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Short Course on TBI for Mental Health Professionals

Introduction to Neuroscience 

For Mental Health Professionals
Document
Presentation on TBI for Mental Health Practitioners July 27, 2012

What is TBI?

TBI occurs when a sudden trauma such as a blow or jolt causes damage to the brain.

There are two types of TBI:

Focal: where there is damage to one area of brain and
Diffuse: where there is damage in more than one area of brain

 

What are the Categories of TBI?

Closed head injury: which results from any trauma that causes the brain to be violently shaken inside of the skull such as a “blast” injury.

Penetrating injury: which results when object goes through the skull and enters the brain. A closed injury.

 

Head Injuries result in lesions on the brain from: Skull fracture; Brain Contusion and DAI (Diffuse axonal injury) which account for over 50% of TBI. The resulting concerns from these head injuries include: Intracranial hemorrhages, brain edema, increased intracranial pressure (ICP), infections, delayed lesions and long term effects.

 

Results of TBI

TBI can cause nerve cells in brain to stretch, tear, or pull apart, making it difficult or impossible for cells to send messages from one part of brain to another and to the rest of body.

TBI can interfere with how brain works, including thinking, remembering, seeing and  controlling movements.

 

Causes of TBI

Brain injuries can occur when the head strikes an object such as a windshield or the ground at a fast rate of speed; or when a flying or falling object strikes the head or finally they can occur without a direct blow to head as in cases of severe "whiplash."

 
 
Fact Sheets on TBI and its impact on Survivors and their Families

Most Common Causes of TBI in total Population

Falls                                                   28%

Motor Vehicle-Traffic Accidents       20%

Struck by/against                               19%

Assault                                               11%

Unknown                                              9%

Other                                                   7%

Pedal Cycle (Non motorized)            3%

Other Transport                                  2%

 

Most Common Causes of TBI for Military

  • Assault Blasts –leading cause of TBI for active duty military in war zones
  • Bullets, fragments, blasts
  • Motor vehicle-traffic crashes
  • Falls

 

Resultant Injury from explosive Devices

Primary Injury–overpressure

Secondary injury–secondary wave-shrapnel

Tertiary injury-person blown into objects

Quaternary-heat and gas

 

Ranges of TBI

Traumatic brain injury can range from mild to very severe depending on many things including: force of the trauma; previous brain injuries and how quickly emergency medical treatment is given

TBI DEFINITIONS

1. Concussion/Mild TBI/ mTBI

  • A confused or disoriented state lasting 24 hours or less
  • Loss of consciousness for up to 30 minutes
  • Memory loss lasting less than 24 hours.

 

2. Moderate TBI
  • A confused or disoriented state that lasts more than 24 hours
  • Loss of consciousness for more than 30 minutes, but less than 24 hours
  • Memory loss lasting greater than 24 hours but less than seven days

 

3. Severe TBI
  • A confused or disoriented state that lasts more than 24 hours
  • Loss of consciousness for more than 24 hours
  • Memory loss for seven days or more

 

4. Penetrating TBI or Open Head Injury

  • The outer layer of the brain is penetrated by a foreign object

 

Department of Defense Numbers on TBI for 2000-2011

Mild:                            175,647                        76%

Moderate:                     38,235                        16.7%

Severe:                           2,360                          1%

Penetrating:                    3,378                          1.6%

Not Classifiable:              9,099                          4%

Total:                          229,106

 

TBI numbers reported by Military Services 2000-2011

Army 57%

Active: 100,373

Guard: 22,489

Reserves: 9,415

Navy 13.9%

Active: 29,597 

Reserves: 2,325

Air Force 13.8%

Active: 27,305

Guard: 2,659

Reserves: 1,611

Marines 14.5%

Active: 30,473

Reserves: 2,859

 

Who are at highest risk for TBI?

Males are about 1.5 times as likely as females to sustain a TBI

Military duty increases risk of sustaining a TBI

Signs and Symptoms of Concussion/Mild TBI/mTBI

  • Headaches
  • Dizziness
  • Excessive fatigue (tiredness)
  • Concentration problems
  • Forgetting things (memory problems)
  • Irritability
  • Sleep problems
  • Balance problems
  • Ringing in the ears
  • Vision changes

 

Signs and Symptoms of Moderate and Severe TBI

  • Coma
  • Severe headaches
  • Seizures/convulsions
  • Nausea/vomiting
  • Inability or difficulty speaking, understanding  and concentrating
  • Confusion, restlessness or agitation
  • Loss of or changes in coordination
  • Memory loss/amnesia
  • Vision changes or loss of vision
  • Paralysis and/or muscle spasticity
  • Chronic pain
  • Sleep disturbances
  • Inability or changes in ability to use senses of taste, touch, sight, sound, smell and taste
  • Loss of bowel and/or bladder control

 

Common late symptoms of Concussions

  • Persistent Headache
  • Lightheadedness and/or dizziness
  • Decreased attention and concentration
  • Poor memory
  • Easy fatigability
  • Anxiety or depressed mood
  • Sleep disturbance

 

How long do symptoms last?

Symptoms of mild TBI or concussion often resolve within hours to days and almost always improve over 1-3 months.

Patients with moderate to severe TBI often have long-term medical problems requiring specialized attention.

NOTE: Symptoms and effects will vary greatly from one patient to another, depending on severity of TBI and the location of the injury.

Recent Research reports of the Long Term Impact of Single Concussion or mTBI

A single traumatic brain injury may prompt long-term neurodegeneration. Researches found Tau tangles & amyloid-beta plaques were present years (1-47 years) after just one Traumatic Brain Injury (concussion) so could be precursor to Alzheimer's or other neurodegenerative conditions. Study was done on brains of over 250 individuals with know mTBI’s.Article is: Johnson, V.E., Stewart, W. & Smith, D.H. (2011). Widespread Tau and Amyloid-Beta Pathology Many Years After a Single Traumatic Brain Injury in Humans. Brain Pathology (22) 142-149 Click here to download article.

 

Can lifelong disabilities result from TBI?

Disabilities from a TBI depend upon:

  • Severity of injury
  • Location of the injury
  • Age and general health of the patient

 

What are the possible long term disabilities from TBI’s

  • Problems with cognition (thinking, memory, and reasoning)
  • Sensory processing (sight, hearing, touch, taste, and smell),
  • Communication (expression and understanding)
  • Behavior or mental health (depression, anxiety, personality changes, aggression, acting out, and social inappropriateness)


 

Information on TBI and PTSD Comorbidity

What measures are used to assess for TBI

1. Military Acute Concussion Evaluation (MACE)  

2. Brief Traumatic Brain Injury Screen (BTBIS)

3. Glasgow Coma Scale (GCS)

 

Military Acute Concussion Evaluation (MACE)

Who should be evaluated on the battlefield with the MACE?

Any one dazed, confused, “saw stars” or lost consciousness even momentarily, as a result of an explosion, blast, fall, motor vehicle crash, or other event. In such event involving abrupt head movement, a direct blow to head, or other head injury.

 

The assessment which is the Standardized Assessment of Concussion (SAC)scoring is:
  • Total possible score = 30
  • Orientation = 5
  • Immediate Memory = 15
  • Concentration = 5
  • Memory Recall = 5

 

Neurological Screen with no points given which includes:
  • Eyes: check pupil size and reactivity.
  • Verbal: notice speech fluency and word finding
  • Motor: pronator drift- which includes asking patient to lift arms with palms up, ask patient to then close their eyes, assess for either arm to “drift” down. Assess gait and coordination if possible with documenting any abnormalities

 

Results on the Mace:

Non-concussed patients, the mean total score was 28

Scores below 25 may represent clinically relevant neurocognitive impairment and require further evaluation for the possibility of a more serious brain injury.

Brief Traumatic Brain Injury Screen (BTBIS)

This simple screening device can be used with patients after they have returned from the battlefield or are back in the states post deployment.

 
First a Clinical History is taken and the three questions are asked which quickly help assess if the person is possibly suffering from TBI.

 

Clinical History

I. Description of Incident

a) What happened?

b) What do you remember.

c) Were you dazed, confused, “saw stars”? Yes or No

d) Did you hit your head? Yes or No

II. Cause of Injury (Choose all that apply):

1) Explosion/Blast

2) Blunt object

3) Motor Vehicle Crash

4) Fragment

5) Fall

6) Gunshot wound

7) Other

III. Was a helmet worn? Yes or No if yes what Type?

IV. Amnesia Before: Are there any events just BEFORE the injury that are not remembered? (Assess for continuous memory prior to injury) Yes or No If yes, how long?

V. Amnesia After: Are there any events just AFTER the injuries that are not remembered? (Assess time until continuous memory after the injury)  Yes or No If yes, how long?

VI. Does the individual report loss of consciousness or “blacking out”?  Yes or No If yes, how long?

VII. Did anyone observe a period of loss of consciousness or unresponsiveness? Yes or No If yes, how long?

VIII. Symptoms (Choose all that apply):

1) Headache

2) Dizziness

3) Memory Problems

4) Balance problems

5) Nausea/Vomiting

6) Difficulty Concentrating

7) Irritability

8) Visual Disturbances

9) Ringing in the ears

10) Other

 

First Question

Did you have any injury(ies) during your deployment from any of the following:

A. Fragment

B. Bullet

C. Vehicular (any type of vehicle, including airplane)

D. Fall

E. Blast (Improvised Explosive Device, RPG, Land mine, Grenade)

F. Other: specify

NOTE: Endorsement of A-E meets criteria for positive TBI Screen

 

Second Question

Did any of the injury received during your deployment result in any of the following?

A. Being dazed, confused or “seeing stars”

B. Not remembering the injury

C. Losing consciousness (knocked out) for less than a minute

D. Losing consciousness for 1-20 minutes

E. Losing consciousness for longer than 20 minutes

F. Having any symptoms of concussion afterward (such as headache, dizziness, irritability, etc.)

G. Head injury

H. None of the above

NOTE: Confirm F and G through clinical interview

 

Third Question

Are you currently experiencing any of the following problems that you think might be related to a possible head injury or concussion?

A. Headaches                                  

B. Ringing in the ears

C. Dizziness                        

D. Irritability

E. Memory Problems          

F. Sleep problems

G. Balance Problems         

Other-specify

 

NOTE:  A service member who endorses an injury [Question 1], as well as an alteration of consciousness [Question 2 A-E], should be further evaluated via clinical interview because he/she is more highly suspect for having sustained an MTBI or concussion. The MTBI screen alone does not provide diagnosis of MTBI. A clinical interview is required.

Glasgow Coma Scale (GCS)

Is used to help determine severity of TBI

Responses are scored using three measures which are scored separately and then combined

1. Eye opening

2. Best verbal response

3. Best motor response

 

Eye Opening (E) Score after item

Spontaneous 4

To speech 3

To pain 2

No Response 1

 

Best Motor Response (M)

To verbal command: obeys 6

To painful stimulus: localizes pain 5

Flexion-withdrawal 4

Flexion-abnormal 3

Extension 2

No response 1

 

Best Verbal Response (V)

Oriented and converses 5

Disoriented and converses 4

Inappropriate Words 3

Incomprehensible sounds 2

Makes no sounds 1

 

Scoring:  Eye Score (E) + Motor Score (M) + Verbal Score (V) = 3-15

 

Classifications of TBI by Glasgow Coma Scale (GCS)

Mild TBI/Concussion GCS Score of 13-15

Moderate TBI GCS score of 9-12

Severe TBI GCS score of 8 or less

Progressive Return to Activity Following Acute Concussion/Mild Traumatic Brain Injury


The Defense and Veteran Brain Injury Center has come out in 2014 with new guidelines to address individuals who experience concussive injuries or mTBI. The model is to monitor the slow progression back to active status for individuals who have experienced these conditions. You can download the procedures at: http://dvbic.dcoe.mil/resources/progressive-return-to-activity

Mental Health Needs of Clients with TBI

The goal with clients with TBI is to reduce stress, overcome common co-occurring conditions such as post-traumatic stress disorder, depression, chronic opioid therapy, and substance use which can be done by following the guidelines of the VA and DoD and utilizing App which they have developed to assist Providers of these Clients. The other goal to handle their states of anxiety, anger or depression which can be done if clinicians utilize the Handbooks Tools for Coping  series on www.coping.us.

 

Evidence Based Practices for Treating TBI

Apps for Clinicians related to Treating TBI

There are two with links below:

  1. mTBI Pocket Guide
  2. Co-Occurring Conditions Toolkit 
  3. PE Coach

These are available as free apps from the National Center for Telehealth and Technology

 

Apps for Clients with TBI

There are links below to obtain these apps:

  1. Breath2Relax
  2. Tactical Breather
  3. Mood Tracker
  4. LifeArmor
  5. PTSD Coach

All are available as free apps from the National Center for Telehealth and Technology

Apps for IPhones, IPads and Androids for Mental Health Professionals and their clients 

 

mTBI Pocket Guide The Mild Traumatic Brain Injury Pocket Guide mobile application for health care providers gives instant access to a comprehensive quick-reference guide on improving care for mTBI patients. Designed to reflect current clinical standards of care, the mTBI Pocket Guide mobile application can help you improve quality of care and clinical outcomes for patients. Read more about it at: http://t2health.org/apps/mtbi

 

Co-Occurring Conditions Toolkit The Co-Occurring Conditions Toolkit targets common co-occurring conditions such as post-traumatic stress disorder, depression, chronic opioid therapy, and substance use with recommendations based on the VA-Dod Evidenced Based Clinical Standards of care. Read more about it at: http://t2health.org/apps/cct


PE Coach mobile app designed to support tasks associated with Prolonged Exposure Therapy for PTSD. Read more about it at: http://t2health.org/apps/pe-coach

 

Breath2Relax Breathing exercises have been documented to decrease the body's 'fight-or-flight' (stress) response, and help with mood stabilization, anger control, and anxiety management. This app uses diaphragmatic breathing to help your clients reduce their stress. Read more at: http://t2health.org/apps/breathe2relax

 

Tactical Breather This app can help your clients gain control over physiological and psychological responses to stress. Read more about it at: http://t2health.org/apps/tactical-breather

 

t2Mood Tracker This app enables your clients to self-monitor, track and reference their emotional experiences over a period of days, weeks, and months. Users can self-monitor emotional experiences associated with common deployment-related behavioral health issues like post-traumatic stress, brain injury, life stress, depression and anxiety. Read more about it at: http://t2health.org/apps/t2-mood-tracker

 

LifeArmor Your clients who can self-monitor emotional experiences associated with common deployment-related behavioral health issues like post-traumatic stress, brain injury, life stress, depression and anxiety. Read more about it at: http://t2health.org/apps/lifearmor

 

PTSD Coach This app will assist your clients who are Veterans and Active Duty personnel (and civilians) who are experiencing symptoms of PTSD. It is intended to be used as an adjunct to psychological treatment but can also serve as a stand-alone education tool. Read more about it at: http://t2health.org/apps/ptsd-coach

TBI Related Websites

Defense and Veterans Brain Injury Center (DVIBC) - Traumatic Brain Injury Resources: http://www.dvbic.org/

 

VA/DoD Evidenced Based Practice Guidelines for Management of Concussion/Mild Traumatic Brain Injury 2009 at:

http://www.healthquality.va.gov/management

_of_concussion_mtbi.as Click here to link to it

 

Traumatic Brain Injury A to Z (Funded by DVBIC): http://www.traumaticbraininjuryatoz.org/

 

BrainLine.org-Preventing, Treating and Living with Traumatic Brain Injury (Funded by DVBIC): http://www.brainline.org/

 

Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury: http://www.dcoe.health.mil/ 

 

Center for Deployment Psychology-Resource for Mental Health Professionals to provide quality Evidenced Based Practices to Military and Veterans: http://deploymentpsych.org/

 

Center for the Study of Traumatic Stress- http://www.centerforthestudyoftraumaticstress.org/

 

Real Warriors Campaign: Resources and tools for combat stress and TBI:

http://realwarriors.net/

 

Deployment Health Clinical Center-PDHealth: Pre- and Post- Deployment Health Clinical Center: http://www.pdhealth.mil/main.asp

 

National Intrepid Center of Excellence (at Walter Reed Military Medical Center)-Advancing traumatic brain injury and psychological health treatment, research and education: http://www.nicoe.capmed.mil/SitePages/Home.aspx

 

National Resource Directory-State and Local Resources for Recovery, Rehabilitation and Community Reintegration: https://www.nationalresourcedirectory.gov/

 

inTransition-Mental Health Coaching and Support Program for Warriors in Transition: http://www.health.mil/InTransition/default.aspx

 

America’s Heroes at Work- Success in the Workplace for Service Members Living with PTSD and TBI: http://www.americasheroesatwork.gov/

 

After Deployment.org: resource for both military members, their families and spouses and their providers: http://afterdeployment.org

 

National Center for Telehealth & Technology – a rich resource of tools in working with clients with TBI, PTSD and other mental health conditions: http://t2health.org/


Joe Namath Neurological Research Center at Jupiter Florida Medical Center - It's mission is  to pioneer a clinical study that explores the effectiveness of hyperbaric oxygen (HBO) therapy as a treatment for the debilitating toll of TBI. http://namathneurocenter.com/

Online Instructions

 

Civilian Provider Education from Health.mil which it the portal for the Department of Defense to provide civilian providers education and training on TBI and PTSD at: http://www.health.mil/Education_And_Training/Civilian_Provider
_Education.aspx Click here to link to it

 

The Effectiveness of Cognitive Rehabilitation – BrainLine.org – Brain Injury Rehabilitation: http://www.brainline.org/content/multimedia.php?id=4636 

Click here to link to it

 

Mild Traumatic Brain Injuries – BrainLine.org – frequency, causes, and symptoms: http://www.brainline.org/content/multimedia.php?id=4434 

Click here to link to it

 

Brain Basics-an interactive view of the different parts of the brain and their functions: http://www.brainline.org/multimedia/interactive_brain/

the_human_brain.html Click here to link to it

 

Interactive Brain – another interactive instructional tool on the workings of the brain at: http://www.traumaticbraininjuryatoz.org/The-Brain.aspx Click here to link

Online Articles:

Iraq, Afghanistan War Veterans Struggle With Combat Trauma – Huffington Post – July 4, 2012: http://www.huffingtonpost.com/2012/07/04/iraq-afghanistan-war-veterans-combat-trauma_n_1645701.html?utm_hp_ref=tw

 

TBI clinic takes individual approach to care-Army Times – April 21, 2012: http://www.armytimes.com/news/2012/04/army-tbi-clinic-take-individual-approach-042112w/

 

New treatment facility helps soldier make rapid progress against TBI – Stars and Stripes – January 30-2012 http://www.stripes.com/news/special-reports/traumatic-brain-injury/new-treatment-facility-helps-soldier-make-rapid-progress-against-tbi-1.167201

 

Single Traumatic Brain Injury May Prompt Long-Term Neurdegeneration, Penn Study Shows – Penn Medicine – July 19, 2011: http://www.uphs.upenn.edu/news/News_Releases/2011/07/brain-injury/ 

with related Journal Article:


Johnson, V.E., Stewart, W. & Smith, D.H. (2011). Widespread Tau and Amyloid-Beta Pathology Many Years After a Single Traumatic Brain Injury in Humans. Brain Pathology (22) 142-149. Brain Pathology ISSN 1015-6305 Click here to download Journal Article