Social Work 644—Issuesin Developmental Disabilities
Traumatic Brain Injury - Don Mickey, Ph.D.
Segment 1 (Audio & Video):
MICKEY:
(Slide 1) In the discussion of traumatic brain injury, I think there’s a couple things that you need to keep in mind throughout this discussion. I think one is that we’re looking at a difference between organic and pathological problems. What happens with traumatic brain injury is generally organically based problems, even though there may be pathological aftermath to those injuries, and I’ll clarify that as we go through this.
And the other part of that is to understand that anybody who has experienced traumatic brain injury has had some sort of life prior to being injured. They had, in some sort of a profession or in school, were doing something prior to that injury. So there was change, dramatic change in their life at that particular point in time.
(Slide 2)The definition of traumatic brain injury is really a sudden insult to the brain which may or may not involve loss of consciousness, and that’s rather a newer definition. We generally don’t think of loss of consciousness, that you have to have loss of consciousness to be brain injured, but in some cases that’s not necessarily true. The brain can be substantially injured without having a loss of consciousness.
(Slide 3)Major causes, as one can suspect, would be car accidents and assaults and falls, things like gunshot wounds, but there’s also damage that can happen from stroke, anoxia, carbon monoxide poisoning, infections, and toxic exposure, a variety of toxic substance, including things like huffing that kids, adolescents, sometimes get into, which can cause fairly severe injuries.
Additionally to that, we’re finding a lot of new veterans returning from the war now with blast related injuries from concussive damage that happens from roadside bombs and those types of things. So there’s also an increase in that population with injuries.
(Slide 4)The prevalence, the highest risk groups really are males, which are 1.5 to 2 points more likely to be injured, sustain an injury than females. The two age groups are zero to four. Obviously, you can think about kids with falls, also sometimes shaken baby syndrome falls into that too. And then 15 to 19-year-old, and, again, you can guess this from high-level risk taking. And again, your male more risk taking than the females.
And then the population of over 75 years of age, which also includes people with falls and those kinds of things. And additionally now, we’ve added another risk group in there, is military, which is also now considered a high risk group for traumatic brain injuries.
(Slide 5) I think just to have a little understanding about the prevalence of this is important. I do some comparisons here, is that TBI results in about one and a half more deaths a year than AIDS. Each year, approximately 230,000 individuals are hospitalized with TBI and survive. It’s the fourth leading cause of death overall. Each day, approximately 500 individuals sustain traumatic brain injuries.
Overall, 80,000 to 90,000 people experience the long-term disability effects and consequences from TBI in a yearly basis.
(Slide 6)If you think about that in big terms, that’s a substantial amount of the population. When you look at it compared to other disability groups, there’s 5.3 million people with TBI disability. That compares to 5 million people with persistent mental illness, 4 million with Alzheimer’s, 500,000 with cerebral palsy, and maybe 400,000 with spinal cord injury.
The differences there, I think, are fairly substantial, especially when you look at it and we know less about traumatic brain injury or we hear less about traumatic brain injury than we do about some of the other disabilities. So I think part of that is really understanding it is a hidden disability, and I’m going to talk a little bit more about that, but it is not one that people advertise and say, gee, I got a traumatic brain injury versus somebody really understanding that a person has Alzheimer’s or they have a mental illness of some type.
Segment 2 (Audio Only):
(Slide 7)What happens to the brain is a couple of different things, and I’m going to go through a brief definition of some of these. There’s two things that really happen at the initial point of impact. One is called an excitotoxic injury. There’s a release of toxins within the brain, and some of those neuro-chemicals are made to stabilize the brain during that period of acute stress that the brain is experiencing.
And then the other kind of thing happens is shear injuries, which are injuries more of white matter and the damage there in the brain, which are lower structures within the overall brain. We can have diffuse injuries, which are more widespread than a focal injury. And a diffuse injury is something like with a car accident, where you’re rolling around in the car, bouncing around. The brain sits on a stock and can shift back and forth. So it bangs up against the skull and you get bleeds at the various places within the brain, besides getting the shear injuries from the brain just twisting at the same time.
You also have what’s called cu-contracu(?) injuries, where the brain may bang up against the front of the skull and then bang back against the back of the skull, so you’ll get bleeds in both areas, or against one side then the other. So those are pretty critical things that happen during brain injuries.
At the initial onset, the pharmalogical intervention timing is very critical. We have Level 1 trauma centers in most major cities, and even when you don’t have them in a major city, there’s usually one nearby that MedFlight can get the person to. So we’ve improved our methods of survival with traumatic brain injury pretty substantially, getting the person in and using medication like mannitol or putting them into a drug-induced coma.
The mannitol would be to stop the swelling of the brain, and the drug-induced coma is to stop inputs and outputs from the external environment so the brain can settle down and calm down and we can stop the swelling. And again, if you think about the brain sitting in an encapsulated space, there’s no place for it to go. If the skull is not breached, it can press down and the internal structures within the brain that keep us alive can be damaged. So sometimes death can be involved from that.
(Slide 8)When you figure outcome, there’s a variety of things that are part of that. I think one thing is that we often look at the extent and location of the gross damage, what’s involved in the damage. Is it the frontal lobe? Is it the temporal lobe, which is the language center? There’s various centers of brain operation that can be damaged, and so how they survive through that particular period is pretty critical. So where is the gross damage and how bad is it?
The extent of the microscopic damage, how much damage is there from small tears and rips within neurotransmitters, neuro-cells throughout the brain. And I think the neurons tearing at that particular point in time, oftentimes, if they’re not torn all the way through, you end up with damage. And when there’s damage, they can, it can get worse over time.
So there’s a problem with what’s called secondary damage, and I’ll just mention that because oftentimes what we’re doing at the initial end, with a pharmalogical intervention is to stop the secondary damage so that there isn’t damage from the swelling, there isn’t damage from additional bleeding. So we’re trying to control those things at the initial onset.
Pre-morbid brain factors, what kind of shape was his brain in prior to that? Is there acute alcoholism involved? Is there a secondary or third injury? Often, people who have one injury, the probability of a secondary injury is pretty high and that’s because sometimes judgment is affected, and so there’s higher level of risk taking.
The other element that has an effect on outcome is how does the person respond to the post-injury therapies? Is the pharmalogical intervention in time? Are they able to stop the secondary injuries at that particular point in time? And I think another measure that can help predict is also the Glasgow coma scale, which really looks at level of response from the individual.
Three is the lowest level you can be at, and lots of times people are found at an accident site, they’re a level three. But if they progress fairly fast up to a higher level, than usually the outcome can be a little bit better than somebody who remains at a level three in kind of a comatose state over an extended period of time.
(Slide 9)Some of the vulnerable areas of the brain are the corpus callosum, the basal ganglia, which often are affected by shear injuries, and that’s more in the white matter. The cu-contracu affects both the frontal lobe, the temporal lobe, and occasionally occipital lobe, which is in the back part of the brain here. And then chronic injuries over an extended period of time also have a tendency to upset the neurotransmitters since they’re not functioning at a normal level. So again, repeat injuries often can be very critical for a person who has gone through one of these injuries.
Segment 3 (Audio Only):
(Slide 10)Well, now that we got the person injured and they’re laying in the hospital, we want to try and figure out where do they go from here, and I want to give you an ideal course of traumatic brain injury. This is probably somebody with a more severe injury versus somebody with a mild traumatic injury. I debate the term mild traumatic brain injury. I think any injury to the brain is not mild. Because you can walk out of the hospital and they say you’re doing okay does not mean that you’re going to be able to recover and have your life back the way it was before.
But I’m going to give sort of an ideal course in relation to what happens when somebody has more of a severe injury. Usually there is some period of coma, and that can be hours, it can be weeks, it can be days, it can be months. Sometimes it can be years. Generally, those people who have shorter periods of coma generally recover better than those who are in lengthier comas. There’s generally a stage of post-traumatic amnesia as the person comes out of the coma, and that includes retrograde, which is memory of past, and anteriograde, an effect on new learning.
There’s general confusion as one could suspect if the memory is upset. And there’s usually some period of time of agitation as the person is laying in the hospital. And maybe that also can be looked at as relating a lot to the problems with the memory and why am I here, what’s going on, I don’t know these people, and trying to put your life together and figuring it out when all the things in your brain aren’t working correctly.
The next ideal stage is you go from the emergency room to some level of inpatient rehabilitation within the hospital, where you would get auxiliary services like occupational therapy, speech and language, physical therapy, maybe rec therapy, some counseling, maybe you’ll see a neuropsychologist at that point and have some testing. But generally, you like to wait until a person has recovered enough that we can really get a good measure of how or where they’re at at that particular point in time. So if they’re still pretty damaged, there probably won’t be extensive testing at that point.
And as they move through hospital rehabilitation, they go into what’s called post-acute rehabilitation. Sometimes post-acute rehabilitation is not always available to everybody. I say that with sort of a look and understanding that we are sort of run by insurance companies now. So if somebody doesn’t have the ability to fund that, they may be going home, and I’ll talk about that shortly.
But if you go through post-acute rehabilitation, it is also a continuation of those therapies that you’re getting at the hospital, some cognitive training, physical therapy to help with use of limbs, occupational therapy to relearn old skills that you already know, and then, and so some level of psychological and social support for the person. And again, I say that that level of support is oftentimes dependent upon insurance.
And then there’s a gradual return from there to community and work, and that may be with or without supports. It depends upon how well one recovers from that particular point of injury.
(Slide 11)The other course of recovery, and I guess that’s the one that I say is not dependent upon insurance is that they’re hospital managed at acute level, they may return to the community with limited outpatient therapies, and then the patient and/or the family is kind of left to figure out what is next. There’s large gap in that particular area about services, of trying to find out.
For families, I often get calls about, well, you know, my son was injured or my husband or wife was injured awhile back. You know, now we’re home, but it doesn’t look like she’s going to be able to go back to work. Where do we go from here? What is the next step? It’s sort of a gap that we have within services that we’re still trying to work on and try and figure out.
Segment 4 (Audio & Video):
(Slide 12)Well, one of the things that I do, I’m a neuropsychologist, and so I do a lot of testing. I’m going to talk a little bit about what I do because I think that it also helps you understand how it fits into the big picture of recovery for an individual. Besides taking an extensive interview with the individual, which involves like how they functioned prior to that particular point of time that they got injured, I may also do collateral interviews with their spouse or with their parents and try to find out information from them about how this person was functioning prior to the injury, and also get some idea about how they’re functioning now, what do they see as problems.
Measure of really critical areas are areas like attention and concentration and orientation. Can he attend to a single stimuli for an extended period of time? Can they multitask, go in between different stimuli? Are they oriented, do they know where they’re at? Do they know what day of the week it is? Do they know their own personal information about themselves?
Memory testing is also a big piece of this, obviously, to try and find out do they have memory. Do they have cue-exposed memory? Can they recall, generate recall of information or do they have to have cues to generate recall? And can they recall information if they have cues? And I say that because I break memory into a lot of different areas.
We break it into contextual based memory. That is memory that is, there’s some sort of context that pulls the information together to help the person recall information, and then something like learning a list of words. Can they just learn how to learn a raw list of words and then recall them at a later point in time? And then figural memory, can they draw a design and remember it 30 minutes later, something like that. Do they remember how to get into the building and go to the bathroom?
One of the things that I do when I’m working with students is saying is that the buy word is that everything you do is neuropsychological assessment. How did the person get here? What kinds of things did they do while they were here? So behavioral observation is a big piece of that, of keeping track of everything that’s going on. It’s a very critical part. I always like to throw a couple of cases in.
I do sometimes do testing for a malingering or we call it response bias, which is kind of a better word, I guess, than malingering, but we do that to find out if the person is really putting in effort. Are they motivated to be successful on the testing process? And one individual who drove 90 miles from the center of a major city to my office, which was located in the center of the city at that time, got there early, at rush hour, and failed a couple of tests, which sort of indicated that she should probably be living in supported living.
So it really raised the question in my mind, you know, how valid is the test results? You know, is she putting out effort? She was involved in a litigation case, and we also have a name for that, and that’s called litigation neurosis. So we have to separate these pieces out, and that’s all part of what we do when we’re testing.
We look for language ability. Can they read? Can they sort things out using language? Can they generate words on a demand basis if we just ask them to? Visual spatial, can they problem solve using visual skills? Can they sort things out? Can they work with fairly good motor speed when they’re working with visual reference points? What’s their motor performance? We do things like grip strength, finger tap, and just simply putting pins into boards, which may seem sort of nonsensical, but those are to measure the . . . of the individual.