Mild Traumatic Brain Injury

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					Mild Traumatic Brain
    What makes “Mild” Mild
Mild TBI- ACRM Definition
“Traumatically induced physiologic
  disruption of brain function” with any
  one of the following:
-     any period of documented LOC (<30 mins)
-   any memory loss for events just before (retrograde) and/or
    after (anterograde) the injury
-   any alteration in mental state beginning at the time of the
    injury event
-   Focal neurologic deficits which may or may not be transient
-   After 30 minutes, an initial GCS of 13-15
-   Results in cognitive, physical, behavioral changes
Different Mechanisms of Injury

   Traumatic injury- a bump on the head or
   “Inertial forces”
       Acceleration-deceleration with injury to the
        “poles,” coup-contra coup
       Rotational, DAI- shearing

   clinical language is not standardized
   concussion- an injury with transient effects (not
    permanent), rapid onset of short-lived impairment
   “concussive” injury
   post-concussive syndrome
   post-traumatic headache

    Effects of repeated concussions are CUMULATIVE
   Not all homes in a Class 3 Hurricane suffer the
                    same damage
     Attention and concentration                    -   depression
     Memory                                         -   anxiety
     Executive functioning                          -   irritability
     Cognitive fatigue                              -   Obssessiveness
     Communication (dysnonmia, aphasia)             -   self-doubt

                          PHYSICAL/SOMATIC DEFICITS
       fatigability                           - vision problems
      low libido                      - sensitivity to light and sound
      sleep disturbance               - headaches
      Dizziness/ vertigo              -  overstimulation
      blurry vision                   -  pain control

Why some and not the others?
   Individual vulnerability: differences in brain structure, neurotransmitter
    balances balances
   Diatheses Stress Model: premorbid coping abilities and stress reactions
   Pre-existing psychological disorder
   Prior brain injury/concussions
   post-injury psychological dysfunction- anxiety and depression, PTSD
   Support (medical, family systems)
   Rehabilitation
   Age
   Socioeconomic states
   Substance abuse
The Course of Mild TBI
    mTBI is often misdiagnosed or missed
    ~3.5 million traffic related injuries annually
    66-75% of admissions for head trauma are
     characterized as “mild”
    Estimates of 325,000 up to 700,000 new cases
     per year
    10-15 % of people who sustain mTBI have
     symptoms that persist beyond 1 year
Perna, Williams, and Durgin, Journal of Cognitive Rehabilitation. May/June 2000
   The PATIENT “I am going crazy. It takes me so long to do
    anything anymore. Bright lights and loud noise bothers me.
    I can’t follow conversations. I am so quick to get angry now. I
    can’t remember names. I get lost in the food store. I cry all the
   The FAMILY “& FRIENDS What is wrong with you? You look
    fine. You arm healed and your cast is off. Get over it.”
   The NEIGHBORS “She doesn’t take care of her garden
    anymore. The newspapers are piling up outside.”
   The CHILDREN “Mom curses now and she never did before.
    She takes naps all the time. She burns dinner. She’s not fun
   The BOSS “Why are you taking so long to complete assignments
    and missing deadlines? Why are you late arriving to work now?
    Why do you need to take breaks more often? You’re fired.”
   The FUNDER “ You’re malingering. This is for secondary gain.”
   The DOCTOR “You have PTSD, fibromaylagia, depression,
    PTSD…….Take this medication, this one, and this one”
   “W hen a person with a mild TBI suddenly
finds himself forgetting things, making errors,
taking longer, being disorganized, irritable,
and getting into conflicts with others and is
told by professionals that there is nothing
wrong……can be more debilitating than the
primary, neurological deficits that fuel it….”
(Kay, 1992)
Who’s Who Among Brain Injury
   “I could never really remember what took place the entire game”
     Troy Aikman, pro football (Players Gather 1995)

   “I would get dazed probably 6 times a year…I was babbling in the
    huddle.” Steve Young, pro football (Players Gather, 1995)

   Pat La Fontaine, pro hockey- highest scoring American-born hickey
    player in the NHL, sixth career concussion in October 1996, listed
    injured for 3 months (headaches, vision problems, incoordination).
    (Shoats, 1996)

   Eric Lindross?

   Pat Hamm at the Oylmpics
              How does this play out in real life?

   You can’t go out to dinner anymore because the background noise bothers you, you are too distracted
    by the restaurant activity to follow a conversation, and you have too much trouble picking out what to
    eat off of the menu.

   You have problems at the food store by the bright lights and noise (especially the ringing of the cash
    register). You can’t find you way around and feel like you’re walking in circles. You get stuck in every
    aisle trying to decide on what brand to purchase. You begin to think self=deprecating thoughts and
    end up leaving your cart half full in the store.

   When you are driving you confuse your right with your left. When the ambulance goes by your head
    starts to spin. You forget where you were going for a minute. By the time you remember, you have
    passed your street. You have no idea how to get back to your street. It’s very hard for you to think on
    your toes and you can’t figure out another way to go to get where you want.

   When you start cooking rice for dinner you get distracted by a dirty kitchen floor. You start mopping
    the kitchen floor and then realize your cabinets are unorganized. You start to reorganize all of your
    cabinets. Then you get distracted by a news story on the TV and you end up sitting down to watch the
    news. You forget completely what you were doing and only remember when the smoke alarm goes
                                DOES THIS SOUND MILD TO YOU?
        How is Mild TBI different from the
                                      Mild vs. moderate
                                          vs. severe
   By definition moderate has a GCS of 9-12 and severe has a GCS score of 3-8
   Severe - usually results in more physical deficits (gait, hemi paralysis, apraxia), seizure disorders,
    behavioral problems such as disinibition or social/sexual inappropriateness
   Severe- typically demonstrate very limited insight, communication problems (aphasia, dysarthria)
   Case examples Sharon C., Peter G., Megan M., Michael L. ,Mark S., Tom S., Stan T., Ray W

                            Mild vs. Mental Retardation/LD
   Plasticity of the may lead to changes in MTBI
   Learning patterns are different
   Organic differences

   Case examples- Michael B., Amy F., Crystal K., Matt P., Brian S.
    Treatment of Mild TBI vs. other Diagnoses

   Early Diagnoses is Key
   Assessment
   Education/counseling
   Symptom specific psychopharmacology
   Pain Management
   Therapies- vestibular, functional
   Cognitive Rehabilitation/Remediation
    How do you retrain the brain
    “Evidence Based Cognitive Rehabilitation: Recommendations
       for Clinical Practice” (Cicerone et al 2000)

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