Application of Behavioral Health Technology Tools in the Clinical Care of Mild Traumatic Brain Injury

Application of Behavioral Health Technology Tools
in the Clinical Care of mTBI
January 15, 2015, 1-2:30pm (EST)
Maj. Pamela DiPatrizio, AN, MSN, CEN, CPEN
Chief, Office of Education Outreach
Defense and Veterans Brain Injury Center (DVBIC)
Defense Centers of Excellence for Psychological
Health and Traumatic Brain Injury (DCoE)
Silver Spring, Md.
David C. Cooper, Psy.D.
Clinical Psychologist, Mobile Applications Lead
National Center for Telehealth & Technology (T2)
Defense Centers of Excellence for Psychological
Health and Traumatic Brain Injury (DCoE)
Joint Base Lewis-McChord, Wash.
Presenters:
Moderator:

Webinar Overview
The Clinical Practice Guidelines produced by the departments of Defense and
Veterans Affairs provide a framework for ensuring evidence-based care for
patients with mTBI. This webinar will demonstrate two mobile applications
produced by the National Center for Telehealth & Technology that offer providers
evidence-informed tools for the treatment and engagement in clinical care of
patients with mTBI. The presenter will review some of the empirical findings that
support the use of these apps, and will demonstrate how to incorporate these
tools into current clinical practice. In addition, he will highlight several emerging
tools that may have some promise for future use with this population.
During this webinar, participants will learn to:
 Compare innovative, behavioral-health technology tools and describe some of
the empirical evidence for their integration in clinical care with mTBI patients.
 Discuss the use of behavioral-health technology tools as assistive devices in
mTBI rehabilitation to facilitate recovery from the adverse effects of mTBI and
increase engagement in care.
 Distinguish between evidence-based standard of care, as described in the
Clinical Practice Guidelines and the acceptable use of evidence-informed
technology tools to supplement clinical care.
2

David Cooper, Psy.D.
3
 Dr. David Cooper is a Clinical Psychologist and
the Mobile Health Program Lead at the National
Center for Telehealth & Technology (T2).
 He earned his Psy.D. and M.A. in Clinical
Psychology from the American School of
Professional Psychology at Argosy University in
Washington, DC.
 Dr. Cooper has been involved in a number of
development projects at T2, including an
application that was selected by the Senior
Military Medical Advisory Committee to be part of
a national pilot study looking at innovative ways
to reduce obesity.
Photo courtesy of: David C. Cooper, PsyD

Disclosures
 The views expressed in this presentation are those of the
presenter and do not reflect the official policy of the
Department of Defense or the U.S. Government.
 Dr. Cooper has no relevant financial relationships to disclose.
 Dr. Cooper will be discussing web and mobile applications
that have been developed by the Defense Department,
including those developed by the National Center for
Telehealth & Technology (T2). Some of these applications
may fall under FDA device regulations, and in those cases we
will consult with the USAMRMC Division of Regulated
Activities and Compliance for guidance.
4

T2 is…
 The National Center for Telehealth &
Technology
 A DoD source for:
 Telehealth policy
 Research on suicide prevention, TBI, and
psychological health
 Mobile applications
 Websites
 Innovation
5

Polling Question #1
 How do you think technology could help
you improve what you’re already doing?
6

Framework for mTBI care in VA/DoD
 VA/DoD Clinical Practice Guidelines
 Promotes evidence-based assessment,
diagnosis, treatment and management of patients
diagnosed with mTBI
 Provides guidelines and recommendations
regarding:
 Return to Work/Duty Activity
 Early Intervention
 Symptom Management
7
(Department of Veterans Affairs/Department of Defense, 2009)

Times are a’ changing
 For 50 years little changed in mTBI
assessment and treatment
 LOTS of paper
 Same tools
 But in the last 5 – 10 years, we have seen
an explosion of new possibilities, including
renewed efforts to identify optimal methods
of TBI rehab
(Cifu et al., 2010)
8

mTBI Rehabilitation
 Substantial evidence to support
interventions for attention, memory, social
communication skills, executive function,
and for comprehensive-holistic
neuropsychological rehabilitation after TBI
(Cicerone et al., 2011)
 Lots of challenges
 Symptom Management
 Compliance
 Return to Duty
9

mTBI Symptom Management
 Common symptoms post-injury
 Headaches
 Sleep disturbances
 Mood changes
 Decreased coordination or balance
 Fatigue
 Nausea
(Hoge, McGurk, Thomas, Cox, Engel & Castro, 2008; Kashluba, Paniak & Casey, 2008)
 All are challenging enough for us, much less
someone with mTBI
10

Return to Duty
 On-the-job training
 Activities of daily living (ADLs)
 Research is unclear on why some patients
slow to return (Wäljas et al., 2014)
 Technology offers some possible solutions
to help
 Need to separate the good from the bad
11

Clinical Reasoning w/ Technology
 Yamkovenko (2014) conducted an interview with
occupational therapists, Rob Ferguson, MHS,
OTRL and Doug Rakoski, OTD, OTR/L, ATP
from the University of Michigan, and discussed
how their use of technology in the clinical care of
stroke patients has:
 Expanded evidence-based practice with everyday
tools
 Allowed technology to facilitate motor, cognitive, and
perceptual abilities
 Encouraged high repetitions of activity in engaging
technologies, such as video games
12

Phone as Assistive Device
 Assistive technology for cognition (ATC)
 Cost-effective
 Early intervention
 Emotionally supportive
 Adaptable, ubiquitous workflow
13

 Cost-effective
 Particularly when compared to time in the clinic
(Luxton, Hansen & Stanfill, 2014)
 Early intervention
 Allows for evidence-based practice to
begin even before intake
 Takes into account current challenges
(Hyatt, Davis, & Barroso, 2014)
14

 Emotionally supportive
 Working with what the patient wants, rather
than forcing what we want
 Adaptable, ubiquitous workflow
 Works in home, office, clinic, etc.
15

But what about…?
 Are they available to those with low income?
 Do they work the same?
 Is there an evidence base?
 Do patients like it?
16

Available to low income?
 Of adults making less than $30K…
 77% 18-29 own a smartphone
 47% 30-49 own a smartphone
 45% go online mostly with their smartphone
 Rates rising ~15-20% over the past few years
17
(Smith, 2013)

Do they work the same?
 Assessments
 Psychometrically equivalent
 Treatments
 Research showing good effect sizes
 Web: high effects, around .5 or greater
(Richards & Richardson, 2012)
 Apps: moderate to high effects, around .3 to .5
(Donker et al., 2013)
18

Is there an evidence base?
 Effective tool for symptom management and symptom
assessments are psychometrically valid
(Bush, Skopp, Smolenski, Crumpton, & Fairall, 2013; Donker, Petrie, Proudfoot,
Clarke, Birch, & Christensen, 2013; Gaggioli, & Riva, 2013)
 Again, similar effect sizes
(Richards & Richardson, 2012; Donker et al., 2013)
 Translational research
 Challenging to be on the forefront
 Evidence-informed practice
 Evidence-based
 Requires knowledge of both
19

Do patients like it?
 Age dependent but…
 70% would like to download an app to
their phone in order to track their condition
on a daily basis (Torous et al., 2014)
 Similar for veterans (Erbes et al., 2014)
 Tech is one way, shouldn’t be the only way
20

Specific Apps and
Specific Problems
21

T2 Mood Tracker
Monitor and track emotional
experiences over a period of days,
weeks and months.
Features
 Self-rating on pre-populated categories
 Full note adding
 Graphed results
 Fully customizable categories
 User-set reminders for self-rating
 Send results to providers
Photo by: National Center for Telehealth & Technology22

T2 Mood Tracker
 Track a variety of factors
 Emotional health
 Pain
 Sharp vs. dull
 Intense vs. slight
 Constant vs. brief
 Research support
(Bush et al., 2013; Bush, Ouelette & Kinn, 2014)
23

Adding / modifying scales
Photo by: National Center for Telehealth & Technology
24

T2 Mood Tracker
25

Concussion Coach
Concussion Coach was designed for veterans,
service members, and others who have
symptoms that may be related to concussion,
or mild-to-moderate traumatic brain injury. This
app can be used by itself, but it may be more
helpful when used along with treatment from a
health provider.
Features include:
 Education on symptoms and treatment.
 Tools for screening / tracking symptoms.
 Relaxation exercises and tools for
managing problems related to concussion.
 Direct links for community-based resources
and support.
26 Photo by: National Center for Telehealth & Technology

Concussion Coach
 All-in-one tool
 Sections
 Learn
 Self-assessment
 Subjective Units of Distress Scale (SUDS)
 Neurobehavioral Symptom Inventory (NSI)
 Manage this moment
 Build resilience
 Resources and support
27

Learning and Assessment
28

Tools
29

Resources
30

CBTi (Insomnia) Coach
T2 collaborated with the VA's National
Center for PTSD to develop this app to
assist veterans and active duty personnel
(and civilians) who are experiencing
symptoms of insomnia. It is intended to be
used as an adjunct to psychological
treatment but can also serve as a stand-
alone education tool.
Features:
 Self-assessment of insomnia symptoms
 Sleep diary to track sleep habits
 Sleep “prescription” to regulate wake and
bed times
 Assistance in finding immediate support
 Customized support information
31 Photo by: National Center for Telehealth & Technology

CBTi Coach
 Sections
 Sleep Diary
 Tools
 Progressive relaxation, cognitive exercises
 Assessment
 Insomnia Severity Index (ISI)
32

Diary & Assessment
33

Tools & Information
34

Tools & Information
35

mTBI Pocket Guide
36
Clinical Practice Guidelines for
treatment of mild Traumatic Brain
Injury
Features:
 Quick results with coding guidance
 Symptom management lists
 Summary of clinical
recommendations
 Patient education resources
 Clinical tools and resources

Polling Question #2
 Now that you’ve heard more, how likely
are you to use some of these mobile apps
with your patients?
37

Polling Question #3
• What would make you more likely to use
these and other apps with patients?
38

Reading
 RSVP (Rapid Serial Visual Presentation)
 Spritz / Squirt
 (Squirt.io)
 Potential to help with saccadic provoked
symptoms post-injury.
39
Photo by: http://www.spritzinc.com/test

Time Management
 Pomodoro
 http://www.brainlinemilitary.org/content/multime
dia.php?id=7779
 Many apps to help / augment time
management
 More incorporating automatic / natural
language entry.
41

Mobile games for
Occupational Therapy
 Emerging movements for fine motor
recovery
 Start on an iPad and work down.
 Incorporate accessories that can reinforce
skills
 Bluetooth buttons, stylus
42

Next Steps
 Download apps for yourself
 Staying up-to-date
43

Next Steps
 Challenges
 Integrating this into your workflow
 Nothing works with the EHR…yet
 Can’t send data in a HIPAA-compliant way
 Finding quality tools
 No central source
 Boudreaux et al. (2014) summarizes seven strategies for
evaluating and selecting health-related apps:
1. Review scientific literature
2. Search app clearinghouse websites
3. Search app stores
4. Review app descriptions, user ratings, and reviews
5. Conduct a social media query
6. Pilot the apps
7. Elicit feedback from patients
44

Summary
During this webinar, participants will learn to:
 Compare innovative, behavioral-health technology tools and
describe some of the empirical evidence for their integration
in clinical care with mTBI patients.
 Discuss the use of behavioral-health technology tools as
assistive devices in mTBI rehabilitation to facilitate recovery
from the adverse effects of mTBI and increase engagement
in care.
 Distinguish between evidence-based standard of care, as
described in the Clinical Practice Guidelines and the
acceptable use of evidence-informed technology tools to
supplement clinical care.
45

Additional mTBI Resources
 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE)
http://www.dcoe.mil/TraumaticBrainInjury/Tips_for_Treating_mTBI/TBI_Information.aspx
 Defense and Veterans Brain Injury Center (DVBIC)
http://www.dvbic.org
 Deployment Health Clinical Center (DHCC)
http://www.pdhealth.mil/TBI.asp
 The Center of Excellence for Medical Multimedia
http://www.traumaticbraininjuryatoz.org
 Brain Injury Association of America
http://www.biausa.org
 Brainline (WETA)
http://www.brainline.org
46

References
Boudreaux, E. D., Waring, M. E., Hayes, R. B., Sadasivam, R. S., Mullen, S., & Pagoto, S. (2014). Evaluating
and selecting mobile health apps: Strategies for healthcare providers and healthcare organizations.
Translational Behavioral Medicine, Advanced online publication
Bush, N. E., Ouelette, G., & Kinn, J. (2014b). Utility of the T2 Mood Tracker mobile application among Army
Warrior Transition Unit service members. Military Medicine, In press.
Bush, N. E., Skopp, N. A., Smolenski, D., Crumpton, R., & Fairall, J. (2013b). Behavioral screening measures
delivered with a smartphone ‘app’: Psychometric properties and user preference. Journal of Nervous and
Mental Disease, 201(11), 991-995.
Cicerone, K. D., Langenbahn , D. M., Braden, C., Malec, J. F., Kalmar, K., Fraas, M., Felicetti, T., Laatsch, L.,
Harley, J. P., Bergquist , T., Azulay, J., Cantor, J., Ashman , T. (2011). Archives of Physical Medicine and
Rehabilitation, 92 (4), 519-530.
47

References
Cifu, D. X., Cohen, S. I., Lew, H. L., Jaffee, M., & Sigford, B. (2010). The history and evolution of traumatic
brain injury rehabilitation in military service members and veterans. American Journal of Physical
Medicine & Rehabilitation / Association of Academic Physiatrists, 89(8), 688–694.
doi:10.1097/PHM.0b013e3181e722ad
Department of Veterans Affairs/Department of Defense (2009). VA/DoD Clinical practice guideline for the
management of concussion and mild traumatic brain injury, version 1.0. Washington, DC: Veterans
Health Administration, Department of Defense.
Department of Defense, Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury,
Portable Field-Based Devices for the Early Diagnosis of Mild Traumatic Brain Injury, September 20,
2010.
Donker, T., Petrie, K., Proudfoot, J., Clarke, J., Birch, M. R., & Christensen, H. (2013). Smartphones for
smarter delivery of mental health programs: A systematic review. Journal of Medical Internet Research,
15(11), e247.
48

References
Erbes, C. R., Stinson, R., Kuhn, E., Polusny, M., Urban, J., Hoffman, J., … Thorp, S. R. (2014). Access,
Utilization, and Interest in mHealth Applications Among Veterans Receiving Outpatient Care for PTSD.
Military Medicine, 179(11), 1218–1222. doi:10.7205/MILMED-D-14-00014
Gaggioli, A., & Riva, G. (2013). From mobile mental health to mobile wellbeing: Opportunities and challenges.
Studies in Health Technology and Informatics, 184, 141-147.
Hoge, C.W ., McGurk, D., Thomas, J., Cox ,A., Engel, C., & Castro, C. A. (2008). Mild traumatic brain injury
in U.S. soldiers returning from Iraq. New England Journal of Medicine, 358 (5), 455-63.
Hyatt, K., Davis, L. L., & Barroso, J. (2014). Chasing the care: soldiers experience following combat-related
mild traumatic brain injury. Military Medicine, 179(8), 849–855. doi:10.7205/MILMED-D-13-00526
Kashluba, S., Paniak, C., & Casey, J. E. (2008). Persistent symptoms associated with factors identified by the
WHO Task Force on Mild Traumatic Brain Injury. Clinical Neuropsychology, 22, 195-208.
49

Luxton, D. D., Hansen, R. N., & Stanfill, K. (2014). Mobile app self-care versus in-office care for stress
reduction: A cost-minimization analysis. Journal of Telemedicine and Telecare, Advanced online
publication.
Richards, D., & Richardson, T. (2012). Computer-based psychological treatments for depression: A
systematic review and meta-analysis. Clinical Psychology Review, 32(4), 329-342.
Smith, A. (2013, October 8). Technology Adoption by Lower Income Populations | Pew Research Center’s
Internet & American Life Project. Retrieved from http://www.pewinternet.org/2013/10/08/technology-
adoption-by-lower-income-populations/
Torous, J., Friedman, R., & Keshvan, M. (2014). Smartphone ownership and interest in mobile applications
to monitor symptoms of mental health conditions. JMIR mhealth and uHealth, 2(1), e2. DOI:
10.2196/mhealth.2994
50
References

Wäljas, M., Iverson, G. L., Lange, R. T., Liimatainen, S., Hartikainen, K. M., Dastidar, P., … Öhman, J.
(2014). Return to Work Following Mild Traumatic Brain Injury: Journal of Head Trauma
Rehabilitation, 29(5), 443–450. doi:10.1097/HTR.0000000000000002
Yamkovenko, S. (2014, December 1). Clinical Reasoning with Everyday Technology - AOTA. Retrieved
December 17, 2014, from http://www.aota.org/Publications-News/AOTANews/2014/QA-Stroke-
rehab-technology.aspx?utm_source=AOTA&utm_medium=front-page&utm_campaign=stroke-tech
51
References

52
David C. Cooper, Psy.D.
http://t2health.dcoe.mil/

Save the Date
Next DCoE Telehealth & Technology Webinar:
Date/Time: Thursday February 19, 2015, 1-2:30pm EST
Title: Clinical Benefits of Technology in Behavioral Health Care
Next DCoE Psychological Health Webinar:
Title: Physical Symptoms and Mental Health
Next DCoE TBI Webinar:
Title: Progressive Return to Activity Following Mild TBI: A Refresh
53

DCoE Contact Info
DCoE Outreach Center
1-866-966-1020 (toll-free)
http://www.dcoe.mil/
resources@dcoeoutreach.org
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Application of Behavioral Health Technology Tools in the Clinical Care of Mild Traumatic Brain Injury

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