mTBI
Reasons why persons with mTBI sometimes fall in the category of "The Silent Epidemic"
The person looks "FINE"; mTBI is little understood by public; underdiagnosed and undiagnosed; untreated; unrecognized; consequences under-appreciated
Model whereby neurologic, biologic, psychological and social factors are considered when treating mTBI
Neurobiopsychosocial model
Most reported physical symptoms of mTBI and well as other physical symptoms. (p. 280-283)
Headache is most reported symptom and tends to last the longest.
Other common symptoms include: poor sleep (fatigue, insomnia, hypersomnia); dizziness (vertigo; disequilibrium, lightheadedness, inner ear damage from blast exposure); balance problems; vision changes (photophobia; visual noise; oculomotor dysfunction); hearing changes (hyperacusis, tinnitus, auditory processing disorder)
Incidence of mTBI in active duty service members
383,947 per 2 million; 82.3% classified mild; mBI sustained across multiple deployjments
The goal of cognitive rehabilitation (p. 305)
"To return the patient to their previous level of functioning."
Team approach to rehab is critical:ST, OT, PT, Nursing; Psychology, Recreation Tx; Social Work; Nursing
Intervention includes: education; counseling; direct therapy, modifications, group therapy
Prevalence of mTBI
42-62 million world wide; 6-8 million in US
about 10% of that number experience persisting brain injury symptoms
Cumulative variables that relate to and effect post-concussive symptoms (p. 276)
mental health history, current life stressors, medical issues, medical issues, chronic pain, depression, substance abuse, genetics
Emotional symptoms associated with mTBI. (P. 283-284)
PTSD; depression; anxiety; frustration; irritability; dysthymia (persistent depressive disorder); apathy; emotional lability
Four mechanisms of Blast Injuries (p. 296)
When a blast occurs the atmospheric pressure changes than is higher than what humans can withstand
primary - results directly from explosion
secondary - results from blast fragments or other flying objects
tertiary- results when person is thrown by blast force
quaternary - all other injury including burns, toxic inhalation; exposure to radiation; asphyxiation
Rehab for acute mTBI encompasses these things: (p. 306-307)
Initial neurological signs/symptoms to confirm diagnosis of mTBI
Loss of consciousness; AMS; amnesia or confusion; Loss of consciousness <30 minutes;Glasgow Coma Scale Score of 13-15; Post-traumatic amnesia </= 24 hours
Risk factors for longer than expected recovery from mTBI (p. 276)
lower education; female; lower military rank; previous TBI or neurologic event; history of learning disability; personal or family history of migraine or behavioral health issues;
Peri-injury factors 0 context and mechanism of injury; history of multiple TBI's depression, anxiety, PTSD, secondary gain
Cognitive Communication Changes associated with mTBI. (p. 284-292)
attention and concentration problems; decreased processing speed/delayed reaction time; memory and learning problems
executive function; social/pragmatic communication problems; language/wordfinding difficulties; decreased reading comprehension; poor written communcation; writing/grammar errors; stuttering
Functional deficits: difficulty maintaining attention to task or maintaining train of though; difficulty following directions, taking notes, following complex multi-step directions. Difficulty encoding information and transferring to LTM. Difficulty following task though to completion; decreased task perserverance
Consequences of Blast-Plus-Impact TBI:
occurs when individuals are exposed to multiple blasts and impact-related blows. Results in complex physical, cognitive, psychological and social impairments
Study showed that patients 6-12 months post injury did not exhibit cognitive deficits but experienced more deficits with PTSD and depression (MacDonald et al., 2014)
These factors related to persisting post-concussive deficits: (p. 307).
demographics; psych history; pyschosocial-emotional functioning; comorbidities
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Normal recovery trajectory for adults, children, military personnel with mTBI
Adults within 14 days
Children within 30 days
Military with combat related mTBI within 90 days
Discuss neurophysiology of concussion (p. 278)
"Disruption in ionic balance of neurons. Potassium rushes out of cells, sodium and calcium flood in; excess amounts of neurotransmitter glutamate is released resulting in dysfunction of sodium-potassium pump. Too much glutamate results in toxic synapses and slowed communication between neurons. Brain goes in "hyperactive" state followed by 7-10 day decreased in cerebral blood flow and hypometabolism." Diffuse axonal injury occurs; unmyelinated cells are susceptible to damage; edema inflammation
Chronic Traumatic Encephalopathy
See you tube video "What is CTE" 1:56
Incidence of Co-occurrence of mTBI and PTSD
over 80% of OEF/OIF/OND vets
Intervention/treatment for persistent mTBI deficits involves these things. (p. 308-
Motivational interviewing (designed to move pt. toward change; helps define functional goals)
Therapeutic Alliance (build rapport and trust)
Education, education, education! (what recovery process might look like; positive prognosis and expectation of recovery; Demand and Capacities Model (reducing co-morbidities during intervention may improve cognitive communication functioning)
Counseling; pt./centered approach; engage pt. in their recovery process ; goal attainment scaling (GAS)
Modifications (maintaing communication with all stakeholders (family, employers, teachers, peers)
Direct Therapy - systematic, structured, functional, errorless learning
3 categories of mTBI
Sports-related concussion (SRC) -sustained during athletic training or competition
Mixed-mechanism mTBI (MM) - due to falls, MVA, assaults, etc
Military-related concussion - blast related; blunt force trauma; boxing/wrestling
Neuroimaging techniques that may be useful in diagnosing for mTBI. (p. 280)
CT and MRI are NOT sensitive to detecting diffuse axonal injury.
Advanced neuroimaging techniques that can provide more information about mTBI include Diffusion tensor imaging (DTI); magnetization transfer imaging (MTI); magnetic resonance spectroscopy (MRS); Functional magnetic resonance imaging (fMRI); positron emission tomography (PET); single-photon emission computed tomography (SPECT)
Neuroimaging is not routinely recommended for mTBI but is recommended when "red flags" are present (i.e., declining LOC, focal neurological deficits, failure to recognize people, disorientation, seizures, heading, repeated vomiting)
Places where mTBI Resources can be found:
DVBIC/DCoE Website
Defense and Veterans Brain Injury Center (DVBIC)
Cognitive Rehabilitation Recommendations for Service Members and Veterans (April 2019)
Clinicians Guide to Cognitive Rehabilitation in Mild TBI: Application for Military Service Members and Veterans
mTBI Rehabilitation Toolkit Chapter 7 (pages 271-472) and Chapter 9 (begins on page 492)
CogSMART (Twamley, E., 2019)
Study of Cognitive Rehabilitation Effectiveness (SCORE) Manual
VA/DoD Clinical Practice Guideline for the Management of Concussion - mTBI
DHA Connected Health
Cognitive Communication Assessment in Acute mTBI
deferred for a minimum of 2 weeks and up to 3 months based on symptoms.
Purpose of assessment - identify and describe strengths and weakness in cognitive, language, social domains and how deficits affect individuals' participation in daily routines
Assessment includes: motivational interviewing; patient-centered/semi-structured interview; information gathering (onset, nature/severity; frequency/consistency of deficits; coping skills, comorbidities; family involvement)
Symptoms Checklist - NSI, ACE, SCAT5
Group setting is beneficial with interdisciplinary facilitators to improve generalization and use of natural communicative context
Areas that would be addressed in cognitive communication treatment: (p. 312
Attention (direct training strategies, compensatory strategies, education, cognitive assistive technology, Smart Pen; minimize distractions)
Processing speed (self-awareness training, self-monitoring; verbal mediation; management of emotions),
memory (semantic associations, visual imagery, mnemonic training; external memory aids/ technology,
Executive functions (goal formulation; decision making; task perseverance, etc)
Metacognitive Strategy Training for goal identification through completion and then reflection(p. 314)
Assistive Technology for Cognition (smart phones/tablets; recording devices; headphones/earbuds; devices that help with planning, organization, time management, note taking navigation [that google girl gets me lost"], etc)
Social Communication - focus on affect, behavior, social skills; teach positive self talk; manage anger/irritability; generalization of skills with help of family/friends; management of emotional and self-esteem issues