TBI Presentation

Neuropsychological Assessment and Rehabilitation: Person Centered Principles Presented at the Pennsylvania Psychological Association Continuing Education and Ethics Conference, Pittsburgh PA., October 9, 2009 Presenters Mick Sittig , Ph.D. Rehabilitation Psychologist, ReMed of Pittsburgh Tad T. Gorske, Ph.D. Assistant Professor, Physical Medicine and Rehabilitation, University of Pittsburgh

“ The presentation of brain facts about specific damages is meaningless to patients unless they can begin to understand how the changes in their brains are lived out in everyday experiences and situations” (Varella, 1991 as stated in McInerney and Walker, 2002)

Definition of Traumatic Brain Injury Closed head injury (CHI) – Skull intact, brain not exposed. Penetrating head injury (PHI) – Open head injury where skull and dura are penetrated by an object. Vascular insults (due to stroke, anoxia, etc. will also be included for today’s purposes.)

Centers for Disease Control TBI Definition Craniocerebral trauma, specifically, an occurrence of injury to the head (arising from blunt or penetrating trauma or from acceleration/deceleration forces) that is associated with any of these symptoms attributable to injury: decreased level of consciousness, amnesia, other neurologic or neuropsychological abnormalities, skull fracture, diagnosed intracranial lesions, or death. Thurman DJ, Sniezek JE, Johnson D, et al., Guidelines for Surveillance of Central Nervous System Injury. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, US Department of Health and Human Services, 1995.

Prevalence of TBI Associated w/ 50,000 – 75,000 deaths annually; 230,000 – 373,000 hospitalizations – nonfatal TBI 80,000 = long term disability 1,975,000 individuals attended to medically US Statistics Incidence average 220/100,000

Rates of TBI hospitalization and death by age group

Proportion of TBI related hospitalizations and deaths Transportation Falls Firearms Assaults Other

Estimated cost of TBI was $260 billion spent in the United States

Mechanism of Brain Injury Primary Injury Damage that results from shear forces; seen in the initial minutes/hours after the insult Cortical disruption Axonal Injury Vascular Injury Hemorrhage

Closed Head Injury Resulting from falls, motor vehicle crashes, etc. Focal damage and diffuse damage to axons Effects tend to be broad (diffuse) No penetration to the skull

Open Head Injury Results from bullet wounds, etc. Largely focal damage Penetration of the skull Effects can be just as serious

TBI: A biological event within the brain Tissue damage Bleeding Swelling

Subdural hematoma - Emergency neuroradiology. Axial CT scan though the level of the lateral ventricles shows right-sided subdural hematoma along the convexity (red arrow) and falx (green arrow), with severe midline shift from right to left. Emergency Neuroradiology Author: M Tyson Pillow, MD, Assistant Director of Medical Education, Ben Taub General Hospital Emergency Center; Assistant Professor, Baylor College of Medicine Coauthor(s): Robert A Mulliken, MD, Medical Director, Adult Emergency Department, University of Chicago and the University of Chicago Hospitals; Christopher M Straus, MD, Assistant Professor, Department of Radiology, University of Chicago

TBI: Changes in functioning Loss of consciousness/coma Other changes due to the TBI Post-traumatic amnesia (PTA)

Injured Brain Does not mend fully Leads to problems in functioning

What Do We Mean by Severity of Injury Amount of brain tissue damage

How to measure “severity”? Duration of loss of consciousness Initial score on Glasgow Coma Scale (GSC) Length of post-traumatic amnesia Rancho Los Amigos Scale (1 to 10)

Mild injury 0-20 minute loss of consciousness GCS = 13-15 PTA < 24 hours Moderate injury 20 minutes to 6 hours LOC GCS = 9-12 Severe injury > 6 hours LOC GCS = 3-8

What Happens as the Person with Moderate or Severe Injury Begins to Recover After Injury?

Recovery and Plasticity Plasticity refers to the ability of the brain to recover and regenerate. Controversial idea; definition and mechanisms are not clear Idea that the CNS is a dynamic system capable of reorganization in response to injury

Determining Recovery Potential Some guidelines Lower Glascow Coma Scale (GCS) Score; Longer coma duration (greater than 4weeks); Longer duration of Post Traumatic Amnesia (PTA)(good recovery unlikely when >3months) Older age assoc. with worse outcomes Neuroimaging features (presence of SAH, cisternal effacement, significant midline shift, EDH or SDH on acute care CT = worse outcomes).

Cognitive Impairments after TBI

Cognitive Impairments after TBI Post Traumatic Amnesia Information processing and attention; Anosognosia (unawareness of deficits); Intellectual functioning Memory Confabulation and delusions Spatial Cognition Chemical Senses (Olfaction and Taste) Executive Functions Social Cognition and Behavior

Comprehensive Rehabilitation Physical Therapy Occupational Therapy Speech Therapy Medical Management Psychological/Neuropsychological Emotional/Psychiatric Management as appropriate Family Support Case Management

The Role of Neuropsychological Assessment: Historical Perspective Period of Neuropsychological Localization Period of Neurocognitive Evaluation Current Period??

Technician / Artist Neuropsychologists are challenged to expand their roles from a purely technical endeavor to a more holistic perspective. Cognitive theorist, functional anatomist

Technician / Artist Neuropsychologists are challenged to expand their roles from a purely technical endeavor to a more holistic perspective. Cognitive theorist, functional anatomist, psychotherapist, family therapist, emotional adjustment, viewing the person from a holistic perspective.

Holistic Neuropsychological Principles Empower patients and families to take an active role in the treatment process; Believe people with neurological disabilities are more like people without neurological disabilities (ie. Go beyond the brain ) ; Convey honesty and caring in personal interactions to form a foundation for a strong therapeutic relationship; Develop practical plans for rehabilitation; explain rehabilitation techniques in understandable language;

Holistic Neuropsychological Principles Help patients and families understand neurobehavioral sequelae of brain injury and recovery; Recognize change is inevitable and help families cope with change; Every patient is important, treat with respect; Remember that patients and families have different perspectives regarding treatment approaches; Be willing to refer if appropriate.

Collaborative Therapeutic Neuropsychological Assessment (Gorske and Smith) A collaborative method of interviewing and providing feedback from neuropsychological assessment; Enlists the patient/family as an active collaborator; Empowers patients/families to be caretakers of their own cognitive health.

Collaborative Therapeutic Neuropsychological Assessment (Gorske and Smith) Comprehensive Neuropsychological Assessment Referral question, records review, behavioral observations, clinical interview, quantitative and qualitative assessment.

Collaborative Therapeutic Neuropsychological Assessment (Gorske and Smith) The Information Gathering / Medical Model Clinician knows best; Fragile patients; Knowledge is dangerous Collaborative Model Clinician is an expert in neuropsychology; the patient/family is the expert on themselves Patients are resilient Knowledge is power

CTNA The spirit of the CTNA lies in Collaborative and Therapeutic Assessment Models Open sharing; explore results contextually; use results to facilitate empathic understanding The framework for conducting the CTNA is drawn from Motivational Interviewing. The CTNA adopts and adapts the MI Personalized Feedback Report

CTNA Feedback Session Two primary components Provide information from neuropsychological test results Interact with clients in a collaborative manner consistent with TA and MI.

CTNA Personalized Feedback Introduction Provide feedback report; explain session purpose; facilitate collaboration and empathic understanding Develop Questions Develop 2 or 3 well defined questions the client hopes the results can answer Explain how strengths and weaknesses are determined Percentiles, determine criteria for strength or weakness

CTNA Personalized Feedback Feedback about strengths and weaknesses Elicit : What skills did the client use to complete the test. Provide : Therapist provides information on the cognitive skill test(s) examine. Elicit : Therapist elicits reactions from the clients and applies results to their real life. OARS

CTNA Personalized Feedback Summarize results and provide recommendations Summary and key question Ask permission to provide recommendations Make recommendations

Pilot Study Results NAFI (Neuropsychological Assessment Feedback Intervention) vs. TAU (Treatment As Usual)

Pilot Study Results: D&A Use NAFI = 6; TAU = 5

Pilot Study Results: Depression NAFI = 7; TAU = 5

Patient Responses “ The assessment was helpful to me. I learned a lot about myself…I would have done it without being paid.” “ Allowed me to see why I may be reluctant to participate in groups.” “ Helped me narrow in on specific steps I need to take with my therapist re: depression and addiction. Identified couple things we can work on.” “ I am so pleased that I participated in the study. It was right on. M- allowed me to share during the process, which really assisted with my overall understanding of the feedback.”

Case of CE Early 50’s Caucasian male TBI due to industrial accident No LOC but combative/confused GCS = 7 Bifrontal subarachnoid hemorrhages, tentorial/subfalcine subdural hematomas, contusions to the right and left temporal lobe and bilateral frontal lobes, and a left occipital epidural hematoma. PTA cleared within 8 days.

Neuropsychological Tests MMSE – Clock Drawing Wechsler Abbreviated Scale of Intelligence Digit Symbol – Coding – Incidental/Free Recall WAIS-IV- Digits, Letter Number Seq. WMS-IV – Logical Memory – Visual Reproduction Rey Complex Figure CVLT-II COWA BNT Complex Ideational Material (BDAE) Stroop C/W Test Wisconsin Card Sorting Test – 64 Others as needed

Neuropsychological Treatment Education and Referral Psychotherapy Family Interventions Support Groups Behavior Management Cognitive Rehabilitation

Cognitive Recovery and Rehabilitation Recovery . A multi-stage process. Continues for years. Differs for each person.

Long-term impact on functioning. Depends on severity of the injury, functions affected, personal meaning of the injury, resources available, and areas not affected by the injury. Cognition. Attention Concentration Memory Speed of Processing

Long-term impact on functioning. Depends on severity of the injury, functions affected, personal meaning of the injury, resources available, and areas not affected by the injury. Confusion Perseveration Impulsiveness Language Processing “ Executive functions”

The “Cognitive Grid Strategy Development and Implementation. Best Learning Mode. “To-Do’s”

Other Physical Changes Physical paralysis/spasticity Chronic pain Sensory/Perceptual. Seizures. Control of bowel and bladder

Other Physical Changes Sleep disorders Loss of stamina Appetite changes Regulation of body temperature Menstrual difficulties

Social-Emotional. Dependent behaviors Emotional lability Lack of motivation Irritability

Social-Emotional. Aggression Depression Disinhibition Denial/lack of awareness Spread-of-Effect. Deviance Disavowal. Stigma Management. Sick-Role Retention.

“ Recovery” –vs. “Improvement” Permanence of Change. Physical recovery Reeducation of the individual Environmental modifications

Generalization Issue(s) Disposition Residence Social milieu Productivity

Resource Utilization Resource Book Support Groups Referrals Follow-ups

Contact Information Mick Sittig, Ph.D. Rehabilitation Psychologist ReMed 5830 Ellsworth Avenue, Ste. 201 Pittsburgh, PA 15232 412-661-0800 Direct 412-661-0808 FAX [email_address] www.remed.com Tad T. Gorske, Ph.D., Assistant Professor Division of Neuropsychology and Rehabilitation Psychology Department of Physical Medicine and Rehabilitation Clinical Neuropsychology Services Mercy Hospital-Building D Room G138 1400 Locust Street Pittsburgh, PA 15219 Phone: 412-232-8901 Fax: 412-232-8910 [email_address] http://www.rehabmedicine.pitt.edu/ http://www.linkedin.com/in/tadgorske

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