Traumatic Brain Injury (TBI) in the Military - Cognitive Rehabilitation The views expressed in this presentation are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

Cognitive Rehabilitation Other terms for Cognitive Rehabilitation Neurorehabilitation Neuropsychological rehabilitation Cognitive remediation Cognitive retraining Speech Pathology Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and Defense and Veterans Brain Injury Center consensus conference

Cog Rehab Goal To provide guidance regarding cognitive rehabilitation of chronic post-concussive symptoms in service members and veterans receiving treatment within military medical settings Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and Defense and Veterans Brain Injury Center cognitive rehabilitation for mild traumatic brain injury summary of clinical recommendations VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

Recommendation If SM has three months or more post concussive injury and persistent cognitive symptoms 1. Assessment 2. Interventions 3. Outcome measures 4. Program implementation. If SM or veteran is 3 months or more post-concussive injury and has persistent cognitive symptoms. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009. http://www.dcoe.health.mil/ForHealthPros/Resources.aspx

Assessment: Part 1 – Initial Evaluation Purpose To determine if the individual has a history of mild traumatic brain injury (mTBI) (also known as concussion) with persistent cognitive symptoms or signs of cognitive impairment and to determine if any co-morbidities exist that may affect cognitive function VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

Initial Evaluation Performed by a TBI-experienced provider. Referral can be made by any provider. Reasons for referral: cognitive symptoms observed by the provider or reported by the patient, family, or leadership. SM displays evidence of cognitive dysfunction in daily social or occupational functioning. Any suspicion of mild TBI with persistent cognitive symptoms warrants further cognitive evaluation Primary Care Manager (PCM) is also familiar with other deployment related health conditions. Even if the SM does not report cognitive difficulties VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

Assessment: Part 2 – Comprehensive Cognitive Evaluation Purpose To determine: Primary factor(s) contributing to symptom 2) Cognitive deficits 3) Need for cognitive rehabilitation 4) Type of rehabilitation needed 5) Short- and Long-term goals. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

Comprehensive Cognitive Evaluation Performed by an interdisciplinary team: neuropsychologist, occupational therapist, speech-language pathologist. Includes a comprehensive neurological evaluation performed by a neurologist or physician Includes a review of the medical records, education level, GT score, etc. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

Intervention Based on a holistic approach and include individual as well as group therapies Target attention, memory, executive functioning and social pragmatics these are the most common cognitive domains affected by TBI. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

Outcome Measures To advance the published science Administrative performance metrics Pre- and post-assessment differences Pre- and post-functional differences Moderating variables Discharge criteria Consumer satisfaction Aggregate program outcome data Evidenced-based medicine has become the cornerstone to informing quality care and identifying advances in therapies number of patients seen; number of patients referred for medical appointments; length of stay in the program, both in terms of treatment duration and daily intensity; length of time the patient is on profile or limited duty; and, return to duty/return to work rates not be limited to formal neurocognitive evaluation, but include and emphasize assessment of symptom status and functional status as well refers to changes in the ability of an individual to function within important areas of daily life - the goals should be objective, measurable, and time-based; that they should be generated by the treatment team with active involvement from the patient; and that they should be functional, based on the patient's lifestyle and needs pain; comorbid physical injuries; type of injury; age, rank, job duties and gender of patient; psychological health and substance abuse; number of deployments; date(s) of injury(s); trauma history to include life events prior to entering the military; family and broader psychosocial support system; aptitude/education; duty status; prior neurologic illnesses or injuries; motivation for retention; expectations of recovery; years of service; and, possible sources of secondary gain. accomplishment of the goals of treatment; plateauing of improvement and/or failure to improve useful for identifying quality improvement possibilities within a program and also are extremely important for identifying whether the program improves the quality of life and functional outcome for the patient and family overlap with the administrative evaluation of the program - type and number of service providers; range of services readily available; consistent and well-defined admission criteria; consistent and well-defined discharge criteria; clear description of the program and interventions; sufficient documentation to permit reasonable consistency of treatment across providers; and, clear documentation to permit audit of patient care against these definitions. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

Program Implementation Assessment prior to treatment Identification of individualized cognitive rehabilitation goals that target symptom reduction through restoration and compensation functional improvements/gains, and a therapeutic alliance Development of an interdisciplinary individualized treatment plan Periodic cognitive reassessment and review of goals Development of a well defined discharge plan VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

Potential Team Members Cognitive Rehabilitation for the SM Neuro-psychology Mental Health Speech Pathology Occupational Therapy Audiologist Case manager Neurologist Neuropsychologist Occupational therapist Ophthalmologist Physical therapist Primary Care Manager Psychiatrist Speech-Language Pathologist Family members are also a vital part of the cognitive rehab process as we invite them into individual as well as group sessions to provide education and instruction to better support their loved one. Just like the sacrifices of war impact not only the SM but also their families, participation in the road to recovery from a concussion will involve care from family members. Cognitive Rehabilitation for Military Personnel with Mild Traumatic Brain Injury and Chronic Post-Concussional Disorder: Results of April 2009 Consensus Conference. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

Comorbidity of Symptoms PTSD or Acute Stress Reaction Mild TBI or Post Concussive Syndrome Stress symptoms Emotional numbing Avoidance Intrusive symptoms Insomnia Impaired Memory Poor concentration Depression Anxiety Irritability Headache Dizziness Fatigue Noise/Light intolerance Symptoms attributable to other factors: demographic, psychosocial, medical, situational. Other reasons for persisting symptoms may include limited cognitive reserve, expectation, somatoform disorder, malingering VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009. Post-Traumatic Stress Disorder and TBI in Returning Service Members & Veterans, Collins, 2009.

Cognitive Symptoms Memory Attention Processing Speed Communication Executive Function VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

Memory Memory Long-Term Memory Explicit (Declarative) Episodic Memory (Events) Semantic Memory (Facts) Implicit (Non-declarative) Procedural Memory Classical Conditioning Short-Term (Working) Memory Different types of memory can be used in therapy to teach strategies to patients. For instance, using active rehearsal or repetition in procedural memory to reinforce recall (i.e. shrine, creating a routine, develop organization) Key Elements of Functional Memory for Those with Brain Injury: Linking Neuroscience to Clinical Practice, Burns, 2010. Key Elements of Functional Memory for Those with Brain Injury: Linking Neuroscience to Clinical Practice, Burns, 2010.

Executive Functions Multi-tasking Problem Solving Planning Organization Multi-tasking Planning Problem Solving Self-Monitoring Intervention for Executive Functions after Traumatic Brain Injury: A Systematic Review, Meta-Analysis and Clinical Recommendations, Kennedy et al, 2008. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

Attention Attention Sustained Divided Alternating Selective Evaluation of Attention Process Training and Brain Injury Education in Persons with Acquired Brain Injury, Sohlberg et al, 2000. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

Speed of Processing Processing time Response time Listening & Distractions Archives of Clinical Neuropsychology, Tombaugh et al, 2007. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

Communication Oral Expression Reading Comprehension Written Expression Auditory comprehension Social pragmatics VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009. Evidence-Based Cognitive Rehabilitation: Recommendations for Clinical Practice, Cicerone et al, 2000.

Memory Aids External Aids Internal Aids Alarms Timers Notebooks Datebooks Calendars Answering machines Electronic organizers Tape recorders Watches with beepers Medication dispensers Highlighters Journals Computers Repetition Creating rhymes Making associations First-letter cues Chunking Mnemonics Visualization Categorization Active observation Evidence-Based Practice for the Use of External Aids as a Memory Compensation Technique, Sohlberg et al, 2007. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

mTBI Cognitive-Communication Group Offer support through group discussion, counseling, and therapeutic activities designed to maximize compensatory and facilitative strategies. Invite guest speakers on topics of interest (e.g., sleep, nutrition, executive functions, meditation/relaxation, coping strategies, transition to school/work, community resources) and involve interdisciplinary care. Group activities: focus on memory, critical thinking, problem solving, attention, organization, planning community outings. Members include SB TBI group via VTC – offer peer support. Provides supportive context and unit cohesion in the military culture. Focus on IDT and the inviting family involvement in SM ‘s care. Cognitive Rehabilitation for Military Personnel with Mild Traumatic Brain Injury and Chronic Post-Concussional Disorder: Results of April 2009 Consensus Conference, Helmick et al, 2010. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

mTBI Cognitive-Communication Group VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

mTBI Cognitive-Communication Group VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

TBI Resources Brainline (DVBIC-sponsored): www.brainline.org Brain Injury Association of America: www.biausa.org Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury: www.dcoe.health.mil Defense and Veterans Brain Injury Center: www.dvbic.org CDC’s National Center for Injury Prevention and Control: www.cdc.gov/ncipc/tbi/TBI.htm National Institute of Neurological Disorders and Stroke (NINDS) Traumatic Brain Injury Information Page: www.ninds.nih.gov/disorders/tbi/tbi.htm Traumatic Brain Injury National Resource Center: www.nrc.pmr.vcu.edu VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.