Traumatic Brain Injury Traumatic Brain Injury Assessment and Rehabilitation:Assessment and Rehabilitation:

A Continuum of CareA Continuum of Care

Presented at the Pennsylvania Psychological Association Presented at the Pennsylvania Psychological Association Annual Convention, Friday June 18, 2010.Annual Convention, Friday June 18, 2010.

PresentersPresenters

Tad Gorske, Ph.D.Tad Gorske, Ph.D.

Assistant Professor Assistant Professor

Clinical NeuropsychologistClinical Neuropsychologist

Director of Outpatient NeuropsychologyDirector of Outpatient Neuropsychology

Division of NeuropsychologyDivision of Neuropsychology

and Rehabilitation Psychologyand Rehabilitation Psychology

University of Pittsburgh School of University of Pittsburgh School of

MedicineMedicine

DisclosuresDisclosures

Director: Outpatient Director: Outpatient Neuropsychology, Department Neuropsychology, Department of Physical Medicine and of Physical Medicine and RehabilitationRehabilitation

Primary Author with Dr. Steven Primary Author with Dr. Steven Smith: Collaborative Smith: Collaborative Therapeutic Neuropsychological Therapeutic Neuropsychological Assessment, Springer Assessment, Springer Publications. Publications.

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DisclaimerDisclaimer

This presentation is designed to provide This presentation is designed to provide information and education on the information and education on the neuropsychology of traumatic brain injury neuropsychology of traumatic brain injury assessment and rehabilitation. Attendance assessment and rehabilitation. Attendance at this workshop does not meet the APA at this workshop does not meet the APA ethical requirements to identify oneself as ethical requirements to identify oneself as an expert or practitioner in traumatic brain an expert or practitioner in traumatic brain injury. injury.

““The presentation of brain facts about The presentation of brain facts about specific damages is meaningless to specific damages is meaningless to patients unless they can begin to patients unless they can begin to understand how the changes in their understand how the changes in their brains are lived out in everyday brains are lived out in everyday experiences and situations”experiences and situations”

(Varella, 1991 as stated in McInerney (Varella, 1991 as stated in McInerney and Walker, 2002)and Walker, 2002)

Definition of Traumatic Brain InjuryDefinition of Traumatic Brain Injury

Closed head injury (CHI) – Skull intact, brain Closed head injury (CHI) – Skull intact, brain not exposed.not exposed.

Penetrating head injury (PHI) – Open head Penetrating head injury (PHI) – Open head injury where skull and dura are penetrated injury where skull and dura are penetrated by an object. by an object.

Vascular insults (due to stroke, anoxia, etc. Vascular insults (due to stroke, anoxia, etc. will also be included for today’s purposes.)will also be included for today’s purposes.)

Centers for Disease Control TBI DefinitionCenters for Disease Control TBI Definition– Craniocerebral trauma, specifically, an occurrence of Craniocerebral trauma, specifically, an occurrence of

injury to the head (arising from blunt or penetrating injury to the head (arising from blunt or penetrating trauma or from acceleration/deceleration forces) that is trauma or from acceleration/deceleration forces) that is associated with any of these symptoms attributable to associated with any of these symptoms attributable to injury: decreased level of consciousness, amnesia, injury: decreased level of consciousness, amnesia, other neurologic or neuropsychological abnormalities, other neurologic or neuropsychological abnormalities, skull fracture, diagnosed intracranial lesions, or death.skull fracture, diagnosed intracranial lesions, or death.

– Thurman DJ, Sniezek JE, Johnson D, et al., Guidelines for Surveillance of Central Nervous 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 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.Disease Control and Prevention, US Department of Health and Human Services, 1995.

Prevalence of TBIPrevalence of TBI

Associated w/Associated w/– 50,000 – 75,000 deaths annually;50,000 – 75,000 deaths annually;– 230,000 – 373,000 hospitalizations – nonfatal 230,000 – 373,000 hospitalizations – nonfatal

TBITBI– 80,000 = long term disability80,000 = long term disability– 1,975,000 individuals attended to medically1,975,000 individuals attended to medically

US StatisticsUS Statistics– Incidence average 220/100,000Incidence average 220/100,000

Rates of TBI hospitalization and death by age groupRates of TBI hospitalization and death by age group

0

50

100

150

200

250

0-4 5--14 15-24

25-34

35-44

45-54

55-64

65-74

75+

Rates per 100,000

AgeGroup

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Proportion of TBI related hospitalizations and deathsProportion of TBI related hospitalizations and deaths

Transportation

Falls

Firearms

Other Assaults

Other

Unknown

Transportation

Falls

Firearms

Assaults

Other

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

Mechanism of Brain InjuryMechanism of Brain Injury

Primary InjuryPrimary Injury– Damage that results Damage that results

from shear forces; seen from shear forces; seen in the initial in the initial minutes/hours after the minutes/hours after the insultinsult

– Cortical disruptionCortical disruption– Axonal InjuryAxonal Injury– Vascular InjuryVascular Injury– HemorrhageHemorrhage

Secondary InjurySecondary Injury– Evolution of brain Evolution of brain

damagedamage– Post traumatic ischemiaPost traumatic ischemia– ExcitotoxicityExcitotoxicity– Cell DeathCell Death– Axonal InjuryAxonal Injury– Cerebral SwellingCerebral Swelling– Inflammation/ Inflammation/

regenerationregeneration

Closed Head InjuryClosed Head Injury

Resulting from falls, motor vehicle crashes, Resulting from falls, motor vehicle crashes, etc.etc.

Focal damage and diffuse damage to axonsFocal damage and diffuse damage to axons Effects tend to be broad (diffuse)Effects tend to be broad (diffuse) No penetration to the skullNo penetration to the skull

Open Head InjuryOpen Head Injury

Results from bullet wounds, etc.Results from bullet wounds, etc. Largely focal damageLargely focal damage Penetration of the skullPenetration of the skull Effects can be just as seriousEffects can be just as serious

TBI: A TBI: A biologicalbiological event within the event within the brainbrain

Tissue damageTissue damage Bleeding Bleeding SwellingSwelling Cell deathCell death StrokeStroke SeizureSeizure Other multiple medical complicationsOther multiple medical complications

TBI: Changes in TBI: Changes in functioningfunctioning

Loss of consciousness/comaLoss of consciousness/coma Other changes due to the TBIOther changes due to the TBI Post-traumatic amnesia (PTA)Post-traumatic amnesia (PTA)

Injured BrainInjured Brain

Does not mend fullyDoes not mend fully Leads to problems in functioningLeads to problems in functioning

What Do We Mean by What Do We Mean by Severity of InjurySeverity of Injury

Amount of brain tissue damageAmount of brain tissue damage

How to measure “severity”?How to measure “severity”?

Duration of loss of consciousnessDuration of loss of consciousness Initial score on Glasgow Coma Scale (GSC)Initial score on Glasgow Coma Scale (GSC) Length of post-traumatic amnesiaLength of post-traumatic amnesia Rancho Los Amigos Scale (1 to 10)Rancho Los Amigos Scale (1 to 10)

Mild injury0-20 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 What Happens as the Person with Moderate or Severe with Moderate or Severe

Injury Begins to Recover After Injury Begins to Recover After Injury?Injury?

Recovery and PlasticityRecovery and Plasticity

Plasticity refers to the ability of the brain to Plasticity refers to the ability of the brain to recover and regenerate. recover and regenerate.

Controversial idea; definition and Controversial idea; definition and mechanisms are not clearmechanisms are not clear

Idea that the CNS is a dynamic system Idea that the CNS is a dynamic system capable of reorganization in response to capable of reorganization in response to injuryinjury

Determining Recovery PotentialDetermining Recovery Potential

Some guidelinesSome guidelines– Lower Glascow Coma Scale (GCS) Score;Lower Glascow Coma Scale (GCS) Score;– Longer coma duration (greater than 4weeks);Longer coma duration (greater than 4weeks);– Longer duration of Post Traumatic Amnesia (PTA)(good Longer duration of Post Traumatic Amnesia (PTA)(good

recovery unlikely when <3months)recovery unlikely when <3months)– Older age assoc. with worse outcomesOlder age assoc. with worse outcomes– Neuroimaging features (presence of SAH, cisternal Neuroimaging features (presence of SAH, cisternal

effacement, significant midline shift, EDH or SDH on effacement, significant midline shift, EDH or SDH on acute care CT = worse outcomes). acute care CT = worse outcomes).

Cognitive Impairments after TBICognitive Impairments after TBI

Post Traumatic AmnesiaPost Traumatic Amnesia Information processing and attention;Information processing and attention; Anosognosia (unawareness of deficits);Anosognosia (unawareness of deficits); Intellectual functioningIntellectual functioning MemoryMemory Confabulation and delusionsConfabulation and delusions Spatial CognitionSpatial Cognition Chemical Senses (Olfaction and Taste)Chemical Senses (Olfaction and Taste) Executive FunctionsExecutive Functions Social Cognition and BehaviorSocial Cognition and Behavior

Comprehensive RehabilitationComprehensive Rehabilitation

Physical TherapyPhysical Therapy Occupational TherapyOccupational Therapy Speech TherapySpeech Therapy Medical ManagementMedical Management Psychological/Neuropsychological Psychological/Neuropsychological Emotional/Psychiatric Management as appropriateEmotional/Psychiatric Management as appropriate Family SupportFamily Support Case ManagementCase Management

The Role of Neuropsychological The Role of Neuropsychological Assessment: Historical PerspectiveAssessment: Historical Perspective

Period of Neuropsychological LocalizationPeriod of Neuropsychological Localization

Period of Neurocognitive EvaluationPeriod of Neurocognitive Evaluation

Current Period??Current Period??

Technician / ArtistTechnician / Artist

Neuropsychologists are challenged to Neuropsychologists are challenged to expand their roles from a purely technical expand their roles from a purely technical endeavor to a more holistic perspective. endeavor to a more holistic perspective.

Cognitive theorist, functional anatomistCognitive theorist, functional anatomist

Technician / ArtistTechnician / Artist

Neuropsychologists are challenged to Neuropsychologists are challenged to expand their roles from a purely technical expand their roles from a purely technical endeavor to a more holistic perspective. endeavor to a more holistic perspective.

Cognitive theorist, functional anatomist, Cognitive theorist, functional anatomist, psychotherapist, family therapist, emotional psychotherapist, family therapist, emotional adjustment, viewing the person from a adjustment, viewing the person from a holistic perspective. holistic perspective.

Holistic Neuropsychological PrinciplesHolistic Neuropsychological Principles Empower patients and families to take an active role Empower patients and families to take an active role

in the treatment process;in the treatment process; Believe people with neurological disabilities are more Believe people with neurological disabilities are more

like people without neurological disabilities (ie. like people without neurological disabilities (ie. Go Go beyond the brainbeyond the brain) ;) ;

Convey honesty and caring in personal interactions Convey honesty and caring in personal interactions to form a foundation for a strong therapeutic to form a foundation for a strong therapeutic relationship;relationship;

Develop practical plans for rehabilitation; explain Develop practical plans for rehabilitation; explain rehabilitation techniques in understandable language;rehabilitation techniques in understandable language;

Holistic Neuropsychological PrinciplesHolistic Neuropsychological Principles

Help patients and families understand Help patients and families understand neurobehavioral sequelae of brain injury and neurobehavioral sequelae of brain injury and recovery;recovery;

Recognize change is inevitable and help families Recognize change is inevitable and help families cope with change;cope with change;

Every patient is important, treat with respect;Every patient is important, treat with respect; Remember that patients and families have Remember that patients and families have

different perspectives regarding treatment different perspectives regarding treatment approaches;approaches;

Be willing to refer if appropriate. Be willing to refer if appropriate.

The Unknown

Existential Issues in TBIExistential Issues in TBI

Awareness of change;Awareness of change; Emotions; Emotions; Struggle of acceptance; Struggle of acceptance; Struggle to make sense and find meaning;Struggle to make sense and find meaning; Struggle to reclaim/find a sense of selfStruggle to reclaim/find a sense of self

TBI Recovery ChallengesTBI Recovery Challenges

Knowledge of deficitsKnowledge of deficits Adapting to deficitsAdapting to deficits Grieving and Coping (Denial, anger, Grieving and Coping (Denial, anger,

bargaining, depression, acceptance).bargaining, depression, acceptance). Learning and re-learningLearning and re-learning Integrating knowledge into the selfIntegrating knowledge into the self Re-discovering meaning and a sense of Re-discovering meaning and a sense of

purposepurpose

“…But be that as it may, those of us who did make it have an obligation to build again. To teach to others what we know, and to try with what's left of our lives to find a goodness and a meaning to this life.” (Quote from the movie “Platoon”, 1986)

How neuropsychological assessment How neuropsychological assessment addresses these challengesaddresses these challenges

1.1. Knowledge of deficitsKnowledge of deficits

2.2. Adapting to deficitsAdapting to deficits

3.3. Grieving and Coping Grieving and Coping (Denial, anger, (Denial, anger, bargaining, depression, bargaining, depression, acceptance).acceptance).

4.4. Learning and re-learningLearning and re-learning

5.5. Integrating knowledge Integrating knowledge into the selfinto the self

6.6. Re-discovering meaningRe-discovering meaning

1.1. Provides information on Provides information on cognitive functioning. cognitive functioning.

2.2. Presents potential Presents potential ameliorative strategies. ameliorative strategies.

3.3. Does not directly address.Does not directly address.4.4. Cognitive rehabilitation Cognitive rehabilitation

and remediation.and remediation.5.5. Presents one aspect of Presents one aspect of

the person (cognition).the person (cognition).6.6. Does not directly address.Does not directly address.

How collaborative neuropsychological How collaborative neuropsychological assessment addresses these challengesassessment addresses these challenges

1.1. Knowledge of deficitsKnowledge of deficits

2.2. Adapting to deficitsAdapting to deficits

3.3. Grieving and Coping Grieving and Coping (Denial, anger, (Denial, anger, bargaining, depression, bargaining, depression, acceptance).acceptance).

4.4. Learning and re-learningLearning and re-learning

5.5. Integrating knowledge Integrating knowledge into the selfinto the self

6.6. Re-discovering meaningRe-discovering meaning

1.1. Provides information on cognitive Provides information on cognitive functioning and seeks individual functioning and seeks individual application.application.

2.2. Presents potential ameliorative Presents potential ameliorative strategies and seeks out the strategies and seeks out the individuals own resources for change.individuals own resources for change.

3.3. Address a person’s experience and Address a person’s experience and reactions to information provided; reactions to information provided; balances education and the I-Thou balances education and the I-Thou interaction.interaction.

4.4. Cognitive rehabilitation and Cognitive rehabilitation and remediation and works to motivate remediation and works to motivate internalization.internalization.

5.5. Presents one aspect of the person Presents one aspect of the person (cognition) and considers it within the (cognition) and considers it within the context of the whole person. context of the whole person.

6.6. Looks toward the future and what all Looks toward the future and what all this means for the person. this means for the person.

Holistic Neuropsychological Holistic Neuropsychological PrinciplesPrinciples

Empower patients and families to take an active role Empower patients and families to take an active role in the treatment process;in the treatment process;

Believe people with neurological disabilities are more Believe people with neurological disabilities are more

like people without neurological disabilities (ie. like people without neurological disabilities (ie. Go Go beyond the brainbeyond the brain) ;) ;

Convey honesty and caring in personal interactions Convey honesty and caring in personal interactions to form a foundation for a strong therapeutic to form a foundation for a strong therapeutic relationship;relationship;

Develop practical plans for rehabilitation; explain Develop practical plans for rehabilitation; explain rehabilitation techniques in understandable language;rehabilitation techniques in understandable language;

Holistic Neuropsychological PrinciplesHolistic Neuropsychological Principles

Help patients and families understand Help patients and families understand neurobehavioral sequelae of brain injury and neurobehavioral sequelae of brain injury and recovery;recovery;

Recognize change is inevitable and help families Recognize change is inevitable and help families cope with change;cope with change;

Every patient is important, treat with respect;Every patient is important, treat with respect; Remember that patients and families have Remember that patients and families have

different perspectives regarding treatment different perspectives regarding treatment approaches;approaches;

Be willing to refer if appropriate. Be willing to refer if appropriate.

Methods of Collaborative Methods of Collaborative NeuropsychologyNeuropsychology

Demystify the neuropsychological assessment Demystify the neuropsychological assessment process: process: Provide feedback report; explain session purpose; Provide feedback report; explain session purpose; facilitate collaboration and empathic understandingfacilitate collaboration and empathic understanding

Answer what the individual wants to know (If Answer what the individual wants to know (If you can).you can).

Explain how strengths and weaknesses are Explain how strengths and weaknesses are determined.determined.

Ensure an understanding of the information Ensure an understanding of the information provided. provided.

Methods of Collaborative Methods of Collaborative NeuropsychologyNeuropsychology

Ensure the information relates to the Ensure the information relates to the persons experience;persons experience;

Or if it doesn’tOr if it doesn’t Explore the discrepancy.Explore the discrepancy. Summarize what has been discussed.Summarize what has been discussed. Make suggestionsMake suggestions Look to the future.Look to the future.

Applications In Brain Injury (BI) Applications In Brain Injury (BI) RehabilitationRehabilitation

Developing rapportDeveloping rapport Encouraging discussion/elaborationEncouraging discussion/elaboration Demystify neuropsychology/brain Demystify neuropsychology/brain Facilitate insight/awarenessFacilitate insight/awareness Provide markers of progressProvide markers of progress

Applications In Brain Injury Applications In Brain Injury RehabilitationRehabilitation

Demystify experience (ie. Why is _____ Demystify experience (ie. Why is _____ happening to me?)happening to me?)

Educate on brain injury recovery (Expect the Educate on brain injury recovery (Expect the worst but hope for the best)worst but hope for the best)

Provide individualized recommendations for Provide individualized recommendations for adaptation/remediationadaptation/remediation

Addressing Existential issuesAddressing Existential issues

Strengths of CTNA in BIStrengths of CTNA in BI

Evaluation of progress, ie. Does recovery seem to be Evaluation of progress, ie. Does recovery seem to be on the right track;on the right track;

Develop personalized recommendations for Develop personalized recommendations for rehabilitation;rehabilitation;

Insight and awareness (more difficult with Insight and awareness (more difficult with anosognosia);anosognosia);

Helps to explain experience;Helps to explain experience; Strengths and challenges for goals;Strengths and challenges for goals; Balance hope and painful realities;Balance hope and painful realities; Finding meaning and exploring the integration of mind Finding meaning and exploring the integration of mind

and spiritand spirit

Case ExampleCase Example

Contact InformationContact Information

Tad T. Gorske, Ph.D., Assistant ProfessorTad T. Gorske, Ph.D., Assistant ProfessorDivision of Neuropsychology andDivision of Neuropsychology andRehabilitation PsychologyRehabilitation PsychologyDepartment of Physical Medicine and Department of Physical Medicine and RehabilitationRehabilitationClinical Neuropsychology ServicesClinical Neuropsychology ServicesMercy Hospital-Building DMercy Hospital-Building DRoom G138Room G1381400 Locust Street1400 Locust StreetPittsburgh, PA  15219Pittsburgh, PA  15219Phone: 412-232-8901Phone: 412-232-8901Fax:  412-232-8910Fax:  412-232-8910gorskett@upmc.edugorskett@upmc.eduhttp://www.rehabmedicine.pitt.edu/http://www.rehabmedicine.pitt.edu/http://www.linkedin.com/in/tadgorskehttp://www.linkedin.com/in/tadgorske