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Diagnosis and Treatment of Traumatic Brain Injury Angela Colantonio, Ph. D, OT Reg. (Ont. Diagnosis and Treatment of Traumatic Brain Injury Angela Colantonio, Ph. D, OT Reg. (Ont. ) Carolyn Lemsky, Ph. D, C. Psych. Catherine Wiseman Hakes, Ph. D Candidate, Reg. CASLPO

Diagnosis & Treatment of Traumatic Brain Injury v March is National Brain Injury Awareness Diagnosis & Treatment of Traumatic Brain Injury v March is National Brain Injury Awareness Month v Traumatic Brain Injury (TBI) is a serious public health problem v TBI: It’s not just an injury

Presenters Angela Colantonio, Ph. D, OT Reg. § § Saunderson Family Chair in Acquired Presenters Angela Colantonio, Ph. D, OT Reg. § § Saunderson Family Chair in Acquired Brain Injury (ABI) Research, Professor at University of Toronto Leads an internationally recognized program of research on ABI Carolyn Lemsky, Ph. D, C. Psych. § § Clinical Director at Community Head Injury Resource Services of Toronto Director of the Substance Use and Brain Injury (SUBI) Bridging Project Catherine Wiseman-Hakes, M. Sc. Reg. CASLPO § § Registered Speech Pathologist and a doctoral candidate, University of Toronto Specializes in the assessment and treatment of children & adults with cognitive communication impairments secondary to TBI

Goals of the Session 1. Prevalence and history of TBI among the homeless population Goals of the Session 1. Prevalence and history of TBI among the homeless population 2. Clinical manifestations of TBI 3. Screening tools for TBI 4. Treating TBI and co-morbidities (e. g. , substance abuse) 5. Communicating with someone with TBI

Improvement in Quality of Life in Adults with ABI in the Population Intervention Studies Improvement in Quality of Life in Adults with ABI in the Population Intervention Studies Providers Consumers / Caregivers Students, Trainees, Visiting scholars Aging with TBI Knowledge Transfer Gender Issues Collaborative links: - Local - Provincial - National - International

Acquired Brain Injury TRAUMATIC § Open § Closed NON-TRAUMATIC § § § Anoxia Aneurysms Acquired Brain Injury TRAUMATIC § Open § Closed NON-TRAUMATIC § § § Anoxia Aneurysms Brain Tumors Encephalitis Meningitis Metabolic Encephalopathy § Stroke with Cognitive Disabilities

Brain Injury isis the leadingcause of death Brain Injury a leading cause of death Brain Injury isis the leadingcause of death Brain Injury a leading cause of death and disability worldwide. Injuries the brain are among most likely to Injuries toto thebrain are among thethe most likely result in death and permanent disability to result in death and permanent disability International Brain Injury Association

Extent of TBI is more common than breast cancer, spinal cord injury, HIV/AIDS and Extent of TBI is more common than breast cancer, spinal cord injury, HIV/AIDS and multiple sclerosis combined Estimated prevalence, 2% of population

Definition of TBI An alteration in brain function, or other evidence of brain pathology, Definition of TBI An alteration in brain function, or other evidence of brain pathology, caused by an external force…” Brain Injury Association of America

The effect of TBI on the health of the homeless (Hwang, Colantonio et al, The effect of TBI on the health of the homeless (Hwang, Colantonio et al, 2008) Ø Have you ever had an injury to the head which knocked you out or at least left you dazed, confused, or disoriented? Yes: 53% (of 904 participants)

TBI in the Homeless Population Age at Time of First TBI (Any Severity): Mean TBI in the Homeless Population Age at Time of First TBI (Any Severity): Mean (SD): 18 years (13 Years) Ø 70% prior to first episode of homelessness

Ø Persons with a history of TBI compared to persons without a history had Ø Persons with a history of TBI compared to persons without a history had significantly higher levels of: – Seizures – Mental health problems – Alcohol problems – Drug abuse problems The risk of these conditions increased significantly with severity of injury

Diagnosis § History of TBI § Length of unconsciousness, post traumatic amnesia § Physical Diagnosis § History of TBI § Length of unconsciousness, post traumatic amnesia § Physical examination § Imaging: CT, MRI § Neuropsychology

Measuring Severity/Level of Consciousness Glasgow Coma Scale: § Eye Opening (1 -4) § Best Measuring Severity/Level of Consciousness Glasgow Coma Scale: § Eye Opening (1 -4) § Best Motor Response (1 -6) § Verbal Response (1 -5) Scoring: § Mild 13 -15 § Moderate 9 -12 § Severe <12

American Congress of Rehabilitation Medicine definition of m. TBI A traumatically induced physiological disruption American Congress of Rehabilitation Medicine definition of m. TBI A traumatically induced physiological disruption of brain function, as manifested by at least one of the following: 1. Any loss of consciousness; 2. Any loss of memory for events immediately before or after the accident; 3. Any alteration in mental state at the time of the accident (e. g. feeling dazed, disoriented, or confused); and 4. Focal neurological deficit(s) that may or may not be transient; but where the severity of the injury does not exceed the following: § Loss of consciousness of approximately 30 min or less; § After 30 minutes, an initial Glasgow Coma Scale (GCS) of 13 -15; and § Posttraumatic amnesia (PTA) not greater than 24 hrs. Katy, et al. (1993)

Consequences of TBI Cognition: concentration, memory, judgment, communication, sleep. Movement abilities: strength, coordination, balance, Consequences of TBI Cognition: concentration, memory, judgment, communication, sleep. Movement abilities: strength, coordination, balance, fatigue. Sensation: tactile sensation, vision, hearing, headaches. Emotion: instability, impulsivity, mood. Community integration: impacts family, work, economic/ social wellbeing

Clinical Sequelae § § Highly variable presentation depending on area of the brain affected Clinical Sequelae § § Highly variable presentation depending on area of the brain affected TBI survivors described like “snowflakes” e. g. , frontal lobe damage can affect social behaviour Occipital lobe damage may affect vision

Women and TBI Impact on reproductive health, women with TBI vs. women without TBI: Women and TBI Impact on reproductive health, women with TBI vs. women without TBI: § 68% of women 5 -10 years post TBI reported their cycles were irregular after injury § 46% experienced amenorrhea § No significant differences in conception but more post partum difficulties § Significantly more mental health issues Colantonio et al. , 2010

SCREENING TOOLS Survey Questions to Identify Traumatic Brain Injuries SCREENING TOOLS Survey Questions to Identify Traumatic Brain Injuries

Background of Surveys to Identify TBI Many surveys exist. Some examples are: § Ohio Background of Surveys to Identify TBI Many surveys exist. Some examples are: § Ohio State University TBI Identification Method § Brain Injury Screening Questionnaire § HELPS Brain Injury Screening Tool

Ohio State University TBI Identification Method (OSU TBI-ID) Inter-rater reliability and predictive validity have Ohio State University TBI Identification Method (OSU TBI-ID) Inter-rater reliability and predictive validity have both proved acceptable when tested in a substance abuse population: – IR (r=0. 849 -0. 951) – Intra-class correlation coefficient all above 0. 80, with 6/7 above 0. 90 Bogner J, Corrigan JD. (2009). Reliability and predictive validity of the Ohio State University TBI identification method with prisoners. J Head Trauma Rehabil, 24: 279 -291. Corrigan JD, Bogner J. (2007). Initial reliability and validity of the Ohio State University TBI identification method. J Head Trauma Rehabil, 22: 318 -329.

Definition of Brain Injury in Context of the Survey § Self-identification of an injury Definition of Brain Injury in Context of the Survey § Self-identification of an injury to the head (Questions 1 -5) PLUS § An Affirmative Answer to one of 6 -8 § Confirmation of head injury and loss of consciousness or episode of blacking out

Neuropsychological Evaluation § § Typically involves many hours of testing Repeatable Battery for Assessment Neuropsychological Evaluation § § Typically involves many hours of testing Repeatable Battery for Assessment of Cognition (RBANS) is a short test

Treatment § Referral for further evaluation and treatment § § Multidisciplinary rehabilitation Wide range Treatment § Referral for further evaluation and treatment § § Multidisciplinary rehabilitation Wide range of treatments with emerging evidence Follow up for disability support services/payments §

CMHA Kelowna and Brain Trust Canada partnership: ABI Outreach Services § Aims to secure CMHA Kelowna and Brain Trust Canada partnership: ABI Outreach Services § Aims to secure residential settlement § ABI Outreach Worker provides the knowledge required to maintain a productive lifestyle, including budgeting, dealing with mental health problems, drug addiction and other physical issues. § ABI Tenant Support Worker assists in providing access to non-emergency medical support, basic needs such as nutritious food, and support with coping skills, personal health practices, etc.

Research Based Theatre § Based on focus groups with consumers, family members and health Research Based Theatre § Based on focus groups with consumers, family members and health care providers § Translated key elements on experience of TBI and experiences with providers § AFTER THE CRASH www. ruckusensemble. com

Carolyn Lemsky, Ph. D, C. Psych. Models of ABI Intervention Carolyn Lemsky, Ph. D, C. Psych. Models of ABI Intervention

Overview w Models of community-based care for ABI w Cognitive compensation (adapting substance use/mental Overview w Models of community-based care for ABI w Cognitive compensation (adapting substance use/mental health interventions) w Principles for working with people living with acquired brain injury

Integration of substance use and mental health intervention in the continuum of Rehabilitation care Integration of substance use and mental health intervention in the continuum of Rehabilitation care Time of Injury ER Acute Care ----or---mild Follow-up Clinic Acute Rehab Post-Acute Rehab Community. Based Supports moderate w. Education of Staff/Patient/Family w. Psycho-educational materials w. Referral to appropriate programming Severe w. Active treatment w. Education w. Harm Reduction w. Case management

Supporting people with ABI in the community Supporting people with ABI in the community

Whatever it Takes 1. No two people with brain injury are alike 2. Skills Whatever it Takes 1. No two people with brain injury are alike 2. Skills are more likely to generalize when taught in the environment where they will be used. 3. Environments are easier to change than people. 4. Community integration should be holistic. 5. Life is a place-and-train venture. Willer and Corrigan (1994)

…Cont’d 6. Natural supports last longer than professionals. 7. Interventions must not do more …Cont’d 6. Natural supports last longer than professionals. 7. Interventions must not do more harm than good. 8. Service delivery systems present many of the barriers to community integration 9. Respect for the individual is paramount. 10. Needs of the individuals last a lifetime, so should their resources.

Case Example Tom’s goal: Get a job Problems Observed: n n n Poor hygiene Case Example Tom’s goal: Get a job Problems Observed: n n n Poor hygiene Limited compensation for memory impairment Socially inappropriate behaviour

Learn and then Place… Stop Problem Behaviour Learn a New Skill Improve Cognitive Compensation Learn and then Place… Stop Problem Behaviour Learn a New Skill Improve Cognitive Compensation Get a Job

Place and Learn See first hand why behaviour interferes with work Get a job Place and Learn See first hand why behaviour interferes with work Get a job Learn that your boss demands good hygiene Keep Job Maintain Change

Good morning, Tom. Your shower is getting warm… I’m going to get them to Good morning, Tom. Your shower is getting warm… I’m going to get them to stop I don’t have to be nagging anywhere me…. GET OUT OF HERE!!!

Hey Tom, Good morning, your shower is getting warm… I don’t feel like it, Hey Tom, Good morning, your shower is getting warm… I don’t feel like it, but I do have to go to work My morning routine may be a pain, but it helps me meet my goal. I’m getting to work on time, well groomed and ready.

“In the absence of meaningful, chosen life activities, all interventions are doomed to failure” “In the absence of meaningful, chosen life activities, all interventions are doomed to failure” Ylvisaker, 1998

Restorative Compensatory Environmental Behavioural Restorative Compensatory Environmental Behavioural

Restorative Therapy activities designed to promote return of function: n n Attention training Aphasia Restorative Therapy activities designed to promote return of function: n n Attention training Aphasia therapies

Compensatory Learning a way to get around the existing impairment: n n n Memory Compensatory Learning a way to get around the existing impairment: n n n Memory books, notes, alarms Meta-cognitive strategies (planning) Routines

Environmental n Reminder signs n Locks n Staff member provides a cue n Routine Environmental n Reminder signs n Locks n Staff member provides a cue n Routine that is driven by others in the environment

Behavioural Using behavioural strategies to train a skill: n n Modeling Rehearsal Chaining Errorless Behavioural Using behavioural strategies to train a skill: n n Modeling Rehearsal Chaining Errorless learning

Program Modifications n n Smaller sessions Simplified materials Flexible programming (breaks/shortened sessions) Integrating rehabilitation Program Modifications n n Smaller sessions Simplified materials Flexible programming (breaks/shortened sessions) Integrating rehabilitation workers into treatment

Why some clients don’t compensate n n Lack of awareness Feeling that compensating means Why some clients don’t compensate n n Lack of awareness Feeling that compensating means ‘giving up’ on progress Stigma and shame Impaired cognition

What does the literature say about treatment of substance abuse after ABI? What does the literature say about treatment of substance abuse after ABI?

Simplified Program Model Brain injury Mild Severe Community Based Mild CHIRS - Based Psycho-educational Simplified Program Model Brain injury Mild Severe Community Based Mild CHIRS - Based Psycho-educational Approach Psycho-educational CAMH – Based Severe CHIRS Support Case Management CHIRS –Based CAMH support Harm reduction Intensive Case Management Adapted from Corrigan (2004)

From the literature… ABI-Specific Treatment Models Common Characteristics: n n n Engagement in meaningful From the literature… ABI-Specific Treatment Models Common Characteristics: n n n Engagement in meaningful activity (incompatible with substance use and addresses mood/behaviour) Skills training Treatment may begin before insight/readiness to change

Case Management Models n n Access to substance abuse services/mental Health Services ABI consultation Case Management Models n n Access to substance abuse services/mental Health Services ABI consultation l l Adapt treatment plans l n Explain Neuro-cognitive Impairment Trouble-shoot Assist with access to other support services

Case Management Outcomes (Heinemann, Corrigan, & Moore, 2004) Compares 2 intensive Case management programs Case Management Outcomes (Heinemann, Corrigan, & Moore, 2004) Compares 2 intensive Case management programs with typical care offered at a major rehab centre: n No changes in substance use at 9 months follow-up n Earlier referral was associated with better outcomes n No differences in community integration n Small changes in health-related QOL n Life satisfaction /family satisfaction improved

Motivational Interviewing n n Main Goal: To produce an internal drive to change, using Motivational Interviewing n n Main Goal: To produce an internal drive to change, using non-confrontational techniques Main Method: Evidence of the negative consequences of the behaviour are elicited from the client, so that the client sees and accepts the advantages of change

Structured Motivational Interviewing Cox, Heinemann et al. (2003): Outcome after 12 sessions of Motivational Structured Motivational Interviewing Cox, Heinemann et al. (2003): Outcome after 12 sessions of Motivational Interviewing – follow-up (mean = 9 months) n Improved Motivational Structure n Reduced negative affect n Reduced substance use

Ohio Valley TBI Network Model Consumer and professional education n Intensive Case Management n Ohio Valley TBI Network Model Consumer and professional education n Intensive Case Management n Consultation to Substance Abuse Services n www. ohiovalley. org

Corrigan Review (2005) n n n Treatment is likely to be protracted Successful programs Corrigan Review (2005) n n n Treatment is likely to be protracted Successful programs will address engagement in treatment Early intervention is important

Findings N=195 (138, male; 57 female) Mean age = 36. 6 (range = 18 Findings N=195 (138, male; 57 female) Mean age = 36. 6 (range = 18 to 72) Mean time since injury = 8. 0 (range = 3 weeks to 55 years) % Complete ISP In 30 days

6 -Month Follow-up Data n n n By 6 -months over 30% had terminated 6 -Month Follow-up Data n n n By 6 -months over 30% had terminated therapy 50% improvement over control for Barrier Reduction and Financial Incentives Brief phone intervention makes a big difference Still in treatment or successfully terminated

Why did these interventions work? n n Financial incentive participants stated that the reward Why did these interventions work? n n Financial incentive participants stated that the reward was not what made a difference in attending appointments Reminders to address memory issues Transportation support to address planning/financial issues Learning by ‘rule’ not by consequence

Barriers to Care n Behaviour resulting from the cognitive impairment that appears uncooperative or Barriers to Care n Behaviour resulting from the cognitive impairment that appears uncooperative or unmotivated n Difficulty recalling information learned n Difficulty generalizing n Difficulty predicting and managing behaviour

5 Principles for Working with ABI clients n n n Pace communications (one concept 5 Principles for Working with ABI clients n n n Pace communications (one concept at a time) Repeat important concepts Illustrate using concrete examples Memory Aids for use in session and outside Environmental modifications (including the involvement of caregivers) Re-direction sometimes necessary to move client to problem-solve or address tangential speech

Communication Problems Associated with Traumatic Brain Injury A Guide for Working with Homeless Persons Communication Problems Associated with Traumatic Brain Injury A Guide for Working with Homeless Persons Catherine Wiseman-Hakes Ph. D. Candidate, Reg. CASLPO Speech Language Pathologist

Communication After Brain Injury • Communication difficulties are common • Some more obvious, and Communication After Brain Injury • Communication difficulties are common • Some more obvious, and some are not! • Subtle (but highly debilitating) communication issues can be misconstrued by a communication partner reflection of poor attitude, disinterest, disrespect, or even substance use.

Communication: Why all the Hype? ? ? • What exactly is communication? • We Communication: Why all the Hype? ? ? • What exactly is communication? • We know when we’ve been involved in a successful communication interaction • AND we all know what it is like to be part of an unsuccessful communication interaction • SO, what exactly is involved?

Components of Communication: Expression • Successful communication involves an exchange by 2 or more Components of Communication: Expression • Successful communication involves an exchange by 2 or more individuals where a message or intent by 1 person is expressed clearly, and received and understood successfully by the communication partner(s) • This involves speech (or other non-verbal alternative system) which is the motor act of forming sounds • The content is the language • This is augmented by the equally important non verbal communication behaviours such as body language, eye contact and tone of voice, known as pragmatics

Pragmatic Communication Personality changes following TBI involving egocentric thinking with loss of social sensitivity Pragmatic Communication Personality changes following TBI involving egocentric thinking with loss of social sensitivity may result in a selfcentered style of communication that is lacking empathic interaction with a conversational partner.

Pragmatic Communication • Personality changes following TBI involving egocentric thinking with loss of social Pragmatic Communication • Personality changes following TBI involving egocentric thinking with loss of social sensitivity may result in a self-centered style of communication that is lacking empathic interaction with a conversational partner • Behavioral changes may also affect communication. Decreased initiation may result in sparse, uninformative interactions whereas impulsivity may result in verbose, tangential communication that is marred by inappropriate remarks.

Components of Communication: Receiving the Message • Successful communication involves an exchange by 2 Components of Communication: Receiving the Message • Successful communication involves an exchange by 2 or more individuals where a message or intent expressed by 1 person is received and understood clearly • This involves hearing, and understanding (comprehension) • Understanding is required at all of the levels of expression; understanding the speech, understanding the content, both explicit and implied, and understanding the non verbal communication behaviours.

Cognition and Communication Underlying successful communication are a number of key cognitive abilities. These Cognition and Communication Underlying successful communication are a number of key cognitive abilities. These include: ü Attention to the speaker, ü working memory, ü long term memory, and ü information processing (this involves the speed, amount and complexity of the information being presented).

Communication Problems Associated with TBI • Slow speed of information processing: this is a Communication Problems Associated with TBI • Slow speed of information processing: this is a hallmark of brain injury • May have motor speech problems, called dysarthria, difficulty forming the words • May have hearing problems, and or problems picking out speech from other background noise • Often slow to initiate, slow to understand, difficulty with implied messages, and difficulty thinking of quick and coherent response • Often have word finding difficulties.

Communication Problems Associated with TBI • Most people with brain injury dread and shy Communication Problems Associated with TBI • Most people with brain injury dread and shy away from multi-person conversations, noisy environments, and conversations with people they don’t know • Many can. NOT block out extraneous stimuli; attention is effortful and hard to sustain over time • Easily fatigued • Easily overwhelmed by too much information (like someone following a conversation in a language they are just learning. . . just give up and tune out).

Communication Problems Associated with TBI: Frontal Lobe Injuries • May be impulsive in their Communication Problems Associated with TBI: Frontal Lobe Injuries • May be impulsive in their responses, may be emotionally labile; difficulty monitoring context • In contrast, they may appear flat, disinterested with reduced affect, limited facial and vocal expression • They may not hear you, they may not understand (or they think they understand, but get it completely wrong) • Problems reading body language, tone of voice and facial expression • If they have motor speech problems they may sound like they are under the influence of alcohol or drugs.

Consequences of Communication Problems after TBI • The consequences of pragmatic communication impairments in Consequences of Communication Problems after TBI • The consequences of pragmatic communication impairments in people with TBI can be devastating. Social communication serves to connect people to their families, friends, and coworkers • Many people with TBI report reduced social contacts and rate social isolation and loneliness as their most frequent complaint. Mac. Lennan et al 2002: The prevalence of pragmatic communication impairments in traumatic brain injury. http: //www. premier-outlook. com/winter_2002/prevelance_pragmatic_communication. html

How to modify your communication to facilitate a successful interaction • If you are How to modify your communication to facilitate a successful interaction • If you are having trouble understanding their speech, assure them you ARE interested in what they have to say, ask them to repeat, maybe use a pen and paper • DON’T misinterpret a slow response and or flat affect for lack of interest or disrespect • Speak calmly and respectfully • Whenever possible, have a conversation in a quieter environment (make sure there is no TV, radio playing etc…. )

Screening Tools for Communication Problems • Latrobe Communication Questionnaire (Douglas, J. ) • Pragmatic Screening Tools for Communication Problems • Latrobe Communication Questionnaire (Douglas, J. ) • Pragmatic Communication Scale (Erlich and Sipes) • Pragmatic Rating Scale (Mac. Lennan et. al. )

Thank You! Thank You!

Questions & Answers Angela Colantonio, Ph. D, OT § § Saunderson Family Chair in Questions & Answers Angela Colantonio, Ph. D, OT § § Saunderson Family Chair in Acquired Brain Injury (ABI) Research, Professor at University of Toronto Leads an internationally recognized program of research on ABI Carolyn Lemsky, Ph. D, C. Psych. § § Clinical Director at Community Head Injury Resource Services of Toronto Director of the Substance Use and Brain Injury (SUBI) Bridging Project Catherine Wiseman-Hakes, M. Sc. Reg. CASLPO § § Registered Speech Pathologist and a doctoral candidate, University of Toronto Specializes in the assessment and treatment of children & adults with cognitive communication impairments secondary to TBI

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