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Traumatic Brain Injury 101:Traumatic Brain Injury 101:Causes, Consequences & Causes, Consequences &

StrategiesStrategies

February 28, 2008February 28, 2008

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Brain Injury Association of Brain Injury Association of OhioOhio State Office-ColumbusState Office-Columbus + + CSN 1, Toledo: Christine VeronieCSN 1, Toledo: Christine Veronie CSN 3, Cleveland: Lori SurtmanCSN 3, Cleveland: Lori Surtman CSN 5, Lima: Jennie HornerCSN 5, Lima: Jennie Horner CSN 8, New Philadelphia: Chris CSN 8, New Philadelphia: Chris

CurtissCurtiss CSN 11, Columbus: Rich HaddixCSN 11, Columbus: Rich Haddix CSN 12, Caldwell: Jenny RuckerCSN 12, Caldwell: Jenny Rucker CSN 13, Cincinnati: Peggy O’NeillCSN 13, Cincinnati: Peggy O’Neill CSN 15, Marietta: Cindy AukerCSN 15, Marietta: Cindy Auker

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ObjectivesObjectives Increase knowledge of demographics & scope Increase knowledge of demographics & scope

of brain injuryof brain injury Gain understanding of common consequences Gain understanding of common consequences

and challenges following brain injury and challenges following brain injury Better understand the impact on the Better understand the impact on the

individual and his or her familyindividual and his or her family Learn about available sources of information & Learn about available sources of information &

assistance + the lack of a “home” agency.assistance + the lack of a “home” agency. Identify skills and strategies to assist Identify skills and strategies to assist

individuals with brain injury individuals with brain injury

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What is a Brain Injury?What is a Brain Injury?

Acquired Brain Injury (ABI)Acquired Brain Injury (ABI) Traumatic Brain Injury (TBI)Traumatic Brain Injury (TBI)

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Acquired Brain InjuryAcquired Brain Injury Any injury to the brain that occurs Any injury to the brain that occurs

after birth as a result of:after birth as a result of:• Physical force (due to an accident)Physical force (due to an accident)• TumorsTumors• StrokesStrokes• Violent Acts (e.g., gun shot wound)Violent Acts (e.g., gun shot wound)• Infectious Diseases (e.g., Infectious Diseases (e.g.,

encephalitis)encephalitis) ABI is the broadest category and ABI is the broadest category and

includes all brain injuries that occur includes all brain injuries that occur after birth.after birth.

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Traumatic Brain InjuryTraumatic Brain Injury

A brain injury from an external A brain injury from an external forceforce• Vehicle accidentsVehicle accidents• Violent Acts (e.g., gun shot wound)Violent Acts (e.g., gun shot wound)• FallsFalls• Physical AbusePhysical Abuse• Sports InjuriesSports Injuries

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Severity ContinuumSeverity Continuum

Things to ConsiderThings to ConsiderSymptomology Symptomology Pre-injury functioningPre-injury functioningSymptoms varySymptoms vary

Mild SevereModerate

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15% of all TBIs are 15% of all TBIs are considered moderate considered moderate to severeto severe

85% of all TBIs are 85% of all TBIs are considered mildconsidered mild

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Mild Brain InjuryMild Brain Injury Traumatically induced physiological disruption of Traumatically induced physiological disruption of

brain function as manifested by at least one of brain function as manifested by at least one of the following:the following:• Loss of consciousness (often measured by the Loss of consciousness (often measured by the

Glasgow Coma ScaleGlasgow Coma Scale• Loss of memory for events immediately Loss of memory for events immediately

before or after the accident (not longer than before or after the accident (not longer than 24 hours)24 hours)

• Alteration in mental state at the time of the Alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented, or accident (e.g., feeling dazed, disoriented, or confused); and/or confused); and/or

• Focal neurological deficits that may or may Focal neurological deficits that may or may not be transient.not be transient.

(Glascow Coma Scale score 13-15)(Glascow Coma Scale score 13-15)

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Moderate Brain InjuryModerate Brain Injury

A loss of consciousness that lasts from a few A loss of consciousness that lasts from a few minutes to a few hours;minutes to a few hours;

Confusion lasts from days to weeks;Confusion lasts from days to weeks; Physical, cognitive, and/or behavioral impairments Physical, cognitive, and/or behavioral impairments

last for months or are permanent; and/orlast for months or are permanent; and/or Persons with moderate traumatic brain injury Persons with moderate traumatic brain injury

generally make a good recovery with treatment or generally make a good recovery with treatment or successfully learn to compensate for their deficits. successfully learn to compensate for their deficits.

(Glascow Coma Scale score 9-12)(Glascow Coma Scale score 9-12)

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Severe Brain InjurySevere Brain Injury

Severe Brain Injury (Glascow Coma Severe Brain Injury (Glascow Coma Scale score 8 or less)Scale score 8 or less)• Almost always results in prolonged Almost always results in prolonged

unconsciousness or coma, brain contusions, unconsciousness or coma, brain contusions, hematomas, damage to nerve fibers and hematomas, damage to nerve fibers and axons, and/or anoxiaaxons, and/or anoxia

• Often results in permanent physical, Often results in permanent physical, behavioral, and/or cognitive impairmentsbehavioral, and/or cognitive impairments

• Significant improvements are generally Significant improvements are generally made during the first year and continue made during the first year and continue thereafterthereafter

• (Glascow Coma Scale score 3-8)(Glascow Coma Scale score 3-8)

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Every Every 2323 seconds, one seconds, one person in the United person in the United

States sustains a brain States sustains a brain injury.injury.

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EpidemiologyEpidemiology An estimated An estimated 5.3 5.3 million Americans have a long-million Americans have a long-

term or life long need for help with activities of term or life long need for help with activities of daily living as a result of TBI (daily living as a result of TBI (est. 227,000 est. 227,000 OhioansOhioans))

An estimated An estimated 1.41.4 million people will sustain a TBI million people will sustain a TBI each year in the United States.each year in the United States.

Of these:Of these: 50,000 die;50,000 die; 235,000 are hospitalized235,000 are hospitalized 1.1 million are treated and released from an ER1.1 million are treated and released from an ER

*The number of people with TBI who are not seen in *The number of people with TBI who are not seen in an ER or who receive no treatment is unknown.an ER or who receive no treatment is unknown.

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Disability Prevalence Rates

500,000 with Cerebral Palsy

2 million Americans with Epilepsy

3 million with Stroke disabilities

4 million with Alzheimer’s Disease

5 million with persistent mental illness

7.3 million Americans with mental retardationNational organizations’ web sites, 4/00; Slide source: Brain Injury Association of America

227,000 Ohioans - Estimate of adults living w/disability due to TBI - source CDC

400,000 with Spinal Cord Injuries

5.3 MILLION WITH TBI DISABILITY

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Leading Causes of TBILeading Causes of TBI11stst Falls (among elderly and very young)Falls (among elderly and very young)

22ndnd Vehicle accidents, bicycle, or pedestrian-Vehicle accidents, bicycle, or pedestrian-vehicle incidents (account for most vehicle incidents (account for most hospitalizations)hospitalizations)

33rdrd Violent actsViolent acts

44thth Sports accidents – An estimated 90% are mildSports accidents – An estimated 90% are mild

and go unreportedand go unreported

(BIA of America Fact Sheet) & (BIA of America Fact Sheet) &

(109 Rehabilitation of Persons with TBI)(109 Rehabilitation of Persons with TBI)

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If you have a brain injury, you If you have a brain injury, you are 3 times more likely to get are 3 times more likely to get

another. After the second another. After the second injury, the risk for the third injury, the risk for the third injury is 8 times greater.injury is 8 times greater.

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Who experiences brain Who experiences brain injuries?injuries?

Extremely DiverseExtremely Diverse Highest risk Highest risk 0-40-4 years, 15-24, and 75 years, 15-24, and 75

years and olderyears and older Males are 1.5 times more likely than Males are 1.5 times more likely than

females to experience TBIfemales to experience TBI 70% of people who incur TBI recover 70% of people who incur TBI recover

“completely”“completely” 15% remain symptomatic for the 15% remain symptomatic for the

remainder of their livesremainder of their lives Alcohol is reported to be associated with Alcohol is reported to be associated with

50% of all TBI50% of all TBI

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TBI is the TBI is the leading cause of death leading cause of death and disability for children, and disability for children,

adolescents, and young adults adolescents, and young adults in the United Statesin the United States. 90,000 of . 90,000 of

those injured will sustain those injured will sustain permanent injuries.permanent injuries.

(www.biausa.org)(www.biausa.org)

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Neuroanatomy and Physiology Neuroanatomy and Physiology of the Brainof the Brain

Deficits vary depending upon location Deficits vary depending upon location and severity of brain injuryand severity of brain injury

Major Brain AreasMajor Brain Areas• Frontal LobeFrontal Lobe• Parietal LobeParietal Lobe• Temporal LobesTemporal Lobes• Occipital LobeOccipital Lobe• CerebellumCerebellum• Brain StemBrain Stem

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Frontal LobeFrontal Lobe(Almost always sustains injury due to coup-contra-coup & boney undersurface (Almost always sustains injury due to coup-contra-coup & boney undersurface

of skull)of skull)

Motor outputMotor output Problem SolvingProblem Solving Self-monitoringSelf-monitoring Expressive language Expressive language

organization (i.e., speech)organization (i.e., speech) PersonalityPersonality EmotionsEmotions Inhibition of BehaviorInhibition of Behavior

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Parietal LobeParietal Lobe

Sense of touchSense of touch Sensory integrationSensory integration Spatial perceptionSpatial perception Visual perceptionVisual perception Identification of size, Identification of size,

shape, colorshape, color

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Temporal LobeTemporal Lobe

Auditory projection Auditory projection (interpretation of (interpretation of speech)/Receptive speech)/Receptive languagelanguage

Memory of new Memory of new informationinformation

Sequencing Sequencing HearingHearing

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Occipital LobeOccipital Lobe

VisionVision

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CerebellumCerebellum

BalanceBalance CoordinationCoordination Skilled motor activitySkilled motor activity

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Brain StemBrain Stem BreathingBreathing Arousal and Arousal and

consciousnessconsciousness Sleep/wake cyclesSleep/wake cycles Attention and Attention and

concentrationconcentration Heart rateHeart rate

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Living with a Brain Injury: Living with a Brain Injury:

The Impact on the The Impact on the IndividualIndividual•Physical

•Cognitive

•Social

•Behavioral & Emotional

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Physical DisabilitiesPhysical Disabilities HeadachesHeadaches DizzinessDizziness Chronic painChronic pain SeizuresSeizures Decreased coordinationDecreased coordination Loss of limbs or use of limbsLoss of limbs or use of limbs Nerve Damage (i.e., optic nerve, facial Nerve Damage (i.e., optic nerve, facial

palsy)palsy) Sensory limitations (visual Sensory limitations (visual

disturbances, hearing loss, decreased disturbances, hearing loss, decreased taste and smell, increased sensitivity to taste and smell, increased sensitivity to noise and light)noise and light)

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CognitionCognition Broad range of symptoms that occur Broad range of symptoms that occur

independently or in combinationindependently or in combination• Memory impairmentMemory impairment• Impaired attentionImpaired attention• Inability to remain on taskInability to remain on task• Difficulty focusing on thoughts, words, Difficulty focusing on thoughts, words,

eventsevents• Deficits in language useDeficits in language use• Deficits in visual perceptionDeficits in visual perception

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Cognition-DeficitsCognition-Deficits in in Executive Skills – the Executive Skills – the

“thumbprint” of brain injury“thumbprint” of brain injury Inability to self-monitor and inhibit Inability to self-monitor and inhibit

responsesresponses Poor initiationPoor initiation Difficulty sequencing steps and Difficulty sequencing steps and

completing activitiescompleting activities Poor judgmentPoor judgment

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SocialSocial Difficulty attending to social cuesDifficulty attending to social cues Relearning appropriate social skillsRelearning appropriate social skills Loss of friendsLoss of friends Loss of familiar activitiesLoss of familiar activities Loss of selfLoss of self Personality changesPersonality changes Problems with emotional controlProblems with emotional control Susceptible to mood and anxiety disordersSusceptible to mood and anxiety disorders Increased risk of suicide Increased risk of suicide EgocentricEgocentric

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Behavioral and EmotionalBehavioral and Emotional

FrustrationFrustration IrritabilityIrritability RestlessnessRestlessness AnxietyAnxiety Low motivationLow motivation DepressionDepression

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Behavioral and Emotional – Behavioral and Emotional – Cont.Cont.

Aggression- reactive, triggered by modest Aggression- reactive, triggered by modest or trivial stimuli, non-reflective, not pre-or trivial stimuli, non-reflective, not pre-meditated, non purposeful, explosive and meditated, non purposeful, explosive and periodic, impulsiveperiodic, impulsive

Exhibits socially inappropriate behaviorExhibits socially inappropriate behavior DisinhibitionDisinhibition

* Cognitive fatigue and/or physical fatigue * Cognitive fatigue and/or physical fatigue can significantly impact all areas of can significantly impact all areas of functioningfunctioning

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MedicationsMedicationsPresently, there are no FDA approved Presently, there are no FDA approved treatments for cognitive, emotional, or treatments for cognitive, emotional, or

behavioral impairments due to TBI.behavioral impairments due to TBI.

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MedicationsMedications Often on multiple medicationsOften on multiple medications

• SSRIsSSRIs (e.g., Prozac) often prescribed for (e.g., Prozac) often prescribed for anxiety and depressionanxiety and depression

• AnticonvulsantsAnticonvulsants (e.g., Tegretol) often (e.g., Tegretol) often prescribed to prevent seizure activity or prescribed to prevent seizure activity or to treat behavioral problems to treat behavioral problems

• Sleep medicationsSleep medications (e.g., Melatonin) (e.g., Melatonin) often prescribed for sleep disturbancesoften prescribed for sleep disturbances

• NeurolepticsNeuroleptics (e.g., Risperdal) (e.g., Risperdal) prescribed for psychosis and/or prescribed for psychosis and/or aggressionaggression

Need for continued re-assessmentNeed for continued re-assessment

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Substance AbuseSubstance Abuse

Higher rates of substance abuseHigher rates of substance abuse• Effects 28%-32% of individuals with TBIEffects 28%-32% of individuals with TBI

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Cognition- Reasoning and Cognition- Reasoning and Problem-SolvingProblem-Solving

Difficulty analyzing situationsDifficulty analyzing situations Inability to draw conclusions and Inability to draw conclusions and

make decisionsmake decisions Lack of logical thinkingLack of logical thinking

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Living with Brain Injury:Living with Brain Injury:The Impact on Support The Impact on Support

Systems Systems (e.g., family, friends, employer)(e.g., family, friends, employer)

GrievingGrieving StressStress Survival AdaptationsSurvival Adaptations

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GrievingGrieving DenialDenial AngerAnger BargainingBargaining DepressionDepression AcceptanceAcceptance

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StressStress Economic StrainEconomic Strain

• Estimates for average lifetime cost of Estimates for average lifetime cost of care for a person with severe TBI exceed care for a person with severe TBI exceed $4 million$4 million

Changed Family goals and rolesChanged Family goals and roles

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Practical Practical Adaptations/AccommodatioAdaptations/Accommodatio

nsns

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Signs in Loss ofSigns in Loss of Attention/Concentration Attention/Concentration

ConfusionConfusion Rambling ConversationsRambling Conversations StaringStaring Unable to finish a taskUnable to finish a task Difficulty attending to more than Difficulty attending to more than

one thing at a timeone thing at a time

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Strategies to Help with Strategies to Help with Attention/ConcentrationAttention/Concentration

Get individual’s attention before Get individual’s attention before beginning a discussion beginning a discussion

Reduce unnecessary noise or Reduce unnecessary noise or unneeded materials on deskunneeded materials on desk

Limit the amount of information Limit the amount of information presentedpresented

Pace the work with short work Pace the work with short work periods followed by brief breaksperiods followed by brief breaks

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Signs of Memory LossSigns of Memory Loss Confusion regarding appointments or Confusion regarding appointments or

daily scheduledaily schedule Unable to remember tasks from day Unable to remember tasks from day

to dayto day Unable to remember new informationUnable to remember new information Confabulates (makes up stories to fill Confabulates (makes up stories to fill

memory gaps; this is not lying)memory gaps; this is not lying)

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Strategies to Help Strategies to Help with Memory Losswith Memory Loss

Establish consistent scheduleEstablish consistent schedule Structure tasksStructure tasks Provide written cues (memory book, Provide written cues (memory book,

chart, etc.)chart, etc.) Provide verbal cues (initial sounds, Provide verbal cues (initial sounds,

choices)choices) Use compensatory tools (alarm, Use compensatory tools (alarm,

watches, calculators)watches, calculators) Link new information with old Link new information with old

informationinformation

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Signs in Loss ofSigns in Loss ofReasoning/Problem SolvingReasoning/Problem Solving

Ineffective problem solvingIneffective problem solving Inappropriate and potentially harmful Inappropriate and potentially harmful

decisionsdecisions Unable to make inferencesUnable to make inferences Disorganized thinkingDisorganized thinking Difficulty drawing conclusionsDifficulty drawing conclusions Rigidity in changing plansRigidity in changing plans

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Strategies to Help inStrategies to Help inReasoning/Problem SolvingReasoning/Problem Solving

Instruct and post note for “Stop and Instruct and post note for “Stop and Think”Think”

Help identify the problem and Help identify the problem and possible solutionspossible solutions

Help predict consequencesHelp predict consequences Break the task down into several Break the task down into several

easier stepseasier steps Write steps in notebook/plannerWrite steps in notebook/planner

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Signs in Loss of Signs in Loss of Impulsivity/Poor Self ControlImpulsivity/Poor Self Control

Acts or speaks without considering the Acts or speaks without considering the consequencesconsequences

Inappropriate comments to or about Inappropriate comments to or about othersothers

Lower tolerance for frustrating Lower tolerance for frustrating situationssituations

Inappropriate laughing or cryingInappropriate laughing or crying Get stuck on one idea or thoughtGet stuck on one idea or thought

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Strategies to Help in Strategies to Help in Impulsivity, Poor Self ControlImpulsivity, Poor Self Control

Encourage the person to slow down and work Encourage the person to slow down and work through taskthrough task

Provide verbal and/or nonverbal feedback in a Provide verbal and/or nonverbal feedback in a supportive waysupportive way

Respond to inappropriate ideas, but maintain Respond to inappropriate ideas, but maintain focus on original discussionfocus on original discussion

Expect the unexpectedExpect the unexpected Provide alternatives for inappropriate or Provide alternatives for inappropriate or

perseverative behaviorperseverative behavior Give frequent and consistent positive Give frequent and consistent positive

reinforcementreinforcement Remove the individual from a frustrating task Remove the individual from a frustrating task

or environmentor environment

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Signs of Impaired Self-awareness, Signs of Impaired Self-awareness, Difficulty with Social SituationsDifficulty with Social Situations

Lack of awareness of deficits and Lack of awareness of deficits and limitationslimitations

Inaccurate self-image/self perceptionInaccurate self-image/self perception

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Strategies to Help withStrategies to Help withImpaired Self-awareness, Impaired Self-awareness,

Difficulty with Social SituationsDifficulty with Social Situations

Anticipate lack of insightAnticipate lack of insight Prompt accurate self-statementsPrompt accurate self-statements Use feedback generously in a positive Use feedback generously in a positive

wayway Give realistic feedback as you observe Give realistic feedback as you observe

behaviorbehavior

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Signs of Problems with Signs of Problems with ConversationsConversations

Does not respond to another person’s Does not respond to another person’s conversation, questions or commentsconversation, questions or comments

Does not start, or is slow to start Does not start, or is slow to start conversations, ask questions, or make conversations, ask questions, or make commentscomments

Leaves long pausesLeaves long pauses Has difficulty explaining what he or she Has difficulty explaining what he or she

meansmeans

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Strategies to Help with Strategies to Help with ConversationsConversations

Encourage the individual to participate, Encourage the individual to participate, e.g., ask “What do you think about that?”e.g., ask “What do you think about that?”

Ask open-ended questions; “Tell me Ask open-ended questions; “Tell me about…”about…”

Give time to organize thoughtsGive time to organize thoughts Give the individual your full attention and Give the individual your full attention and

allow them to complete the thoughtallow them to complete the thought Re-phrase what the person has said, “Do Re-phrase what the person has said, “Do

you mean…”you mean…”

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Signs of Non-verbal Signs of Non-verbal CommunicationCommunication

Poor eye contactPoor eye contact Does not understand non-verbal cuesDoes not understand non-verbal cues Stands to closeStands to close Uncomfortable number/type of physical Uncomfortable number/type of physical

contactscontacts Body language/facial expressions don’t Body language/facial expressions don’t

seem to “match” what is said (flat seem to “match” what is said (flat affect)affect)

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Strategies to Help withStrategies to Help withNon-verbal CommunicationNon-verbal Communication

Ask the person to maintain a comfortable Ask the person to maintain a comfortable distancedistance

Politely ask the individual to modify their Politely ask the individual to modify their physical contacts; explain that you are physical contacts; explain that you are uncomfortable with such contactuncomfortable with such contact

Tell the person you are confused by the Tell the person you are confused by the difference in body language and spoken difference in body language and spoken messagemessage

Ask the person what he or she is feelingAsk the person what he or she is feeling Politely ask the individual to stop distracting Politely ask the individual to stop distracting

movementsmovements

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General SuggestionsGeneral Suggestions

Structure the environmentStructure the environment Break tasks into component partsBreak tasks into component parts Pace the work (consider headaches, Pace the work (consider headaches,

fatigue, etc.)fatigue, etc.) Help develop organizational systems Help develop organizational systems BE CONSISTENTBE CONSISTENT

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Remember the Fatigue Factor!Remember the Fatigue Factor!

Both Both cognitivecognitive and and physicalphysical fatigue fatigue often impact multiple areas of often impact multiple areas of functioningfunctioning

5757

Brain Injury Association of OhioBrain Injury Association of OhioServices & SupportsServices & Supports

Information & Resource Coordination:Information & Resource Coordination: HelplineHelpline Community Support Network (CSN) Community Support Network (CSN)

field offices located throughout the field offices located throughout the statestate

Education & TrainingEducation & Training Peer SupportPeer Support Outreach & PreventionOutreach & Prevention AdvocacyAdvocacy

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The Ohio PlanThe Ohio Plan

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ResourcesResources to Rememberto Remember TBI Technical Assistance Center at TBI Technical Assistance Center at

NASHIA NASHIA (National Association of State (National Association of State Head Injury Administrators)Head Injury Administrators)‘‘

http://www.tbitac.nashia.org/tbics/http://www.tbitac.nashia.org/tbics/Brain Injury Association of America (Their Brain Injury Association of America (Their

mission is to create a better future through mission is to create a better future through brain injury prevention, research, education brain injury prevention, research, education and advocacy): and advocacy): www.biausa.orgwww.biausa.org

Brain Injury Association of Ohio (BIAOH)Brain Injury Association of Ohio (BIAOH)

1-866-644-6242 1-866-644-6242 www.biaoh.orgwww.biaoh.org

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That’s All Folks!That’s All Folks!

Thank You

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Logan Logan Logan Regional HospitalLogan Regional Hospital

Phone: (435) 716-5010Phone: (435) 716-5010

Deb SmithDeb Smith

   Bear River Health DepartmentBear River Health Department

Phone: (435) 792-6510Phone: (435) 792-6510

Sandra HogganSandra Hoggan

TBI Support GroupTBI Support Group

Options for IndependenceOptions for Independence

Phone: (435) 753-5353Phone: (435) 753-5353

Vicki SmithVicki Smith