Brain InjuryCalista Nabors, LMSWSedrick Jackson, LCSW

What is Brain Injury Injury to brain tissue that temporary or

permanently impairs brain function

“Brain injury is not an event or an outcome. It is the start of a misdiagnosed, misunderstood, under-funded neurological disease.”

-Brain Injury Association of America

Disability Prevalence Why is this

important? Depression Stroke Epilepsy

The “Silent Epidemic”

Depres

sion MR TB

IStr

oke AD

Epile

psy CP SCI

048

121620

Millions

Incidence Annual Rates 1.7 Million per year (CDC)

50,000 Deaths 235,000 Hospitalizations 1,100,000 ED visits

Comparison

HIV/Aids

Colon Cancer

Breast Cancer

All Cancers combined

TBI

0 100 200 300 400 500 600

Per every 100,000 people

Incidence of Select Health Problems in the U.S

Traumatic Brain Injury Act of 1996

Passed July 29th, 1996 Acknowledged the incidence and

prevalence of brain injury nationally “to expand efforts to identify methods of

preventing traumatic brain injury; expand biomedical research efforts or minimize the severity of dysfunctions a result of such an injury; and to improve the delivery and qualify of services through State Demonstration Projects”

Funding Private Insurance Department of

Defense/Veterans Administration

Some Federal grants for TBI-No feveral money for ABI

Private Pau Non-Profit support-

Scholarships given from community fundraising

Medicaid After

hospitalization Only 5% of

individuals with severe brain injuries have adequate funding for long term treatment

Cost Staggering

Life-long costs Year 2000

$60 Billion Lifetime cost

$406 Billion Neurological Rehab

starts at approx $30,000 per month

No two brain injuries are exactly the same

The effects of a brain injury are complex and vary greatly from person to person

The effects of a brain injury depend on such factors as cause, location, and severity

Types of Brain Injury Traumatic Brain

Injury (TBI) Penetrating:

foreign objects enters the brain Example: bullet

Closed Head: blow to the head Example: car

accident

Acquired Brain Injury (ABI)

occurred after birth, but is not related to congenital defect or degenerative disease

CausesTBI

Falls Motor Vehicle-Traffic

Accidents Struck by/against Assaults Blasts- Leading

cause of TBI for active military in war zones.

ABI Hypoxia Illness Infection Stroke Substance abuse Toxic exposure Tumor

Severity Mild Brain Injury

Loss of consciousness for less than 30 minutes (or no loss)

Glasgow Coma Scale of 13-15 Post-Traumatic amnesia less than 24

hours Temporary or permanently altered mental

state Post-concussion symptoms

Severity Moderate

Coma more than 20-30 minutes but less than 24 hours

Glasgow Coma Scale of 9-12 Skull fractures may be present Signs on EEG, CT or MRI Long term problems in one or more areas

of life

Severity Severe Coma longer than 24 hours Glasgow Coma Scale of 3-8 Bruising, bleeding in brain Signs on EEG, CT or MRI Long term impairments in one or more

areas of life.

Brain and Behavior Relationships

Brain Stem Breathing Heart Rate Arousal/Consciousness Sleep/Wake funtions Attention/Concentration

Cerebellum Balance Coordination Skilled motor

activity Occipital Lobe

Vision

Temporal Lope Memory Hearing Understanding language Organization & sequencing

Frontal Lobe Initiation Problem-solving Judgment Inhibition of behavior Planning/Anticipation Self-monitoring Motor planning

Personality/Emotions Awareness of

abilities/Limits Organization Attention/Concentration Mental Flexibility Speaking

Common Disabilities 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

More serious injuries my result in unresponsiveness with periods of alertness; a persistent vegetative state

Substance Abuse 58% of individuals with acquired brain

injury had a history of alcohol abuse or dependence prior to injury (Kreutzer, Dougherty, &Harris, et al., 1990

Post Injury As many as 50% of individuals with an

acquired brain injury will return to using drugs and alcohol post-injury. (Sparadeo, Strauss &Barth, 1990)

Treatment Initial

Little can be done to reverse the initial brain damage, medical personnel try to stabilize an individual and focus on preventing further injury

Mild injury Mild traumatic brain injuries usually require no treatment

other than rest and over-the-counter pain relievers to treat a headache.

Moderate to severe cases Rehabilitation that involves individually tailored treatment

programs in the areas of physical therapy, occupational therapy, speech/language therapy, physiatry (physical medicine), psychology/psychiatry, and social support.

Medication Therapy Depakote and Tegretol –work well for

aggression Desyrel (sedating property) Anti- Depressants

No MAOI’s- due to dietary constraints Inderal and Clonidine (antihypertensive

medications) Antipsychotics- impair recovery, memory,

learning, and lower seizure threshold.

Social Workers Role Social workers play a very meaningful role.

LMSW: facilitates access to service agencies, assists with care decisions and planning, and facilitates communication among various professionals, care providers and family members

LCSW: continue support services to families and client. Facilitate support groups and provide individual therapy for the client and family members

Advocacy Currently one of the hottest medical topics Funding for treatment and placement is very limited

Medicaid does not pay for neurological rehabilitation

Common Therapy Models Cognitive Behavioral Therapy (CBT)

Mild/Moderate Cognitive Rehabilitation Therapy (CRT)

Mild/ Moderate Dialectical behavior therapy (DBT)

Moderate/Severe Behavioral Therapy

Mild/ Moderate/Severe

Cognitive Behavioral Therapy CBT- Mild to Moderate

Cognitive-behavioral therapy focuses on altering thoughts or perceptions that are causing psychological distress

For those with moderate brain injury Therapist train the client to continuously ask questions

about strong emotional response Example: What is it that's really making me angry? Did it

always make me angry? Did it always make me this angry? Computer-based cognitive therapy programs have

helped many individuals suffering from brain injuries Fun way to exercise each the brain with card games,

mystery games etc. that can improve each area of the brain.

Cognitive Rehabilitation TherapyCRT

patient-specific and goal-oriented increase their ability to process and interpret

information Its goal is to help the client enhance his or her ability to

move through daily life by recovering or compensating for damaged cognitive functions

CRT involves a variety of treatments and often involves the participation of family or caregivers

CRT interventions are promising, however the Department of Defense recommends an investment in research to further define, standardize, and assess the outcomes of CRT interventions.

Dialectical Behavior TherapyDBT

Multi-treatment approach Individual Therapy Coaching Structure

Managing Crises Multiple stages

Connection between borderline personality disorder and brain injury Certain brain mechanisms underlying the impulsivity, mood instability

and negative emotions are responsible for maladaptive behaviors The amygdala, which normally regulates arousal and emotions,

may be involved in the disruption of normal emotional responses due to injury

Behavioral Therapy Clients with moderate to severe brain

injury's may not be able to cognitively process actions Severe brain injury may leave someone

intellectually inept Behavioral Therapy

Reward and punishment systems Operant conditioning Positive reinforcement

Treatment Plan Break it down!

Outcomes: the big idea Goals: break the general outcome down Objectives: no ambiguity, clearly defined

Person Centered Supportive Simple Consistency Positive Daily Planner: Slowly adjusting daily plan.

Adjustment for All6 stages of adjustment for the family

1)Shock, Hope, Denial 2)Recognition and Helplessness 3) Annoyance, Expectations, Reality, Seeking

information 4)Realism, Exhausted, Pulling away, Bereavement 5) Sadness, grief, mourn 6) Understanding, acceptance, family unit

PTSD for entire family: acute or delayed anxiety

Change Identifying events in environment: ABCs

Antecedent Behavior Consequence

Positive reinforcement Yes or No questions Stay Calm Maintain a Sense of Humor Avoid Arguments Don’t Take things personally Redirection

Quiz What part of the brain causes the most change in

personality when injured? True or False: CBT is the best treatment for all clients with

Brain Injury Are open ended questions appropriate for brain injured

clients? True or false: all brain injuries are the same? What are the two types of brain injury? True or false: All brain injuries are the same. True or False: Punishment for bad behavior is good

practice? How many stages of adjustment are their? True or False: Medicaid covers brain injured individuals

long term care What is the 3rd most prevalent disability seen in the United

States?

References American Speech Language Hearing Association; Traumatic Brain

Injuryhttp://www.asha.org/public/speech/disorders/TBI.htm Brain Injury Association of America; http://www.biausa.org/living-with-brain-injury.htm Brain Injury Resource Center; http://www.headinjury.com/rehabcognitive.html Centers for Disease Control and Prevention; http://www.cdc.gov/TraumaticBrainInjury/index.html Institute of Medicine; http://www.iom.edu/Reports/2011/Cognitive-Rehabilitation-Therapy-for-Traumatic-

Brain-Injury-Evaluating-the-Evidence.aspx The Gale Group Inc., Gale…. Gale Encyclopedia of Alternative Medicine Mayo Clinic; http://www.mayoclinic.com/health/traumatic-brain-injury/DS00552/TAB=indepth National Institute of Health; NINDS Traumatic Brain Injury National Institute of Mental Health: Borderline Personality Disorder PsycCentral;http://psychcentral.com/news/2011/10/13/cognitive-rehabilitation-therapy-for-traumatic-brain-

injury-tbi-does-it-work/30325.html Texas Health and Human Services Commission; office of Acquired Brain Injury;

http://www.hhsc.state.tx.us/hhsc_projects/abj/index.shtml The Bridge of Central Massachusetts: DBT for Individuals with Intellectual Disabilities Kreutzer, JS Dougherty DR, and Harris AZ. Et al (1990). Alcohol use among persons with traumatic brain

injury. Journal of Head Trauma Rehabilitation 5:9-20 Sparadeo, FR, Strauss D &Barth, JT(1990). The incidence, impact and treatment of substance abuse in

head trauma rehabilitation. Journal of Head Trauma Rehabilitation 5 (3), 1-8 The Essential Brain Injury Guide Academy of Certified Brain Injury Specialists, Brain Injury Association of

America.