions whereas impulsivity may result in verbose, tangential communication that is marred by inappropriate remarks.
Components of Communication: Receiving the Message
• Successful communication involves an exchange by 2 or more individuals where a message or intent expressed by 1 person is received and understood clearly
• This involves hearing, and understanding (comprehension)
• Understanding is required at all of the levels of expression; understanding the speech, understanding the content, both explicit and implied, and understanding the non verbal communication behaviours.
Cognition and Communication
Underlying successful communication are a
number of key cognitive abilities. These include:
Attention to the speaker, working memory, long term memory, andinformation processing (this involves the speed,
amount and complexity of the information being presented).
Communication Problems Associated with TBI
• Slow speed of information processing: this is a hallmark of brain injury
• May have motor speech problems, called dysarthria, difficulty forming the words
• May have hearing problems, and or problems picking out speech from other background noise
• Often slow to initiate, slow to understand, difficulty with implied messages, and difficulty thinking of quick and coherent response
• Often have word finding difficulties.
Communication Problems Associated with TBI
• Most people with brain injury dread and shy away from multi-person conversations, noisy environments, and conversations with people they don’t know
• Many canNOT block out extraneous stimuli; attention is effortful and hard to sustain over time
• Easily fatigued
• Easily overwhelmed by too much information (like someone following a conversation in a language they are just learning...just give up and tune out).
Communication Problems Associated with TBI: Frontal Lobe Injuries
• May be impulsive in their responses, may be emotionally labile; difficulty monitoring context
• In contrast, they may appear flat, disinterested with reduced affect, limited facial and vocal expression
• They may not hear you, they may not understand (or they think they understand, but get it completely wrong)
• Problems reading body language, tone of voice and facial expression
• If they have motor speech problems they may sound like they are under the influence of alcohol or drugs.
Consequences of Communication Problems after TBI
• The consequences of pragmatic communication impairments in people with TBI can be devastating. Social communication serves to connect people to their families, friends, and coworkers
• Many people with TBI report reduced social contacts and rate social isolation and loneliness as their most frequent complaint.
MacLennan et al 2002: The prevalence of pragmatic communication impairments in traumatic brain injury.
http://www.premier-outlook.com/winter_2002/prevelance_pragmatic_communication.html
How to modify your communication to facilitate a successful interaction
• If you are having trouble understanding their speech, assure them you ARE interested in what they have to say, ask them to repeat, maybe use a pen and paper
• DON’T misinterpret a slow response and or flat affect for lack of interest or disrespect
• Speak calmly and respectfully• Whenever possible, have a conversation in
a quieter environment (make sure there is no TV, radio playing etc….)
Screening Tools for Communication Problems
• Latrobe Communication Questionnaire (Douglas, J.)
• Pragmatic Communication Scale (Erlich and Sipes)
• Pragmatic Rating Scale (MacLennan et. al.)
Thank You!
Questions & Answers
Saunderson Family Chair in Acquired Brain Injury (ABI) Research, Professor at University of Toronto
Leads an internationally recognized program of research on ABI
Angela Colantonio, PhD, OT Carolyn Lemsky, PhD, Catherine Wiseman-Hakes,
C. Psych. M.Sc. Reg. CASLPO Clinical Director at
Community Head Injury Resource Services of Toronto
Director of the Substance Use and Brain Injury (SUBI) Bridging Project
Registered Speech Pathologist and a doctoral candidate, University of Toronto
Specializes in the assessment and treatment of children & adults with cognitive communication impairments secondary to TBI
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