Training Objectives - Michigan Traumatic Brain Injury ... · Then, based on the body’s response and medical care, there is the possibility of a secondary event , or further injury

Training Objectives

Describe TBI.Explain how the brain may be affected by different types of injuries.Explain the significance of TBI.Describe TBI in Michigan.Explain the possible long-term impacts of TBI to individuals.Explain the possible long-term impacts of TBI to family members.Recognize some of the changes or issues that may arise due to a TBI.Identify strategies to handle people with TBI appropriately.Recall that each letter in the HELPS acronym stands for a question in theTBI screening tool.Recall how to score the TBI screening tool positive or negative.Identify when a referral for further assessment for TBI is appropriate.List appropriate referrals to public agencies for services from which peoplewith TBI may benefit and for which they may be eligible.

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Significance of TBI and introductory information on how the brain worksObjectives of Module 1 are to:

Learn what TBI is and how the brain is affected by different types of injuries1.Realize the significance of TBI in Michigan2.Understand the possible long-term impacts to the individual and family as a result of TBI

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When you complete this module, you should know:

The definition of TBI•Facts about TBI in the US•Facts about TBI in Michigan•Who is at risk•How an injury can affect the different areas of the brain•What the TBI severity labels, “mild,” “moderate,” and “severe” mean•Why people with TBI often end up in the public service system•

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Section A: Introduction to TBIBrain injury definitionsBrain injury is any injury that results in brain cell death and loss of function.

Traumatic brain injury (TBI): TBI is defined as an alteration in brain function, or other evidence of brain pathology, caused by external force. (Brain Injury Association of America, 2011).

Acquired brain injury (ABI): An acquired brain injury is an injury to the brain, which is not hereditary, congenital , degenerative, or induced by birth trauma. An acquired brain injury is an injury to the brain that has occurred after birth. (Brain Injury Association of America, 2011)

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Section A: Introduction to TBIIncidence of TBI in the USAn estimated 1.7 million people sustain a TBI annually, of them:

52,000 die,•275,000 are hospitalized, and•1.365 million, nearly 80%, are treated and released from an emergency department.

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( Faul M, Xu L, Wald MM, Coronado VG.Traumatic Brain Injury in the United States: Emergency Department Visits,

Hospitalizations and Deaths 2002–2006. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury

Prevention and Control; 2010. ).


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Section A: Introduction to TBIComparison of new cases annually in the US

This graphic is based on data from the Centers for Disease Control and Prevention, American Cancer Society and the National Multiple Sclerosis Society. *"Serious" TBI includes those injuries that result in hospitalization and/or death.


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Section A: Introduction to TBITBI and children in the USEvery year among children ages 0 – 14 years, TBI results in an estimated:

35,000 hospitalizations •519,600 emergency department visits (Faul et al., 2010) •

Among children and adolescents who sustain a TBI resulting in hospitalization:

Falls are the leading cause of injury among 0 – 4 year olds •Males aged 0 to 4 years have the highest rates of TBI-related emergency department visits, hospitalizations, and deaths combined.

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The leading cause of injury among 5 - 19 year olds is transport-related (Faul et al., 2010).

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The cost of TBI in the US alone is estimated to be $60.4 billion annually, including direct medical costs and indirect costs, such as lost productivity (Finkelstein et al., 2006).

Between 2002 and 2006, Michigan Medicaid-Fee for Service paid out about $20 million annually for claims in which TBI was the

primary or secondary diagnosis.

This is only one Medicaid program through which people with TBI may access services. Therefore,

this amount does not capture the total cost to Michigan Medicaid.

Section A: Introduction to TBICost of TBI in the US


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For additional information about TBI in Michigan (including research

methodology), click here to view the MDCH report: Addressing

Michigan’s Public Service Gaps for Persons with Traumatic Brain Injury

Analysis of Michigan data revealed that on an annual basis, about 57,000 individuals sustain a TBI in Michigan. Of these:

about 1,550 are TBI-related1 •9,500 are TBI-related non-fatal hospitalizations2 •46,000 are TBI-related non-fatal and non-hospitalized emergency department visits3

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CDC estimates that:

around 3,900 new cases of TBI-related long-term disability occurs annually in Michigan

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1Source: 1999-2006 mortality data from the Division for Vital

Records and Health Statistics, MDCH. 2Source: 1999-2006 Michigan Inpatient Database. 3Source: weighted 2001 data from the Michigan Emergency

Department Community Injury Information Network.

Section A: Introduction to TBINew cases of TBI in Michigan


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Section A: Introduction to TBIFatal and non-fatal Hospitalized TBI Cases by Age (2003 – 2008)


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Overall, unintentional falls are the leading cause of TBI in Michigan, followed by motor vehicle traffic incidents and assaults. The following charts display the leading causes of TBI for TBI-related nonfatal and fatal hospitalizations.

Source: Division of Vital Records & Health Statistics, MDCH

Section A: Introduction to TBICauses of TBI in Michigan


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Section A: Introduction to TBIWho is most at risk for TBI?Anyone can get a brain injury. Yet some are more at risk than others. A 2010 CDC report found that, between 2002– 2006, the highest rates of injury resulting in emergency department visits were among:

Males age 0-4 (1,347/100,000) and females age 0-4 (1,150/100,000) •Males age 15-19 (926/100,000) and females age 15-19 (578/100,000) •Males over 75 (504/100,000) and females over 75 (555/100,000) •Males are approximately 1.4 times more likely than females to sustain a brain injury

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(Faul et al., 2010). Individuals with a history of concussion seem more susceptible to effects of subsequent head injuries (Collins et al., 2002)


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More people are surviving brain injury than ever before because of better emergency response systems (e.g., expanded use of “911”), faster transportation (e.g., air transport to trauma centers), and improved safety technology and techniques (e.g., seatbelts, airbags, helmets).

Most people don’t know about brain injury, let alone its consequences or how it affects people

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A concussion IS a brain injury•Most concussions do not involve loss of consciousness•Multiple concussions can result in cumulative and long-lasting life changes•

Section A: Introduction to TBIWhy haven’t we heard about TBI before?


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When a traumatic brain injury occurs, there is a primary event or an initial injury. Then, based on the body’s response and medical care, there is the possibility of a secondary event, or further injury to the brain due to the reaction of the brain to the primary event. For example, striking one’s head hard against a blunt object could result in immediate damage from impact and tearing of brain tissue (primary event). The brain’s reaction to this primary event (e.g., swelling), could put pressure on brain tissue and lead to further damage (secondary event). This process is explained in more detail in the following slides.

The purpose of acute care management is to limit the occurrence of secondary events

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Damage resulting from a secondary event can be more severe than damage from the primary event

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Section B: What happens when a TBI occurs?TBI Events


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Axonal Shearing:When the brain is slammed back and forth inside the skull after a head trauma, it is alternatively compressed and stretched because of its soft, gelatin-like structure. The long, fragile axons of the neurons (brain cells) that make up the brain are also compressed and stretched. If the impact is severe enough, axons can be stretched until they are torn. This is called axonal shearing. When this happens, the neuron dies. An injury with substantial axonal shearing is more diffuse – spread throughout the brain. Axonal shearing cannot be directly treated at this time. Contusion: The brain’s violent slamming against the bones of the skull can also result in contusion, which is bruising and bleeding. This results from tearing of small blood vessels. It can also result in the death of neurons and is the second leading cause of neuron death after a traumatic brain injury. Small contusions are usually not treated (e.g., concussion) unless blood flow is interrupted.

Section B: What happens when a TBI occurs?Primary events - what happens during trauma


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Coup Contracoup Coup-contracoup: (Coo-contracoo) After a traumatic brain injury, contusion (i.e., bruising and bleeding) can occur anywhere in the brain. Most contusions are on the underside of the frontal and temporal lobes because of the irregular and rough texture of the bones underlying these parts of the brain. In addition, specific sites of bruising and bleeding can occur at the site of the blow to the head (“coup”) and the site directly opposite the blow (“contracoup”). Depressed skull fracture:When bones of the skull are broken or cracked, loose bone fragments may actually place pressure on or penetrate the brain, thereby causing damage.

Section B: What happens when a TBI occurs?Primary events (continued)


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Brain swelling (cerebral edema): After a severe trauma, the brain swells just like any other part of the body. Brain swelling can lead to neuron damage by squeezing the cells or by disrupting the flow of blood and oxygen to the brain, causing anoxia (see below). Very severe swelling can cause death by compressing the brain stem.

Hematomas: If the damaged blood vessels are large enough, they may create a pool of blood or hematoma. A hematoma can cause brain injury by directly damaging the neurons it comes in contact with, or by squeezing neurons through increased pressure in the brain due to the volume of blood. When possible, the treatment for a hematoma is to surgically drain it.

Increased intracranial pressure: Pressure can build up within the brain because fluid formed as a result of swelling or bleeding has nowhere to go (being encased in the skull). This pressure can result in further brain damage. Hypovolemic shock: After injury, loss of blood volume further compromises healthy brain tissue. Anoxia:A lack of oxygen to the brain can cause further damage to brain cells.

Section B: What happens when a TBI occurs?Secondary events - the body’s response


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When providing post acute care, it is appropriate to fully evaluate current functioning rather than rely on diagnoses of

severity made immediately after the injury.

TBI is classified as "mild", "moderate", or "severe". It is important to know that the severity of TBI is diagnosed based on immediate post injury conditions such as length of loss of consciousness or amnesia. The severity of injury is related to long-term consequences, but does not determine long-term recovery or outcomes. Moreover, each of these terms actually represents a spectrum of severity. The Glasgow Coma Scale (GCS): A commonly used scale for initial assessment of brain injury severity. The GCS uses a 15 point scale to rate eye opening, motor, and verbal response functions, with a higher score indicating higher functioning. Unfortunately, in practice the time of the assessment can vary (e.g., at the scene of injury, upon examination in the emergency department, etc.) – making results from one patient to the next difficult to compare. Moreover, GCS results may not be valid for children, people under the influence of alcohol, or people with language differences.

Section B: What happens when a TBI occurs?Severity of TBI


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Mild TBI is medically defined as a brief period of loss of consciousness (typically less than 15 minutes), any loss of memory for events immediately before or after the accident, or any alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented or confused). Mild TBI generally does not include posttraumatic amnesia greater than 24 hours (NIH, 1998). Mild TBI is associated with a GCS of 13-15.

Symptoms may not appear until later and can include temporary headaches, dizziness, mild mental slowing and fatigue

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Symptoms of mild brain injury most often improve spontaneously over 1-3 months; in fact, most mild TBIs resolve themselves

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Mild brain injury is also known as concussion or brain contusion•An estimated 75% of all brain injuries are mild•Often, people with mild brain injury do not seek medical assistance because, at the time, they do not believe the injury is severe enough

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Mild TBI does not always show up on a neurological exam •Because signs and symptoms of mild brain injury are similar to other problems (e.g., learning disability, emotional disturbance), it is often misdiagnosed

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Section B: What happens when a TBI occurs?Mild TBI


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A moderate brain injury is medically defined by a loss of consciousness lasting between 15 minutes and a few hours and is followed by a few days or weeks of confusion. Persons with moderate TBI may have a longer period of impaired consciousness, more impaired verbal memory shortly after the injury and a lower likelihood of achieving a good recovery within 6 months than persons suffering mild TBI (NIH, 1998).

Moderate TBI often is associated with a GCS of 9 – 12 •10% – 30% of TBIs are classified as moderate •80% of people who sustain a moderate TBI can be expected to return to work within one year of injury

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Section B: What happens when a TBI occurs?Moderate TBI


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Severe brain injury is medically defined by a loss of consciousness, or coma, for 6 hours or longer, either immediately after the injury or after an intervening period of clarity. Individuals who suffer a severe TBI are at risk for long-term disability. Their behavior can be disinhibited, and at times they may disregard social conventions. Some have difficulty remaining employed, maintaining pre-injury relationships and establishing new social contacts (NIH, 1998).

Severe TBI is often associated with a GCS of 8 or lower •One-third to one-half of all cases of severe TBI result in death •The incidence of severe TBI is lower than the incidence of mild or moderate TBI

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Section B: What happens when a TBI occurs?Severe TBI


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No two brain injuries are exactly alike, and brain injuries are very complex for several reasons:

The severity of injury can range from mild to severe •Different areas of the brain can be injured, resulting in a unique combination of disabilities

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The injury differs depending on how the brain was injured (e.g., axonal shearing vs. contusion)

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Recovery from TBI is different for each individual; recovery can take weeks to years, or can be a lifelong process

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The next slides are intended to show the major cognitive and physical functions controlled by each area of the brain.

People with TBI often injure multiple areas of the brain; disability may

result from changes in interaction between the injured areas.

Section B: What happens when a TBI occurs?Complexity of TBI


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Left side of brain:

Difficulties in understanding language (receptive language) •Difficulties in producing language (expressive language) •Catastrophic reactions (e.g., depression, anxiety) •Verbal memory deficits •Decreased control over the right side of the body •Impaired logic •Sequencing difficulties•

Section C: Impact of TBIGeneral patterns of dysfunction by location of injury


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Right side of brain:

Impairments in visual-spatial perception •Left-neglect, or inattention to the left side of space or the body •Decreased awareness of deficits •Altered creativity and music perception •Loss of the Gestalt, or "big picture" •Visual memory deficits •Decreased control over left-sided movements•



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Diffuse injury:

Reduced thinking speed •Increased confusion •Reduced attention and concentration •Increased fatigue •Impaired cognitive functions across all areas•



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Click the links to discover which functions are controlled by each area of the brain.

Section C: Impact of TBIFunctions of the brain


Frontal Lobe

Parietal Lobe

Occipital Lobe

Temporal Lobe

Cerebellum

BrainStem

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Click the links to discover which functions are controlled by each area of the brain.Functions of the frontal lobe Executive functions

Initiation•Organization•Self-monitoring•

Cognitive functions

Problem solving•Judgment•Inhibition of behavior•Planning/anticipation•Motor planning•Personality and emotions•Awareness of abilities and limitations•Attention/concentration•Mental flexibility•Speaking (expressive language)•



Frontal Lobe

Parietal Lobe

Occipital Lobe

Temporal Lobe

Cerebellum

BrainStem

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Click the links to discover which functions are controlled by each area of the brain.Functions of the parietal lobe Sensory functions

Touch perception•Differentiation of size, shape, and color

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Spatial perception•Visual perception•



Frontal Lobe

Parietal Lobe

Occipital Lobe

Temporal Lobe

Cerebellum

BrainStem

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Click the links to discover which functions are controlled by each area of the brain.Functions of the occipital lobe Sensory functions

Visual perception•



Frontal Lobe

Parietal Lobe

Occipital Lobe

Temporal Lobe

Cerebellum

BrainStem

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Click the links to discover which functions are controlled by each area of the brain.Functions of the temporal lobe Cognitive functions

Memory•Understanding language (receptive language)

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Executive functions

Organization and sequencing•

Sensory functions

Hearing•



Frontal Lobe

Parietal Lobe

Occipital Lobe

Temporal Lobe

Cerebellum

BrainStem

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Click the links to discover which functions are controlled by each area of the brain.Functions of the cerebellum Motor functions

Balance•Coordination•Skilled motor activity•



Frontal Lobe

Parietal Lobe

Occipital Lobe

Temporal Lobe

Cerebellum

BrainStem

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Click the links to discover which functions are controlled by each area of the brain.Functions of the brain stem Regulatory functions

Breathing•Heart rate•Arousal/consciousness•Sleep/wake functions•Attention/concentration•



Frontal Lobe

Parietal Lobe

Occipital Lobe

Temporal Lobe

Cerebellum

BrainStem

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There are many reasons that persons with TBI might come to rely on the public service system for their health care. A person who is injured in a car crash in Michigan is covered by Michigan’s auto no-fault insurance. However, up to 70% of Michigan residents experiencing TBI are not injured in an auto crash. For these individuals, Medicaid often becomes the payment source for long term care services, because:

As a result of injury, they may lose their job and their health insurance•They reach the maximum payout available from private insurance coverage but still need services

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They had no health insurance to begin with•

Section C: Impact of TBINeed for public services


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Clinical experience has shown that family involvement and support is very valuable to a person with TBI throughout rehabilitation. The needs of the family member with a TBI affect the entire family. Relationships, communication and the sharing of responsibilities can change dramatically.

The physical and emotional strain of caregiving may lead to anxiety, stress, guilt, loneliness and depression among family members (Kreutzer, 1998).

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If the injured person was the main financial provider, the family could also experience income losses. Loss of income is even more severe if other family members can no longer work because they have to care for the injured individual.

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Family members need support to fulfill their new roles, including emotional and social support from others in similar situations, and the opportunity to take a break from care-giving tasks. In addition, they may need help and advice to access crucial benefits.

Section C: Impact of TBIEffects on family members


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Because a child’s brain is still developing, injury may alter the course of development of the brain and its functions (TBINET, 2004).

After a brain injury, previously learned information, which provides important building blocks for subsequent learning, is often retained and used. However, in very young children, these building blocks have not yet been learned, handicapping them as learners in comparison to similarly brain-injured older children or adults who have larger foundations of intact information.

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The effects of the TBI on the child may not be seen directly after injury, but only become apparent when, during the course of the child’s development, affected skills are called upon. For example, problems in abstract thinking may not be evident until the child with a TBI reaches an age when this skill normally develops.

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When there is a lag in the emergence of problems, the TBI might not be identified as the cause of the problems. Frequently, such problems are dealt with as if they are due to learning disabilities or emotional issues. A child can suffer from misdiagnosis in two ways: feeling diminished or confused because no one knows what is really wrong, and being damaged as a learner because the learning environment does not meet his or her needs.

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Section C: Impact of TBIEffects of TBI on children


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Studies have shown that there is a significant link between being intoxicated and incurring a serious injury. Alcohol and other drugs that alter judgment and cognitive abilities play a role in both intentional injuries (i.e., assault or suicide) and unintentional injuries (e.g., vehicle crashes, falls). Not only does alcohol & drug use play a role in the incidence of TBI, alcohol has been found to have a detrimental effect upon the acute phase of recovery. Additionally, persons with TBI may have an increased risk for post-injury alcohol use (NIH, 1998).

Section C: Impact of TBISubstance abuse and TBI


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Just as each individual is unique, each brain injury is unique. Recovery from a brain injury is often slow, and the person may experience changes, for better or worse, which may affect them for the rest of their lives. Each person’s recovery is unique due to his or her pre-injury personality, learning style, location and severity of injury, time elapsed since the injury and the individual’s psychological reaction to the injury. Additional complications:

TBI is often misdiagnosed •Symptoms of TBI may not show up for weeks or months after the injury

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Recovery is slow and often incomplete•

Section C: Impact of TBIRecovery


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You now have the option to view a short video that illustrates how TBI has affected the lives of a few individuals. This video is comprised of segments from the video Faces of Brain Injury developed by the Brain Injury Association of Florida. Click the button below to view the video. If you would like to skip the video, use the next button at the bottom of the page to continue with Module 1.

Click here to view the video

Click here to view the transcript

Section C: Impact of TBICase study


Segments from video Faces of Brain Injury - transcript (Michael) I went to work one Sunday morning, and from there, I don’t know. Brain injury, it’s the last thing on your mind. (Maria) Before the accident I was all over the place. I was a professor. I just had a million things that I was doing. And now, I just can’t find the energy. (Michael) I modeled, I worked as a mechanic. I want to get back to work. I don’t care doing what, but I want to get back to work. (Jonathan) I was in ninth grade. I was a really good soccer player. I was one of the best. To have something for fifteen years and then have your skill, and not be as fast, everything taken away from you in a split second, it’s one of the hardest things that could ever happen to anybody. Brain injury, it’s the last thing on your mind. (Michael’s wife) All of Michael’s skills have diminished due to seizures. It’s almost like a long term project that we’ve decided to be completely committed to, no matter what it takes, no matter what path it’s going to bring us to. We are just going to… (Michael) …make it. And together we will make it. (Maria) Since my accident, everything about being a professor would be difficult for me. My concentration is very short limited. Now I can barely read. I start at the beginning of the paragraph. By the time that I get to the end of the paragraph, I have forgotten what I’ve read. There was a time where I thought I’d be teaching for the rest of my life. Now there’s a big question mark. Brain injury, it’s the last thing on your mind…until it’s the only thing.

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This final section of Module 1 consists of nine questions. You must complete the questions to receive a score for this module on your training transcript.

When you submit an answer for each question, a box will appear stating whether or not your answer was correct, along with an explanation of the correct answer.

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Once you submit an answer for each question, it cannot be changed. However, you may return to the assessment section of this module on another day and retake the test. Your most recent score will appear on your transcript.

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Begin Test

Section D: AssessmentTest your knowledge

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1.All of the following injuries are examples of traumatic brain injury , except:

(a) Concussion sustained after being hit by a baseball (b) Intracranial hemorrhage sustained as a result of an assault (c) Gun shot wound to the head (d) Cognitive disability relating to a near-drowning incident

Submit


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That is correct. A near-drowning incident in which lack of oxygen results in brain damage is called an acquired brain injury. Since there was no trauma, it is not considered to be a traumatic brain injury.

Next Question


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2. Each year there are more new cases of serious TBI in the United States than:

(a) HIV/AIDS (b) Breast Cancer (c) Spinal Cord Injury (d) All of the above

Submit


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That is correct. There are 285,000 new cases of serious TBI annually in the United States, as compared with 205,000 new cases of breast cancer, 41,289 new cases of HIV/AIDS, and 11,000 spinal cord injuries. (Note: For this analysis, "serious" TBI is that resulting in hospitalization or death.)

Next Question


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3. TBI is classified as mild, moderate, or severe based on:

(a) Assessment of the injured individual’s state of consciousness immediately post injury. (b) The injured individual’s long-term outcomes, including physical disabilities, cognitive impairment, and social functioning. (c) Both 'a' and 'b' (d) Neither 'a' nor 'b'

Submit


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That is correct. The severity of TBI is classified based on an assessment immediately post-injury of the length of time the person remained unconscious, the degree of amnesia, and his or her degree of consciousness during assessment.

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4. Mild TBI does not lead to long term impairment.

(a) True (b) False

Submit


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That is correct. Because every brain injury is different and the causes of long term impairment are not well-understood, it is possible for what is originally diagnosed as mild TBI to cause long term impairments in brain functioning. However, current research indicates that in most cases of mild TBI, symptoms resolve within 3 months (McCrea et al., 2003). But since mild TBI is so common, a provider may nevertheless have clients with long term impairments resulting from a mild TBI. These impairments may themselves not be mild if they affect the individual’s ability to organize, create rewarding social relationships, or hold down a job!

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5. An injury to the temporal lobe is immediately life threatening because this is where the brain regulates basic bodily functions such as breathing and heart rate.

(a) True (b) False

Submit


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That is correct. Breathing and heart rate are regulated in the brain stem. Brain activity in the temporal lobe relates to memory, hearing, organization and sequencing, and understanding language.

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6. Which of the following may be the result of an injury to the frontal lobe?

(a) The need for an immediate tracheotomy because the brain is unable to regulate breathing. (b) A series of difficulties that make it difficult to function in society, including: saying whatever is on one’s mind even if it is inappropriate, disorganization, and an inability to focus on the task at hand. (c) Memory loss and blindness (d) Inability to walk or sit up straight

Submit


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That is correct. An injury to the frontal lobe can result in: saying whatever is on one’s mind even if it is inappropriate (lack of self-monitoring), disorganization, and an inability to focus on the task at hand.

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7. Sara and Jon both sustained traumatic brain injuries when they were thrown from Sara’s motorcycle. Sara’s injury was classified as moderate, and she has experienced difficulty with organization, problem solving, and judgment since the injury. Jon’s injury was classified as severe, and he has experienced difficulties with motor skills, balance, and executive functions. What might explain these differences?

(a) Different areas of the brain may have been injured. (b) Sara and Jon may have suffered different primary and secondary events. (c) These differences are impossible because both injuries were sustained in the same accident. (d) Both ‘a’ and ‘b’ are correct.

Submit


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That is correct. Each brain injury is unique for several reasons. Sara and Jon’s injuries may have differed in the area of the brain that was injured and in the primary and secondary injuries they suffered.

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8. Children are better able to overcome TBI-related impairments than adults, because the brain can compensate for the injury as it develops.

(a) True (b) False

Submit


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That is correct. The earlier the brain injury, the fewer skills the child has developed to help compensate for a brain injury or to serve as a basis for further learning.

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9. A four year old child who regains consciousness and seems fine after a concussion will:

(a) Reach normal developmental milestones (b) Show no symptoms of brain injury for many years, but begin to have difficulty with school in junior high (c) Both A and B are unlikely (d) Both A and B are possible

Submit


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That is correct. It is difficult to predict with certainty what the outcomes of any individual brain injury will be. Certainly there is cause for optimism if the child regains consciousness and shows no impairments after a concussion. Most likely, the child will develop normally. However, because children develop skills over time, it is possible that the effects of an injury to the brain will not become apparent until that child fails to reach a particular developmental milestone.

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Beckwith B, Dimambro L. TBI Basics. Brain Injury Association of Michigan AnnualConference. 1996-2002.

Black K. Caregiver college presentation. Michigan: Detroit Medical Center,Rehabilitation Institute of Michigan. 1998.

Brain Injury Association of America website. Acquired Brain Injury. 1997. Availableat: http://www.biausa.org/Pages/types_of_brain_injury.html#aquired. Accessed July15, 2005.

Brain Injury Association of America website. “What is the Difference Between anAcquired Brain Injury and a TBI”. Available at:http://www.biausa.org/FAQRetrieve.aspx?ID=43913&A=SearchResult&SearchID=2840376&ObjectID=43913&ObjectType=9.Accessed September 7, 2011

Brain Injury Association of America website. “BIAA Adopts New TBI Definition”.2011. Available at http://www.biausa.org/AnnouncementRetrieve.aspx?ID=66290&A=SearchResult&SearchID=2840249&ObjectID=66290&ObjectType=7.Accessed September 7, 2011.

Braunling-McMorrow D, Davie C, Ferriera-Bedford T, et al. Acquired Brain InjuryPrograms, Preservice Materials Manual. Illinois: Mentor, 2000.

Centers for Disease Control and Prevention. Heads Up: Facts for Physicians AboutMild Traumatic Brain Injury (MTBI). 2003. Available at:http://www.cdc.gov/ncipc/pub-res/tbi_toolkit/physicians/mtbi/diagnosis.htm.Accessed July 15, 2005.

Centers for Disease Control and Prevention, National Center for Injury preventionand Control. (1999, Dec.) Traumatic Brain Injury in the United States: A Report toCongress.

Center for Disease Control. Report to Congress on Mild TBI in the US: Steps toPrevent a serious Public Health Problem. 2003. Available athttp://www.cdc.gov/traumaticbraininjury/pdf/mtbireport-a.pdf. Accessed onSeptember 7, 2011

Faul M, Xu L, Wald MM, Coronado VG.Traumatic Brain Injury in the United States:Emergency Department Visits, Hospitalizations and Deaths 2002–2006. Atlanta(GA): Centers for Disease Control and Prevention, National Center for InjuryPrevention and Control; 2010.

Collins MW, Lovell MR, Iverson GL, Cantu RC, Maroon JC, Field M. Cumulativeeffects of concussion in high school athletes. Neurosurgery. 2002, 51(5), 1175-79.

Corrigan JD, Lamb-Hart GL, Rust E. A program of intervention for substance abusefollowing traumatic brain injury. Brain Inj. 1995 Apr;9(3):221-36.

Corrigan PW, Bach PA. Behavioral Treatment, in Textbook of Traumatic BrainInjury. Edited by Silver JM, McAllister TW, Yudofsky SC. Arlington, VA, AmericanPsychiatric Publishing, Inc.; 2005, pp 661-678.

References

http://www.biausa.org/Pages/types_of_brain_injury.html#aquired

http://www.biausa.org/FAQRetrieve.aspx?ID=43913&A=SearchResult&SearchID=2840376&ObjectID=43913&ObjectType=9

http://www.biausa.org/FAQRetrieve.aspx?ID=43913&A=SearchResult&SearchID=2840376&ObjectID=43913&ObjectType=9

http://www.biausa.org/AnnouncementRetrieve.aspx?ID=66290&A=SearchResult&SearchID=2840249&ObjectID=66290&ObjectType=7

http://www.biausa.org/AnnouncementRetrieve.aspx?ID=66290&A=SearchResult&SearchID=2840249&ObjectID=66290&ObjectType=7

http://www.cdc.gov/ncipc/pub-res/tbi_toolkit/physicians/mtbi/diagnosis.htm

http://www.cdc.gov/traumaticbraininjury/pdf/mtbireport-a.pdf

Cross T, Bazron BJ, Dennis, KW, Isaacs MR. (1989). Toward a CulturallyCompetent System of Care: Vol.1, Washington, DC, National Technical AssistanceCenter for Children’s Mental Health, Georgetown University Child DevelopmentCenter.

Dunn K.A., Thurman D.J., Clinton J.A. (1999). The Epidemiology of Traumatic BrainInjury Among Children and Adolescents. Centers for Disease Control andPrevention.

Faces of Brain Injury. Produced by the Brain Injury Association of Florida, Inc.(www.biaf.org); funded in part by Florida Department of Health, Brain & Spinal CordInjury Program and Health Resources Services Administration Grant #: CFDA#93-234A.

Finkelstein EA, Corso PS, Miller TR, and Associates. The Incidence and EconomicBurden of Injuries in the United States. New York, NY, Oxford University Press, Inc.,2006, p. 136.

Kreutzer JS, Consequences of Traumatic Brain Injury for the Family, NIHConsensus Development Conference on the Rehabilitation of Persons withTraumatic Brain Injury. 1998; Oct 26-28:14.

Langlois JA, Rutland-Brown W, Thomas KE. Traumatic Brain Injury in the UnitedStates: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta (GA):Centers for Disease Control and Prevention, National Center of Injury Preventionand Control; 2004.

Martelli MF, Grayson R, Zasler ND: Post traumatic headache: psychological andneuropsychological issues in assessment and treatment. Journal of Head TraumaRehabilitation. 1999; 1:49-69.

McCrea M, Guskiewicz KM, Marshall SW, Barr W, Randolph C, Cantu RC, OnateJA, Yang J, Kelly JP. Acute effects and recovery time following concussion incollegiate football players: the NCAA Concussion Study. JAMA, 2003;290(19):2556-63.

National Institute of Health. National Institute of Health Consensus DevelopmentConference on Rehabilitation of Persons with Traumatic Brain Injury; Epidemiologyof Traumatic Brain Injury. U.S. Department of Health and Human Services, 1998.

O’Shauick GJ, O’Shauick AM. Personality Disorders, in Textbook of Traumatic BrainInjury. Edited by Silver JM, McAllister TW, Yudofsky SC. Arlington, VA, AmericanPsychiatric Publishing, Inc.; 2005, pp 245-258.

Picard M, Scarisbrick D, Paluck R. International Center for the Disabled, U.S.Department of Education, Rehabilitation Services Administration. 1991. Grant#H128A00022.

Prigatano GP, Roueche JR, Fordyce DJ. Nonaphasic language disturbances afterbrain injury, in Neuropsychological Rehabilitation after Brain Injury. Edited byPrigatano GP. Baltimore, MD, Johns Hopkins University Press, 1986, pp 18-22.

Rao V, Rollings P, Spiro J. Fatigue and Sleep Problems, in Textbook of TraumaticBrain Injury. Edited by Silver JM, McAllister TW, Yudofsky SC. Arlington, VA,American Psychiatric Publishing, Inc.; 2005, pp 369-384.

TBINET, Research and Training Center on Community Integration of Individuals withTraumatic Brain Injury, Mount Sinai School of Medicine. Available at:www.mssm.edu/tbinet. 2004. http://www.mssm.edu/tbinet/. Accessed July 15, 2005.

http://www.biaf.org/

http://www.mssm.edu/tbinet/

Thurman DJ, Sniezek JE, Johnson D, Greenspan A, Smith SM. Guidelines forSurveillance of Central Nervous System Injury. Centers for Disease Control andPrevention. 1994.

Turner AP, Bombardier CH, Rimmele CT. A typology of alcohol use patterns amongpersons with recent traumatic brain injury or spinal cord injury: implications fortreatment matching. Achives of Physical Medicine Rehabilitation. 2003;Mar:84(3):358-64.

Navigation TipsThis course contains four modules plus supplementary information. You may complete the modules atyour own pace. You must complete each module and spend at least three hours studying coursematerial to receive CE credit. Please see Continuing Education (CE) Credit Requirements for moreinformation.

Throughout this course, you may have five main windows open in your browser at any given time. If youhave a window open but in the background, and click on a link that would normallyopen in that background window, it will not automatically come to the fore. The linkwill open, but you will have to use your program buttons at the bottom of yourscreen to switch to that window. Training content that will appear in each of the windows is asfollows:

1. Main menu

The first window, the Main menu, will remain open while you are logged into this course,unless you use your browser buttons to move forwards, backwards, or exit. From the Mainmenu you may access any module by clicking on the module number. You may also accesssupplementary materials from the sidebar at the left of the screen.

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The modules will open in a second window. You will not have access to your browser buttonsfrom this window. To advance through these modules, click on the arrows on the bottom, rightcorner of the screen. You may exit a module at any time by selecting Exit from the sidebar onthe left. If from the Main menu you select a module other than one that is already open, themodule you select will replace the open one in this window.

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3. Supplementary information

Supplementary information will appear in a third browser window. This information will beavailable from the sidebar on the left of the Main menu screen and the modules.

1. Navigation tips: This document.

2. Glossary: You may also access the glossary by selecting any underlined word inthe modules.

3. References: You may also access references by clicking on any referencesthroughout the modules.

4. Resource links: List of links to additional information available from otheragencies/organizations on the World Wide Web.

In addition, the following supplementary material is available from the Main menu screen:

5. Course outline: Lists the content contained in each module.

6. Update registration/password information: Update the information on youremail address, place of work, etc., so that we may notify you in the case of majorchanges in course content. Also, you may change your password for purposes ofcourse login from this page.

7. Course transcript: View the results of your quiz scores for each module, updateyour time log, or submit for SB CE credit once all necessary requirements are met.

8. Continuing Education (CE) Credit Requirements (click here): Explains therequirements that must be met in order to earn CE credits for completion of this TBItraining course.

4. Case studies

At the end of each module you will have the opportunity to view case studies relating to thetopics covered. These case studies will open up in a fourth window. Please note: If you arecurrently using Mozilla or Firefox you may need to reopen the training site in Netscape orInternet Explorer in order to view these case studies. Also, if you have difficulty viewing thevideos or hearing the audio, you will have the option to read the video transcript.

5. Websites outside of the training course

Throughout the modules and on the Resource Links page you will have the chance toaccess information from many websites outside of the training course. These external sites willopen up in a fifth window. Only one external site may be opened at a time, with each new sitereplacing the one that was opened last.

If you are having technical difficulties, please report them to us at: [email protected].

mailto:[email protected]

Continuing Education (CE) CreditRequirementsIn order to activate the training with the correct features for earning CE credit, you must FIRST indicate your interest inearning CE credit on the Course Registration page. If you have not already done this, go back to the Main Menu pageand select "Update Registration/Password Information" from the blue bar on the left. On the Course registration page youmust select yes for earning CE credits, indicate the type of profession, update all necessary information, and then click"Submit" at the bottom of the page.

Professionals in the areas of

Nursing (3 Contact Hours available)Education (3 SB-CEU available)Case Management (3 Clock Hours available)Social Work (3 Instructional Continuing Education Hours available)Nursing Home Administrators (3 Credit Hours available)Licensed Professional Counselors (3 Clock Hours available)Disability Management Specialists (4 Clock Hours available)Rehabilitation Counselors (4 Clock Hours available)Adult Foster Care (3 CEU's available)Certified Health Education Specialists (3 CECH)

have the opportunity to earn continuing education (CE) credits toward their respective Michigan licenses for completion ofthe “Traumatic Brain Injury and Public Services in Michigan” training course. In order to earn CE credits toward one ofthese licenses, each participant must meet the following requirements:

(1) Time Log: You must record all time spent on the “Traumatic Brain Injury and Public Services in Michigan” training inthe online time log. This time log is available from the Main Menu page of the training by clicking the “Course Transcript”link in the blue bar at the left. The instructions on the course transcript will ask you to enter the date and the number ofhours/minutes spent going through the TBI training materials. You will need to add an entry to your time log each time youaccess the training and review more materials, and then save the changes by clicking the “Save Time Log Updates”button at the bottom of that page. Because this is an online training and can be completed in multiple sessions, you mayneed to make several entries into your time log before finishing the entire training. The time log will serve as a personalaccount of your efforts put toward this training and must be completed for CE credit. Note: to earn the number ofhours/credits listed above you must spend at least three hours studying the curriculum.

(2) 84% Cumulative Quiz Score (Total Score): You must complete the multiple choice quiz at the end of each ofthe four training modules and obtain a Total Score of 84%. Each quiz contains 8-10 questions – there are 37 questionstotal. To obtain the necessary 84% Total Score, you must answer at least 31 questions correctly. This means you canmiss a total of six questions.

Upon completion of a quiz, the score and the date of the quiz will be recorded into your course transcript. Quizzes may beretaken as many times as desired. Your Total Score will be calculated on your course transcript once all four modulequizzes have been completed.

(3) Evaluation: You must complete an online evaluation of the TBI training course. When you have completed theModule 4 quiz, you will be directed to this evaluation. Completion of this evaluation will also be recorded on your coursetranscript and is required for CE credit.

When you have met the above requirements, please review the information on your course transcript one last time. If allinformation is correct and complete, please print by clicking the “Print Course Transcript” button toward the bottom of thecourse transcript page and save this copy for your records.

In order to submit your completed course transcript for credit toward your professional license, you will need to click the“Submit for CE credit” button at the bottom of the course transcript page. Clicking this button indicates that you agree thatall the information on the course transcript is correct, complete, and meets the above requirements. Once you haveclicked the submit button you will receive a confirmation that your course transcript has been submitted successfully.Assuming all requirements were met, you can expect to receive your Course Completion/CE Credit Certificate in the mailwithin 4-6 weeks following submission.

Additional Information on Nursing Contact Hours

This continuing nursing education activity was approved by the Ohio Nurses Association (OBN-001-91), anaccredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

Approval valid through July 15, 2012. Assigned ONA #14,391-I3.0 nursing contact hours will be provided.This continuing education activity will be available to nurses until July 15, 2012.

Criteria for successful completion include finishing all four training modules and receiving a cumulative quiz average of atleast 84%. Participants must also complete the evaluation survey at the end of the training. Certificates of completion willbe mailed to eligible training participants.

The authors and planning committee have declared no conflict of interest. There is no commercial support orsponsorship for this event.

If you have any questions or problems, please contact [email protected].

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A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Acquired brain injury (ABI): An acquired brain injury is an injury to the brain,which is not hereditary, congenital, degenerative, or induced by birth trauma. Anacquired brain injury is an injury to the brain that has occurred after birth.

Activities of daily living (ADLs): Basic tasks that a person performsthroughout the course of his/her day, such as: eating, bathing, toileting,grooming, transferring and moving about. Tasks that are related to independentliving are called instrumental activities daily living and include: takingmedications, preparing meals, laundry, housework, shopping, and errands.

Acute: In reference to healthcare for TBI, describes the medical proceduresundertaken to stabilize a patient in a hospital; care that is provided on a short-term basis for an immediate need, usually right after the injury occurred. Postacute care is care provided after initial stabilization on a longer-term basis.

Advocate: To argue for a cause, or plead on another’s behalf for education,legal, personal, or vocational rights, or a person who argues for their own, oranother person’s rights.

Anoxia: The cessation of oxygen supply to the brain -- can lead to brain celldeath and loss of function.

Assistive technology (assistive devices, adaptive technologies, adaptiveequipment): Any technology that enables someone to do something that s/henormally cannot do. A special device that assists in the performance of self-care,work, play/leisure, or physical exercise. Some assistive technologies can beuseful in compensating for cognitive deficits. Examples include: personal digitalassistants, voice organizers and recorders, reminders, watches, and smartphones.

Antecedents: Factors or events that occur prior to a current situation. Attentionto antecedents can assist in promoting desired behaviors and avoiding negativebehaviors.

Ataxia: Inability to coordinate voluntary muscle movements.

Axonal shearing: When the brain is moved back and forth against the skullafter a head trauma, it is alternatively compressed and stretched because of itssoft, gelatin-like structure. The long, fragile axons of the neurons that make upthe brain are also compressed and stretched. If the impact is severe enough,axons can be stretched until they are torn. This is called axonal shearing. Whenthis happens, the neuron dies. An injury with substantial axonal shearing is morediffuse -- spread throughout the brain.

Axons: Long nerve fibers that conduct impulses away from the cell body of aneuron.

Glossary

Brain injury: Any injury that results in brain cell death and loss of function.

Brain Injury Association of Michigan (BIAMI): A non-profit consumerorganization that works to improve the lives of those affected by brain injurythrough education, advocacy, research and local support groups.

Brain swelling (cerebral edema): The brain swells after a severe trauma, justlike any other part of the body. This is also a major cause of damage after braininjury. Very severe swelling can cause death by compressing the brain stem.Brain swelling can lead to neuronal damage by squeezing the cells or fromanoxia caused by disrupting the flow of blood and oxygen to the brain.

Centers for Disease Control and Prevention (CDC): One of 13 majoroperating components of the Department of Health and Human Services; andleads the nation’s public health efforts to prevent and control infectious diseases,injuries, workplace hazards, disabilities, and environmental health threats.

Centers for Independent Living (CILs): Centers located throughout Michiganto provide services designed to maximize self-sufficiency and independence ofpeople with disabilities.

Cognitive functioning: A function of the brain that refers to how one thinks,reasons, stores, and processes information.

Community Mental Health Services Programs (CMHSP): Programscontracted by the Michigan Department of Community Health to provide a fullarray of community-based support services for eligible individuals (persons witha qualifying developmental disability or mental illness) and their families. Whilesome CMHSPs may directly operate treatment programs, most CMHSPs establisha network of agencies and professionals to provide treatment services.

Congenital condition: Circumstance that is present at birth.

Contusion (of the brain): Bruising and bleeding of the brain due to the tearingof small blood vessels upon impact. It can lead to the death of neurons. Smallcontusions (as in concussion) are not usually treated unless blood flow isinterrupted.

Coordinating Agency (CA): Agencies contracted by MDCH, Office of DrugControl Policy, to provide access to publicly funded substance abuse services.They have administrative responsibility for an Access Management System thatdetermines eligibility, manages resources and assures quality of care.

Coup-contracoup: A pattern of contusion whereby one contusion occurs at thesite of the initial impact on the brain ("coup") and another at the site directlyopposite ("contracoup"). This pattern is the result of the brain moving back andforth inside the skull upon impact.

Culture: An integrated pattern of socially transmitted human behavior thatincludes thoughts, communication, actions, customs, beliefs, values, institutions,and all other products of human work or thought, characteristic of a particularcommunity or population (Cross et al., 1989). Though culture is often viewed assimply race and ethnicity, the term encompasses much more. Other groups of

people display distinct cultural characteristics and in turn receive culturallyinsensitive responses from society. Examples of such groups include the poor,the homeless, and the disabled.

Cultural competence: The ability and the will to respond to the unique needs ofan individual client or family that arise from the client’s culture and the ability touse the person’s cultural strengths as resources or tools to assist with thetreatment, intervention or helping process. Cultural competence is generallyregarded as a long term process towards which one strives. In addition, culturalcompetence can be thought of as an attribute of an individual provider and as anattribute of an organization.

Department of Human Services (DHS) (formerly Family IndependenceAgency or FIA): Michigan state agency that directs the operations of publicassistance and service programs in every county in Michigan. In particular, DHSdetermines eligibility for the Medicaid insurance programs and provides AdultServices to persons who are Medicaid eligible.

Depressed skull fracture: This is when bones of the skull are broken orcracked with loose bone fragments actually placing pressure or penetrating thebrain, thereby causing damage.

Developmental disability (DD) -- According to the Michigan Mental HealthCode, a developmental disability is a severe mental or physical impairment that:1) occurs before an individual is 22 years old; 2) is likely to continue indefinitely;3) results in substantial functional limitation in three or more of the followingareas of major life activities: self care, mobility, learning, self direction, receptive& expressive language, capacity for independent living, and economic selfsufficiency; and 4) reflects the individual’s need for special, interdisciplinarytreatment, or other services that are of lifelong or extended duration. For minorsfrom birth to age five, a developmental disability is a substantial developmentaldelay or a specific congenital or acquired condition with a high probability ofresulting in developmental disability if services are not provided.

Diffuse injury: An injury to the brain in which damage is not limited to onelocation in the brain, but affects multiple areas.

Eligibility: Requirements that need to be met by the applicant, in order toreceive services or enroll in a program.

Executive functioning: Cognitive functions having to do with planning, abstractreasoning, problem-solving, information processing, judgement,workingmemory, etc.

Glasgow Coma Scale (GCS): The GCS is commonly used for initial assessmentof brain injury severity. The GCS uses a 15 point scale to rate eye opening,motor, and verbal response functions. Unfortunately in practice, the time of theassessment can vary (e.g., at the scene of injury, upon arrival in the emergencydepartment, etc.) -- making results from one patient to the next difficult tocompare. Moreover, GCS results may not be valid for children, people under theinfluence of alcohol, or people with language differences.

HELPS: Acronym for the brain injury screening tool described in this training.Each letter of the acronym stands for one of the five questions of the tool.

Hematoma: If the blood vessels damaged by the impact inside the skull arelarge enough, they may bleed enough to create a pool of blood or hematoma. Ahematoma can cause brain injury by directly damaging the neurons it comes incontact with or by squeezing neurons through increased pressure in the braindue to its volume. The treatment for a hematoma is to surgically drain it, ifpossible.

Hypovolemic shock: After injury, loss of blood volume can further compromisehealthy brain tissue.

Incidence: In reference to TBI data, incidence refers to the number of a giventype of events, or new instances of TBI, in a year.

Increased intracranial pressure: intracranial pressure occurs because of abuild-up of pressure within the skull. Because the brain, membranes andcerebrospinal fluid are encased with the bones of the skull, the fluid formed as aresult of swelling or bleeding "backstop" in the brain causing increased pressureinside the brain which results in further damage to brain tissue.

Individualized Education Program (IEP): A written plan for a child or studentwho has a disability and who qualifies for special education services. The IEPmust include, among many other specific features, measurable annual academicand functional goals; and the types of special educational and related servicesand supplementary aids and services that the child will receive (such as speechand language services, or physical or occupational therapy) to enable the child orstudent to be involved in and make progress in the general educationcurriculum. The IEP is developed, reviewed and revised in a meeting consistingof a team that includes school personnel, family members, and other individuals.

Individuals with Disabilities Education Act (IDEA): A federal law, firstenacted in 1975 and most currently re-authorized and revised in 2004, thatrequires public schools to determine whether a child has a disability, develop aplan that details the education and support services that children and studentswill receive, provide the services, and re-evaluate the plan periodically. There isfederal funding available for some of these responsibilities.

Initiation: The act of beginning a task or setting in motion a course of events.

Long Term Care services: Long term care (LTC) services are the medical,social, personal care, and supportive services needed by people who have lostcapacity for self-care due to a chronic illness or condition. It's different fromacute health care because assistance is required for an indefinite period of time,and because recovery of function may be incomplete.

Medicaid Fee for Service (FFS): A Medicaid service plan in which coveredservices are reimbursed separately. Most individuals in Michigan who are onMedicaid are not covered by Medicaid FFS, but are enrolled in a Medicaid(managed care) Health Plan. (Although most Long Term Care is covered byMedicaid FFS)

Mental illness (MI): A mental condition characterized by a substantial disorderof thought or mood that interferes with an individual’s ability to function in day-to-day life.

Michigan Department of Community Health (MDCH): The department ofstate government that is responsible for health policy and management of thestate's publicly-funded health service systems.

Michigan Department of Education (MDE): The department of stategovernment that is responsible for, or interacts with those responsible for, allaspects of education of the state’s 1.8 million children and students in publicschools. An eight-member elected State Board of Education oversees the work ofthe department.

Michigan Protection and Advocacy Service (MPAS): A private, nonprofitorganization that provides information and advocacy to people with disabilities inMichigan.

Michigan Rehabilitation Services (MRS): Part of the Department of Laborand Economic Growth, MRS offers services necessary to assist eligible individualswith disabilities in preparing for, securing, retaining, or regaining employment.

Mild TBI: Medically defined as any period of loss of consciousness (typically lessthan 15 minutes); any loss of memory for events immediately before or after theaccident; or any alteration in the mental state at the time of the accident (e.g.,feeling dazed, disoriented or confused). Mild TBI generally does not includeposttraumatic amnesia greater than 24 hours (NIH, 1998). Mild TBI is associatedwith a Glasgow Coma Scale score of 13-15.

Moderate TBI: Medically defined as a loss of consciousness that can lastminutes or a few hours and is followed by a few days or weeks of confusion.Persons with moderate TBI may have a longer period of impaired consciousness,more impaired verbal memory shortly after the injury and a lower likelihood ofachieving a good recovery within 6 months than persons suffering mild TBI (NIH,1998). Moderate TBI often is associated with a GCS of 9 -- 12.

Motor functioning: Involving or relating to movements of the muscles.

Multidisciplinary Evaluation Team (MET): The team that assesses studentsto determine eligibility for special education or early intervention services.

Negative reinforcement (escape and avoidance): When the consequence ofa behavior resulted in avoiding or getting out of an unpleasant situation, and theeffect is to encourage the behavior again in the future.

Neurologic: Related to the nervous system and its structure and functions.

Neurologic exam: An examination conducted by a neurologist, which mightinclude the following: a detailed medical history and assessment of neurologicfunctions (reflexes, cranial nerve functioning, gross movements, muscle tone,and perception of sensory stimuli).

Neuropsychological assessment/evaluation: A thorough testing of cognitive,emotional, and intellectual functioning that can assist in diagnosing brain injury

and planning care.

Neurons: Impulse conducting cells that constitute the brain, spinal column, andnerves, consisting of a nucleated cell body with one or more dendrites and asingle axon.

Neuropsychologist: A professional who evaluates the relationship betweenbrain and behavior; conducts extensive testing and counseling; does notprescribe medication.

Occupational therapy (OT): The use of self-care, work and play activities toincrease independent function, enhance development and prevent disability; OTmay include the adaptation of a task or the environment to achieve maximumindependence. An Occupational Therapist is a professional who helps a personto regain skills in activities of daily living (e.g., dressing, eating, bathing, etc.)and routine “occupations” (e.g., cooking, shopping, scheduling, driving, etc.).

Physical Disability Services (PDS): PDS are those necessary services andexpenditures targeted for medically stable persons 18 years of age or older whohave functional limitations which are physical in nature. Services are provided toenable functionally limited people to live as independently as possible.

Physical therapy (PT): Treatment that uses physical agents such as exerciseand massage to restore or facilitate recovery of physical abilities. A PhysicalTherapist is a professional who treats injury or physical dysfunction withexercises and other physical treatments to restore or facilitate recovery ofphysical abilities.

Positive reinforcement (rewards): When good things happen following abehavior and that behavior is repeated in the future in order to achieve thatresult, the behavior is likely to continue -- it has been reinforced.

Posttraumatic amnesia: The loss of memories of events after the brain injury;also refers to the length of time that it takes for the return of full consciousnessand memory for recent events following trauma.

Posttraumatic depression: The occurrence of the psychiatric condition ofdepression following brain injury.

Primary event: In reference to TBI, brain damage, such as contusion andaxonal shearing, that occurs during the initial phase of injury (during impact).The primary event is distinguished from the secondary event, or subsequentbrain damage, that occurs because of the body’s reaction to the primary event(such as brain swelling and anoxia).

Psychiatric evaluation: An assessment of mental, emotional, or behavioraldisorders.

Psychological/behavioral strategies of pain management: Behavioraltechniques to deal with physical pain. The focus of treatment is to increase aperson’s ability to manage, function, and cope with pain. Such techniques mayinclude relaxation training, developing coping skills to deal with emotions such assadness, anxiety, or anger, and to deal with beliefs and expectations related topain. Problem-solving techniques and communication skills regarding expressing

and dealing with pain may also be included.

Psychological testing: Standardized assessment of emotional and intellectualfunctioning, and the personality characteristics of an individual.

Skull fracture: Bones of the skull are broken or cracked. Injury severity canrange from simple, undisplaced fractures to compound fractures which involveloose bone fragments placing pressure on or penetrating the brain.

Secondary event: In reference to TBI, this is the injury or complicationresulting from the reaction of the brain to the primary event, including: brainswelling (edema), pooling of blood (hematoma), increased intracranial pressure,hypovolemic shock, and loss of oxygen (anoxia).

Seizures: Waves of synchronized nerve cell activation that can involve the entirebrain, or can be confined to a particular area of the brain. When the entire brainis involved it is called a generalized seizure or grand mal; and symptomsinclude loss of consciousness, rhythmic jerking body movements, and otherpossible symptoms. If only part of the brain is involved, it is called a partial orfocal seizure; generally the person does not lose consciousness and othersymptoms depend on the area of the brain affected.

Self monitoring: Regarding behavior, the ability to act appropriately and refrainfrom inappropriate behavior based on a given social situation.

Sequencing: The ability to recognize the necessary order of events.

Severe TBI: Medically defined by a loss of consciousness, or coma, for 6 hoursor longer, either immediately after the injury or after an intervening period ofclarity. Severe TBI is often associated with a GCS of 8 or lower.

Sleep routines: The activities and environment surrounding sleep can affect aperson’s ability to get enough rest. The following might have an impact: going tobed on a consistent schedule, limiting sleep during the day, having a relaxingbedtime routine, having a comfortable sleeping environment, etc.

Sleep study: Monitoring the cycles and stages of sleep using direct observationor by using electrodes to make continuous recordings of brain waves, electricalactivity of muscles, eye movement, respiratory rate, blood pressure, bloodoxygen saturation, and heart rhythm. The test is performed for people who sufferfrom insomnia, excessive daytime sleepiness, obstructive sleep apnea, breathingdifficulties during sleep, or behavior disturbances during sleep.

Spasticity: Involuntary increase in muscle tone (energy sent to the musclesfrom the brain and spinal cord) which causes the muscle to resist being stretchedand move in an coordinated fashion.

Special Education and Early Intervention services: The commonly usedphrase that encompasses the wide variety of services and supports availablethrough intermediate, local public school districts and charter schools (PublicSchool Academies) to eligible children and students from the ages of birththrough age 21, who have not earned a regular high school diploma. Servicesavailable are based on federal and state laws and rules and are often consideredaccording to the ages of the youth being served: Early On is a system inMichigan designed to arrange for services and supports for infants and toddlers

ages birth to 3 years and their families; while Special Education in Michiganusually means the wide array of services and supplemental aids and services forchildren and students through ages 25. (See also Individualized EducationProgram and Individuals with Disabilities Education Act).

Speech and language therapist: A professional who evaluates and treatscommunication and cognitive skills including speaking and understanding writtenand spoken language.

Substance Abuse services: Services to treat substance abuse issues that mayinclude types of outpatient therapy, short-term and long-term residentialtreatment, detoxification, and intensive outpatient services.

Traumatic Brain Injury (TBI): TBI is defined as an alteration in brain function,or other evidence of brain pathology, caused by external force.

Links and Additional Resources

Additional information on public services for individuals with TBI in Michigan is available atwww.michigan.gov/tbi. If you want more information about a topic you do not see here, try BIAMI firstat www.biami.org. Also see other websites listed below under “General brain injury information,advocacy, and support.”

Try the links below for more detailed information (presented in alphabetical order by topic area):

Assistive technologyAgency/organization websites

Michigan Assistive Technology Loan Fundhttps://www.disability.gov/viewResource?id=1830858Michigan Assistive Technology Programhttp://www.copower.org/assistive-tech.htmlMichigan’s Integrated Technology Supports (for Michigan PK-12 public schools) http://mits.cenmi.org/LendingLibrary.aspx

ChildrenAgency/organization websites

Michigan Department of Education (MDE) http://www.michigan.gov/mdeMichigan Intermediate School District (ISD) – County Office Informationhttp://michigan.gov/cepiNational Dissemination Center for Children with Disabilitieshttp://www.nichcy.org/

Documents/training materialsBack to School [After a TBI] http://www.biausa.org/LiteratureRetrieve.aspx?ID=43317&A=SearchResult&SearchID=1989375&ObjectID=43317&ObjectType=6A Training Program for School Personnel in Indiana http://www.biausa.org/LiteratureRetrieve.aspx?ID=47494&A=SearchResult&SearchID=1989375&ObjectID=47494&ObjectType=6Guidance & Technical Assistance from the Office of Special Education and EarlyIntervention Services http://focus.cenmi.org/wp-content/uploads/2010/08/GATA06-02.pdfTeaching Strategies for Students with Brain Injuries http://www.biausa.org/LiteratureRetrieve.aspx?ID=48657&A=SearchResult&SearchID=1989346&ObjectID=48657&ObjectType=6Traumatic Brain Injury (TBI) Central - Students with Traumatic Brain Injury:Identification, Assessment, and Classroom Accommodations http://www.mssm.edu/research/centers/brain-injury-research-center-of-mount-sinai/publications/students-with-tbi

Concussion/Mild Traumatic Brain InjuryAgency/organization websites

Centers for Disease Control and Prevention - “Heads Up: Concussion in HighSchool Sports” http://www.cdc.gov/concussion/HeadsUp/high_school.htmlCenters for Disease Control and Prevention - “Heads Up: Concussion in YouthSports”http://www.cdc.gov/concussion/HeadsUp/youth.htmlCenters for Disease Control and Prevention - “Heads Up to Schools: Know YourConcussion ABCs”http://www.cdc.gov/concussion/HeadsUp/schools.html

http://www.michigan.gov/tbi

http://www.biami.org/

https://www.disability.gov/viewResource?id=1830858

http://www.copower.org/assistive-tech.html

http://mits.cenmi.org/LendingLibrary.aspx

http://www.michigan.gov/mde

http://michigan.gov/cepi

http://www.nichcy.org/

http://www.biausa.org/LiteratureRetrieve.aspx?ID=43317&A=SearchResult&SearchID=1989375&ObjectID=43317&ObjectType=6




http://focus.cenmi.org/wp-content/uploads/2010/08/GATA06-02.pdf



http://www.mssm.edu/research/centers/brain-injury-research-center-of-mount-sinai/publications/students-with-tbi

http://www.mssm.edu/research/centers/brain-injury-research-center-of-mount-sinai/publications/students-with-tbi

http://www.cdc.gov/concussion/HeadsUp/high_school.html

http://www.cdc.gov/concussion/HeadsUp/youth.html

http://www.cdc.gov/concussion/HeadsUp/schools.html

Centers for Disease Control and Prevention - "Heads Up: Brain Injury in YourPractice Tool Kit" (available to order, free of charge) http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.htmlSports Concussion Information for Athletes - BIAMIhttp://sportsconcussionsmichiganathletes.com/Sports Concussion Information for Coaches - BIAMIhttp://sportsconcussionsmichigancoaches.com/Sports Concussion Information for Parents - BIAMIhttp://sportsconcussionsmichiganparents.com/

Cultural competenceAgency/organization websites

National Center for Cultural Competence http://gucchd.georgetown.edu/nccc/index.htmlNational Library of Medicine – American Indian Health http://americanindianhealth.nlm.nih.gov/National Library of Medicine – Asian American Health http://asianamericanhealth.nlm.nih.gov/

Documents/training materialsMinnesota Department of Human Services – Guidelines for Culturally CompetentOrganizations https://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-3963-ENG

Defense and veterans' issuesAgency/organization websites

Defense and Veterans Brain Injury Center http://www.dvbic.orgMichigan Department of Military and Veterans Affairs http://www.michigan.gov/dmvaMilitary HOMEFRONT is the central source for Service members and families toobtain information about all Quality of Life programs and services http://www.militaryhomefront.dod.mil/Military Severely Injured Joint Support Operations Center (MSIJSOC) http://www.military.com/supportTraumatic Brain Injury: The Journey Home (for Veterans) http://www.traumaticbraininjuryatoz.org

Documents/training materials“Veterans Health Benefits 101 for TBI Advocates,” Archived webcast, Maternaland Child Health Bureau (MCHB) of the Department of the US Department ofHealth and Human Services, Health Resources and Services Administration http://128.248.232.90/archives/mchb/dcafh/tbi/july2005/mchbtbijuly2005transcript.htmTraumatic Brain Injury Among Veterans http://www.nashia.org/pdf/tbi_among_veterans_may_2011.pdf

Employment and vocational rehabilitation of people with TBIAgency/organization websites

Freedom to Work Web Site http://www.freedomtoworkmedicaid.comMichigan Department of Licensing and Regulatory Affairs - Michigan RehabilitationServices http://www.michigan.gov/mdcd/0,1607,7-122-25392---,00.html

Documents/training materialsAchieving Vocational Success After Traumatic Brain Injuryhttp://www2.ed.gov/rschstat/research/pubs/vrbriefs/vrbrief-success-after-tbi.pdfJob Accommodation Network – Work-site Accommodation Ideas for Persons withBrain Injuryhttp://www.jan.wvu.edu/media/BrainInjury.htmlMichigan Department of Career Development http://www.state.mi.us/career/Core/pdfactsheet/MRS-198.htmlTraumatic Brain Injury Facts: Vocational Rehabilitation and Employment Services

http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html

http://sportsconcussionsmichiganathletes.com/

http://sportsconcussionsmichigancoaches.com/

http://sportsconcussionsmichiganparents.com/

http://gucchd.georgetown.edu/nccc/index.html

http://americanindianhealth.nlm.nih.gov/

http://asianamericanhealth.nlm.nih.gov/

https://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-3963-ENG

http://www.dvbic.org/

http://www.michigan.gov/dmva

http://www.militaryhomefront.dod.mil/

http://www.military.com/support

http://www.traumaticbraininjuryatoz.org/

http://128.248.232.90/archives/mchb/dcafh/tbi/july2005/mchbtbijuly2005transcript.htm

http://128.248.232.90/archives/mchb/dcafh/tbi/july2005/mchbtbijuly2005transcript.htm

http://www.nashia.org/pdf/tbi_among_veterans_may_2011.pdf

http://www.freedomtoworkmedicaid.com/

http://www.michigan.gov/mdcd/0,1607,7-122-25392---,00.html

http://www2.ed.gov/rschstat/research/pubs/vrbriefs/vrbrief-success-after-tbi.pdf

http://www.jan.wvu.edu/media/BrainInjury.html

http://www.state.mi.us/career/Core/pdfactsheet/MRS-198.html

http://nashia.org/pdf/hotopics/vrbrief-success-after-tbi%202010.pdf

General brain injury information, advocacy, and supportAgency/organization websites

Brain Injury Association of Michigan (BIAMI) http://www.biami.orgBrain Injury Association of America (BIAA) www.biausa.orgBrainLine.org www.brainline.orgCDC: Injury Control and Prevention: Traumatic Brain Injury http://www.cdc.gov/TraumaticBrainInjury/Center for Neuro Skills(CNS)www.neuroskills.com/resources.shtmlCommission on Accreditation of Rehabilitation Facilities (CARF)www.carf.orgDepartment of Health and Human Services, Health Resources and ServicesAdministration - Traumatic Brain Injury Program http://www.hrsa.gov/gethealthcare/conditions/traumaticbraininjury/Lash & Associates Publishing / Training, Inc. http://www.lapublishing.com/Michigan Department of Community Health - Injury & Violence Prevention Section

https://www.michigan.gov/mdch/0,1607,7-132-54783_54879---,00.htmlMichigan Disability Rights Coalition (MDRC) http://www.copower.org/Michigan Protection and Advocacy Service (MPAS) http://www.mpas.orgNational Association of State Head Injury Administrators (NASHIA) www.nashia.orgNational Information Rehabilitation Center (NARIC) www.naric.comNational Resource Center for Traumatic Brain Injury http://www.neuro.pmr.vcu.edu/The Southeastern Michigan Traumatic Brain Injury System (SEMTBIS) http://www.semtbis.org/semtbis/The Rehabilitation Research and Training Center on Community Integration ofPersons with TBI at Texas Institute for Rehabilitation and Research http://www.tbicommunity.org/resources/index.htm

Documents/training materialsArchived webcasts of the HRSA-MCHB http://www.mchcom.com (click on ‘Archived webcasts’, then ‘TBI’)Brain Injury Research Center of Mount Sinai School of Medicine http://www.mssm.edu/research/centers/brain-injury-research-center-of-mount-sinai/publicationsModel Systems Knowledge Translation Center - TBI Consumer Information http://msktc.washington.edu/tbi/factsheets/index.asp

Housing and residential placementAgency/organization websites

Disability Network Michigan http://dnmichigan.org/Department of Human Services, Adult Services http://www.michigan.gov/dhs/0,1607,7-124-5452_7122---,00.htmlDepartment of Human Services, Michigan Community Service Commission http://www.michigan.gov/mcsc/0,1607,7-137-55459---,00.htmlDepartment of Human Services, Statewide Search for Adult Foster Care/Homesfor the Aged Facilities http://www.cis.state.mi.us/brs_afc/sr_afc.aspHabitat for Humanity http://www.habitat.org/local/affiliate.asp?place=59

http://nashia.org/pdf/hotopics/vrbrief-success-after-tbi%202010.pdf

http://www.biami.org/

http://www.biausa.org/

http://www.brainline.org/

http://www.cdc.gov/TraumaticBrainInjury/

http://www.neuroskills.com/resources.shtml

http://www.carf.org/

http://www.hrsa.gov/gethealthcare/conditions/traumaticbraininjury/

http://www.lapublishing.com/

https://www.michigan.gov/mdch/0,1607,7-132-54783_54879---,00.html

http://www.copower.org/

http://www.mpas.org/

http://www.nashia.org/

http://www.naric.com/

http://www.neuro.pmr.vcu.edu/

http://www.semtbis.org/semtbis/

http://www.tbicommunity.org/resources/index.htm

http://www.mchcom.com/

http://www.mssm.edu/research/centers/brain-injury-research-center-of-mount-sinai/publications

http://www.mssm.edu/research/centers/brain-injury-research-center-of-mount-sinai/publications

http://msktc.washington.edu/tbi/factsheets/index.asp

http://dnmichigan.org/

http://www.michigan.gov/dhs/0,1607,7-124-5452_7122---,00.html

http://www.michigan.gov/mcsc/0,1607,7-137-55459---,00.html

http://www.cis.state.mi.us/brs_afc/sr_afc.asp

http://www.habitat.org/local/affiliate.asp?place=59

Michigan Home Ownership Coalition - HomeChoice Mortgage http://www.hud.gov/local/mi/homeownership/mihoc.cfmMichigan’s MI Choice Waiver Program http://www.michigan.gov/mdch/0,1607,7-132-2943_4857_5045---,00.htmlMichigan Office of Services to the Aging http://www.miseniors.netMichigan Statewide Independent Living Council http://misilc.org/National Association of Area Agencies on Aging – Links to state specific agencieshttp://n4a.org/about-n4a/?fa=aaa-title-VI#MIRefinance & Mortgage Guide for People with Disabilities http://www.refinancemortgagerates.org/mortgage-guide-for-people-with-disabilities/Tenant-based Section 8 Housing Vouchers: MSHDA http://www.michigan.gov/mshda/0,1607,7-141-5555-22085--,00.htmlTenant-based Section 8 Housing Vouchers: Public Housing Authorities (PHA) http://www.hud.gov/offices/pih/pha/contacts/states/mi.cfmUSDA Rural Development http://www.rurdev.usda.gov/mi/

Management of TBI for cliniciansDocuments/training materials

Centers for Disease Control and Prevention - "Heads Up: Brain Injury in YourPractice Tool Kit" (available to order, free of charge) http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.htmlVeterans Health Initiative - Traumatic Brain Injury, Independent Study CourseReleased: April 2010http://www.publichealth.va.gov/docs/vhi/traumatic-brain-injury-vhi.pdf

Public agencies in MichiganAgency/organization websites

Community Mental Health Services Programs – County Office Informationhttp://www.michigan.gov/documents/cmh_8_1_02_37492_7.PDFDepartment of Human Services (DHS) - Home http://www.michigan.gov/dhsDepartment of Human Services – County Office Information http://www.michigan.gov/dhs/0,1607,7-124-5461---,00.htmlMichigan Association of Community Mental Health Boards (MACMHB) http://www.macmhb.org/Michigan Department of Community Health (MDCH) http://www.michigan.gov/mdchMichigan Department of Education (MDE) http://www.michigan.gov/mdeMichigan Department of Licensing and Regulatory Affairs - Michigan RehabilitationServiceshttp://www.michigan.gov/mdcd/0,1607,7-122-25392---,00.htmlMichigan Rehabilitation Services - Locations by City http://www.michigan.gov/mdcd/0,1607,7-122-25392_41191---,00.html

Screening and assessmentAgency/organization websites

The Center for Outcome Measurement in Brain Injury http://www.tbims.org/combi/

Documents/training materialsBrain Injury Resource Center of Mount Sinai: Brain Injury Screeninghttp://www.mssm.edu/research/centers/brain-injury-research-center-of-mount-sinai/resources/technical-assistance/brain-injury-screeningOhio Valley Center for Brain Injury Prevention and Rehabilitation – TBI Screeninghttp://ohiovalley.org/informationeducation/screening/

Statistics

http://www.hud.gov/local/mi/homeownership/mihoc.cfm

http://www.michigan.gov/mdch/0,1607,7-132-2943_4857_5045---,00.html

http://www.miseniors.net/

http://misilc.org/

http://n4a.org/about-n4a/?fa=aaa-title-VI#MI

http://www.refinancemortgagerates.org/mortgage-guide-for-people-with-disabilities/

http://www.refinancemortgagerates.org/mortgage-guide-for-people-with-disabilities/

http://www.michigan.gov/mshda/0,1607,7-141-5555-22085--,00.html

http://www.hud.gov/offices/pih/pha/contacts/states/mi.cfm

http://www.rurdev.usda.gov/mi/

http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html

http://www.publichealth.va.gov/docs/vhi/traumatic-brain-injury-vhi.pdf

http://www.michigan.gov/documents/cmh_8_1_02_37492_7.PDF

http://www.michigan.gov/dhs

http://www.michigan.gov/dhs/0,1607,7-124-5461---,00.html

http://www.macmhb.org/

http://www.michigan.gov/mdch

http://www.michigan.gov/mde

http://www.michigan.gov/mdcd/0,1607,7-122-25392---,00.html

http://www.michigan.gov/mdcd/0,1607,7-122-25392_41191---,00.html

http://www.tbims.org/combi/

http://www.mssm.edu/research/centers/brain-injury-research-center-of-mount-sinai/resources/technical-assistance/brain-injury-screening

http://www.mssm.edu/research/centers/brain-injury-research-center-of-mount-sinai/resources/technical-assistance/brain-injury-screening

http://ohiovalley.org/informationeducation/screening/

Agency/organization websitesCenters for Disease Control and Prevention – Traumatic Brain Injury: Topic Home http://www.cdc.gov/node.do/id/0900f3ec8000dbdc

Substance abuseAgency/organization websites

Ohio Valley Center for Brain Injury Prevention and Rehabilitation – SubstanceAbuse and Brain Injurieshttp://ohiovalley.org/informationeducation/substanceuseinformation/Substance Abuse & Mental Health Services Administration – Substance AbuseTreatment Facility Locatorhttp://www.findtreatment.samhsa.gov/

Documents/training materials2004/2005 Regional Coordinating Agencies Contact Listhttp://www.michigan.gov/mdch/0,1607,7-132-2941_4871-14983--,00.html

Questions? Contact Us.

For more information about specific service programs in Michigan, contact:

Michael Daeschlein

Manager, Home and Community-Based Services Section at the Michigan Department ofCommunity Health

[email protected]

For comments and feedback regarding this training: [email protected]

http://www.cdc.gov/node.do/id/0900f3ec8000dbdc

http://ohiovalley.org/informationeducation/substanceuseinformation/

http://www.findtreatment.samhsa.gov/

http://www.michigan.gov/mdch/0,1607,7-132-2941_4871-14983--,00.html

