Assessment and Treatment of Traumatic Brain Injury within the ECHCS Polytrauma System of Care Estela Bogaert-Martinez, Ph.D. Director, Traumatic Brain Injury Team

Acknowledgement Thanks to Rod Vanderploeg, PhD Neuropsychologist, Polytrauma Center Tampa VAMC, and to Michael Craine, Ph.D., Co- Director, VISN19 Polytrauma Network Site, for contributions to this material.

Background  Many of those returning from current conflicts had experiences that put them at risk for TBI.  Mild symptoms of TBI may be difficult to recognize, or confused with other conditions.  Treatment of symptoms may be very different for TBI patients.

War Injuries: Explosive Blasts Most common cause of injury Most common cause of injury 64% of war injuries caused by blasts 64% of war injuries caused by blasts 41% of blast injured at WRAMC had TBI (01/ /06) 41% of blast injured at WRAMC had TBI (01/ /06)

Key Iraq wound: Brain trauma By Gregg Zoroya, USA TODAY “A growing number of U.S. troops whose body armor helped them survive bomb and rocket attacks are suffering brain damage as a result of the blasts. It's a type of injury some military doctors say has become the signature wound of the Iraq war.”

Traumatic Brain Injury  Insult to the brain caused by an external physical force  Produces a diminished or altered state of consciousness Dazed and confused for several minutes orDazed and confused for several minutes or Knocked out / Rendered unconscious and/orKnocked out / Rendered unconscious and/or With memory gaps for some or all of the immediate period after the eventWith memory gaps for some or all of the immediate period after the event  Results in impairments in physical, cognitive, behavioral, and/or emotional functioning

Consequences of TBI  Cognitive Memory deficits, poor concentration, thinking problems  Emotional-Behavioral Depression, anxiety, irritability, mood swings Impulsivityapathy, agitation, aggression Impulsivity, apathy, agitation, aggression  Physical Headache, dizziness, fatigue, noise/light intolerance, insomnia/sleep disturbance

Levels of Severity Mild Mild Complicated Mild Complicated Mild Moderate Moderate Severe Severe

3 Cognitive LevelCognitive Level Preinjury Functioning PTA Coma INJURYINJURY Retro- Grade Amnesia Months Mild TBI Moderate TBI Severe TBI Ongoing Cognitive Problems Brief PTA PTA Ongoing Cognitive Problems

TBI Treatment Considerations  Treatment varies based upon: Severity of injury Severity of injury Time since injury Time since injury Constellation of impairments Constellation of impairments

Continuum of Care for TBI / Polytrauma Trauma Care Long-Term Care Subacute Rehab Acute Rehab Post-Acute Rehab Community Rehab Outpatient Specialty Care

Interdisciplinary Traumatic Brain Injury Team - an Interdisciplinary Rehabilitation Approach Rehabilitation medicine physician Rehabilitation medicine physician Physical therapist Physical therapist Occupational therapist Occupational therapist Speech Therapist Speech Therapist Supported employment/Vocational rehabilitation specialist Supported employment/Vocational rehabilitation specialist Social Worker Social Worker Rehabilitation Psychology Rehabilitation Psychology Neuropsychology Neuropsychology

TBI Education & Support TBI Education & Support Cognitive Deficits: Cognitive Deficits: Compensatory Training/Cognitive Remediation Stimulant Medications; physical activation Vocational Rehablitation/ Supported Employment Vocational Rehablitation/ Supported Employment Stress Management Training Stress Management Training Social Skills Training Social Skills Training Specialty Treatment for Secondary Conditions: Specialty Treatment for Secondary Conditions: PTSD, Depression, Anxiety, Chronic Pain, HA, etc. PTSD, Depression, Anxiety, Chronic Pain, HA, etc. TBI Rehabilitation Interventions to Support Reintegration to Family, Community and Work

Follow-up Additional Specialized Assessments and Treatment  TBI: TBI Team  PTSD: PTSD Program, Mental Health  Chronic Pain: Pain Program, PM&RS  Depression, Anxiety, Stress: Mental Health  Seizures, Neurologic Conditions: Neurology

What to Know: Relevant Background  Mild TBI Symptoms There is no symptom that is unique to or diagnostic of mild TBI There is no symptom that is unique to or diagnostic of mild TBI Many postconcussion symptoms occur in normal healthy individuals Many postconcussion symptoms occur in normal healthy individuals All symptoms/problems overlap with one or more other conditions (PTSD, Depression, Anxiety, Chronic Pain, Somatoform Disorder, chronic health conditions) All symptoms/problems overlap with one or more other conditions (PTSD, Depression, Anxiety, Chronic Pain, Somatoform Disorder, chronic health conditions)

+ PTSD Re-experiencing Avoidance Social withdrawal Memory gaps Apathy ? Mild TBI TBIResidual Difficulty with decisions Mental slowness ConcentrationHeadachesDizzy Appetite changes FatigueSadness Arousal Sensitive to noise Concentration ConcentrationInsomniaIrritability + Depression