Neuropsychology of Traumatic Brain Injury
Resent Findings on Signs, Symptoms, Diagnosis, Treatment, and Prognosis
Martin L. Rohling, Ph.D. Assistant Professor Department of Psychology University of South Alabama
Martin L. Rohling, Ph.D.
1
Epidemiology of TBI: Data From TBI Model Systems
Mean age in years = 36 Gender = 75% male Race = 57% white; 31% African-American Marital status = 71% unmarried Education = 12.0; 36% without HS degree Average GCS score upon admission = 7
Martin L. Rohling, Ph.D. 2
Epidemiology of TBI: Data From Rohling et al. (2001)
Incidence & prevalence
1.3 million Americans experience TBI yearly
Severity defined by LOC: 88% experience LOC Average LOC 3.8 days; However,
40% LOC = < 1 hr
21% LOC = 1-23 hrs
15% LOC = 1-6 days 10% LOC = 7-13 days
8% LOC = 14-28 days 6% LOC = > 28days
Martin L. Rohling, Ph.D.
3
Epidemiology of TBI: More Data CDC & TBIMS
5.3 million Americans currently living with this condition 60% employed at time of injury
Only 25% employed 1-year post injury
Martin L. Rohling, Ph.D.
4
Epidemiology of TBI: More TBIMS Data
TBI resulting in hospitalizations or death was 95 per 100,000. 22% of TBI resulted in death. 80,000 Americans incur significant disability consequent to TBI each year. Best predictors of pediatric TBI outcome is family functioning premorbidly.
Martin L. Rohling, Ph.D. 5
Etiology of Injury
57% due to motor vehicle accidents 29% due to violence
56% of these blunt (closed head injury) 23% of these penetrating (open head injury)
11% due to falls 3% other causes
Martin L. Rohling, Ph.D.
6
Visual Aid for TBI Explanation
Martin L. Rohling, Ph.D.
7
TBI: Alcohol Use at Injury
Persons with TBI tested positive for alcohol at time of injury in 49% of cases.
Of these, blood alcohol levels of 100mg/ml (i.E., Common legal limit for DUI) were detected in 62% of cases.
Martin L. Rohling, Ph.D.
8
Violence and TBI
44% of death due to TBI due to gunshot 9% of non-fatal TBI due to violence Who suffers TBI due to violence:
Older than other types of TBI (modal age = 40) 3 times more likely to be a minority More likely single/divorced & living alone Lower educational levels & more unemployment
Martin L. Rohling, Ph.D. 9
Violence Induced TBI: Recovery Results
Higher ETOH at admission than nonviolent. Less severe injuries (GCS = 9.6 vs. 8.3). Shorter lengths of stay both acute & rehab. Payor is Medicaid in 58% of cases, which is 3X that of the non-violently injured. No difference on FIM at admission or d/c. Higher rates of unemployment and ETOH use postinjury than non-violently injured.
Martin L. Rohling, Ph.D. 10
TBI Treatment: Cost of Care
Average acute care costs for treating TBI patients in 1999 were $96,606. Mean costs for inpatient rehab care for these individuals was $43,435
Martin L. Rohling, Ph.D.
11
Epidemiology of TBI: More TBIMS Data
Inpatient length of stay (LOS): going down LOS data from 1994:
22 days acute care 39 days rehab unit 19 days acute care 27 days rehab unit
Martin L. Rohling, Ph.D. 12
LOS data from 1999:
TBIMS in Alabama
University of Alabama at Birmingham traumatic brain injury care system contact: Dr. Tom Novack, project director, Spain rehabilitation center, 1717 6th Ave. S., Birmingham, AL 35233-7330. Phone: 205934-3454. Fax: 205-975-4691. E-mail: novack@sun.rehabm.uab.edu.
Martin L. Rohling, Ph.D. 13
TBIMS at UAB: Studies Currently Underway
(1) the utility of utilizing routine D-DIMER measurement as a screen for proximal deep vein thrombosis will be examined in collaboration with the model center in Mississippi; (2) the use of constraint induced therapy, which has proven effective for people having hemiparesis after CVA, will be examined in people with TBI; (3) competency to make medical and financial decisions will be examined twice in the course of recovery after TBI; (4) A home-based cognitive remediation program that can be implemented by family members will be developed in cooperation with ADRS;
Martin L. Rohling, Ph.D.
14
TBIMS at UAB: Studies Currently Underway
(5) the utility of the useful field of view test, which has proved very effective with older drivers, will be examined for people with TBI, specifically as a means of screening before an the on-the-road driving evaluation takes place; (6) impact of an intentional injury, such as an assault or through a selfinflicted trauma, will be examined as compared unintentional injury, such as occurs in a motor vehicle crash; (7) outcomes as a result of diffuse axonal injury as compared to focal TBI will be examined; (8) in collaboration with the model center in Mississippi, UAB will be participating in a study evaluating self-awareness of deficits after TBI and specifically the correlation with depression and impact on outcome a year after trauma.
Martin L. Rohling, Ph.D. 15
Cohort Outcome Measures
Measure
Functional Independence Measure (FIM) Disability Rating Scale (DRS)
Rehab Unit
Rehab D/C
Year 1
Year 2
Year 5
Year 10
56 12.7 N/A
97 6.0 N/A
115 3.0 15.6
116 2.9 15.7
116 2.7 16.0
117 2.7 17.7
Community Integration (self)
Community Integration (other)
N/A
N/A
13.9
13.7
13.8
18.6
16
Martin L. Rohling, Ph.D.
Factors Affecting Rate of Neurological Recovery
Recovery following TBI is multifaceted
1 yr post TBI significant individual differences
Age, education, and injury severity
Important factors premorbidly are:
Cognitive recovery past 1 year minimal and only in measures of complex attention Rate of recovery dependent on cognitive domain and location of injury
Martin L. Rohling, Ph.D. 17
Impact of TBI Severity on Cognition 1-yr Post TBI
65 60
Maximum 90th %ile
55
75th %ile
50
50th %ile
y = -2.25x + 59.1
45
25th %ile 10th %ile
40
y = -2.87x + 57.1 y = -2.63x + 53.5
Minimum
35
y = -2.78x + 49.7
30
y = -2.83x + 44.7
25
y = -3.03x + 41.6 y = -2.62x + 36.2
20 0 1 2 3 4 5 Severity Groups Based On TFC
6
Martin L. Rohling, Ph.D.
18
Effects of Financial (2nd Gain) on TBI Recovery
Binder & Rohling (1996) found the effect size of litigation/compensation = .60 sd units. Binder, Rohling, & Larrabee (1997) found the effect of Mild TBI to be non-significant (ES is between .07-.10 sd units). For Mild TBI w/ financial incentives, impairment is 6 to 9 times more likely to be caused by incentives than neurological factors.
Martin L. Rohling, Ph.D. 19
Symptom Validity or Suboptimal Performance
Base rate of exaggeration estimated to be 27% all TBI cases (Rohling et al., 2000). Base rate for symptom exaggeration higher in patients with mild TBI versus severe TBI (54% versus 21%). Impairment equals 1.2 to 1.5 sd units.
For LOC < 1 hr, deficit = 14-28 days LOC.
Martin L. Rohling, Ph.D. 20
Pediatric TBI: Differences Between Kids and Adults
Developmental stage at time of injury is much more important in determining outcome. Family and school support much more relevant in improving long-term outcome. Delayed effects of TBI can be expected.
ADHD, LD, behavioral disorders.
Martin L. Rohling, Ph.D. 21