VCU
OCTOBER 22, 2012
TRAUMATIC BRAIN INJURY: WHAT VOCATIONAL SPECIALISTS NEED TO KNOW
Services Provided by:Caption First, Inc.
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> Dr. Zasler: …..Impairment issues, things like bleeds within the ventricles to put somebody at risk for encephalitis, a predictor of PTA, strong predictor. If PTA is greater than two months, that is a very poor prognostic sign for functional independence of the individual. As I mentioned, positive drug and alcohol screens at time of acute injury are the risk factors for hypoxic ischemic brain injuries.
About whiplash injuries, in my 25plus years of doing this, these are often missed and can explain a lot of the symptom that patients before and after injuries that occur concurrent, like a concussion along with cervical whiplash.
Issues being present often taking the form of referred headache. The problem is in the neck, but perception of the pain is more in the head, typically referred to the same side of the head.
Cervicogenic dizziness, a problem in whiplash patients overall attributed to central causes due to the brain injury. Myofascial changes associated with overstretch injury to the muscle and activation of what are called triggerpoints with pain, including what I referenced earlier, referred pain, not just pain where the problem is, but pain going to other sites as well.
Then there have also been reports with types of migraine being generated with whiplash injury, particularly in younger women who has been referred to as Vikerstaff's migraine more commonly referred to as basilar migraine.
You can also see vascular or nerve injuries four carotid dissections that may result in further brain damage if not caught early and treated. So again, a complex type of injury often underappreciated by ee valuating solutions, in my experience.
Now we also move to another type of injury that doesn't again necessarily imply that you had a brain injury, but can be seen concurrently with TBIs, mild to severe, And that is damage to the head or structures within the head.
It is important to separate these out from the impairments associated with brain injury. On the basis of banging your head hard enough, whether it is due to a vehicle accident or fall or assault, or a simple thing like throwing yourself backward on your bed and hitting the backward with your head.
You can have dizziness, ringing it the ears or tinnitus, smell and taste impairments, visual problems, and peripheral nerve injuries, as well as vascular trauma.
From the standpoint of brain trauma which is what we're here to really focus on, but I thought it was worthwhile mentioning the other conditions. So it is important to understand the natural history of the condition and what kind of recovery is expected.
So typically people with more mild forms of injury generally do well and do not have long term sequelaeor problems for the vast majority of those patients. And if you look at the literature, it is relatively sparse looking at patients beyond a year post hinge injury after concussion in terms of sound methodological research.
But overall research shows probably 5% or less have longterm neurologicallybased problems consequential to an otherwise mild form of brain injury.
Whereas people with moderate to severe injury, typically the rule of thumb is those people are going to have longterm impairments but there is often quite a range.
So you can see people with even the most severe brain injuries return to independent living, returning to their prior job, that is not out of the question, just inherent in the fact they had that type of injury.
Although it will be statistically more likely that they would not, but it is certainly possible that they would. Understanding preexisting conditions, whether the type of problems I talked about before, to issues like what was their preinjury personality? A obsessive compulsive person will have a difficult time adjusting to subtle changes after the injury, rather than somebody was a typeB personality, for example.
Another factor with preexisting conditions, looking at how personality typically changes. Typically what you see is amplification of pre-injury personality traits.
So if someone had a temper before, more likely than not they will have an amplification of those tempercontrol problems, post significant traumatic brain injury.
Also we need to do have leverage great between issues of impairment and disability. Impairment is what the clinician finds on exam, like weakness in the right arm.
Disability is how it impacts that individual functionally.
We also need to understand rare versus common neurological sequelae after acquired brain injury from the standpoint of the clinician, therapist or physician. From is a voc perspective if you see things you have not seen before, my recommendation is you speak with a treating doctor and clarify how you can best broach that problem in the workplace or the work reentry process.
Then understanding prognostication issues. There is quite a bit of literature looking at that are the types of variables that most prognosticate better versus poorer return to work rates.
It is important for folks like yourself to be familiar with that literature. The main impairment areas we see in these types of patients you need to be aware of include impairments and cognition, emotional control, behavior, physical impairments such as limb, motor weakness, sensory deficits which could be limbrelated or they can be related to the traditional senses, vision, hearing, smell, taste, et cetera.
Neuromedical issues such as epilepsy probably being the one that scares people the most, but again when properly managed, in my experience most epileptic disorders are controllable with appropriate intervention, assuming the patient is compliant.
And language and communicationbased impairments which often in the community are probably one of the more challenging things to deal with. If people have dysphasia or difficulty understanding that you are telling them, or language impairment as far as expressing themselves. Those can be quite challenging.
The other impairmentwise area I find most challenging in terms of re-centering work, people who have dense amnesia and can't consolidate memory from one hour to another and one day to the next. Those patients are challenging to work with.
Cognitive dysfunction. It is important to understand brain injury is one of many things that can cause cognitive impairment. Pain, if present, can certainly interfere with moderate to severe with cognitive processes, particularly attention and secondarily memory consolidation because you are in the able to attend as well to task, affective disorder and anxiety and depression can negatively impact cognition, among other conditions I listed here which we won't get into simply because of time.
But you can look at them and read up on them. Behavioral dysfunction, common after TBI, more after moderate to severe injury. You can see a range of problems, depression, anxiety related disorders probably being the most common. For the record for this discussion, posttraumatic stress disorder received a lot of attention mainly because of the military experience.
It would be considered under the anxiety umbrella, as far as affective disorders rarely or more rarely you can see conditions such as psychosis, bipolar disorder resulting from a traumatic brain injury, although there is some debate about those conditions and their causal relationship to traumatic brain injury.
It is important to understand also that often times particularly with depressive disorders, this is a delay of onset, so it doesn't necessarily show up right away. Your 12 highest risk depression, whereas anxiety depression usually appear earlier.
Again, various other factors need to be considered here in the context of things that can perpetuate behavioral dysfunction, include lack of sleep or poor sleep that is non-restorative not physiologically restful.
Pain problems can also make patients more irritable and be the light under or adding fuel to the fire, making the condition worse. Those kinds of things need to be looked at as well.
Examination of the patient with traumatic brain injury, it is important for the clinician to know what to expect, and similarly to know what not to expect. Be thorough in terms of how the clinician evaluates patients.
I also find clinicians are rushed in today's world of managed care and don't take sufficient time to do good exams that look at both neurologic and orthopedic aspects of the examination, particularly after multitraumatype injuries.
It is important to include for both myself and y'all, voc rehab people, adequate mental status testing so that you have an understanding of that person's cognitive ability and limitations, as well as appropriate psychoemotional testing.
So if somebody has a social phobia, that is clearly important to identify early and treat it so that you are not getting a patient to has inadequately or never been treated for a problem that may interfere with their vocational reentry.
It is also important particularly in cases where there are clear secondary gain issues, and I know people don't often like to talk about it, but the realities are there for things like worker's comp, social security, legal cases.
There is a much higherness dense of what is termed "response bias" that is patients coloring report and performance on tests of function. There is ways to evaluate that in terms of test could or, how well someone is reporting, if they are reporting down the middle, being stoic and underreporting versus exaggerating. That is important for clinicians to look at too
Diagnostics, just a few words on that. Clearly neurodiagnostics are only as good as the tests being done. The ceiling and floor effect, and the person interpreting the test, because a test is normal doesn't mean the patient is normal and one needs to understand what the limitations of the test are, what the specificity and sensitivity of the test is, among other parameters.
Neuropsychological testing is one example that can show a pretty clean level of function, but then when you get that person out in the community, they don't do particularly well. That is particularly true with patients with frontal executiverelated impairments who maybe do better under the structured circumstances of the inlab neuropsych test scenario, but break down when taken into community and are not in a structured environment.
That is referred to as the "ecological validity" of the test. So it is important for people to understand those nuances and the contexts of looking at test data. There are also tests that can be overinterpreted, depending on how a person giving the test wants to interpret them.
And unfortunately, you can give the same test results to three different clinicians who are the same specialty, and you may get three different interpretations. So again, it is important to make sure that your patients are being treated by people who understand brain injury, understand how to interpret tests and what tests are relevant, versus not relevant.
There is also in this field as with many other fields, junk science issues to be aware of in terms of how tests are used, what normative data is used, how much data there is for that test relative to its use in traumatic brain injury versus other disease entities.
A few comments on neuropsychological testing. When someone is sent for this testing, it is important to get good data and interpretation based on good data. Often times there are controversies about that the cause of that person's cognitive issues are, so it goes to what is termed differential diagnosis.
A good neuropsychologist will take issues like mood into consideration, issues such as depression, anxiety, issues of pain. Those are maybe the three most important. In terms of differentiating that is related to brain injury versus what is not, there are clearly other issues we won't get into today, but a long laundry list of differential diagnostics that need to be considered.
And then understanding what that individual's pre-injury baseline level of function was, cognitively as well as psycho emotionally, do they have vulnerability. For example, did they go through sexual abuse or trauma, important factors to consider, and issues of status and motivation relative to response and bias and what is termed effort.
Now there are actually tests we can do to assess for an individual's level of effort in the context of testtaking. This gets us into issues of causality determination, which may not be as relevant for y'all vocationally, because when you get a patient you are basically told this is what is wrong with them, A and B and C and D.
You work off that list, but words of wisdom, if you have questions about that, please feel free to address those two people like myself, the treating clinicians. That is why we are here. In my opinion, it should be a team process
But again, we get into issues about when symptom started after an injury in the context of understanding if it is attributable to an injury, and then corroborating those observations with other individuals, as well as consistency of complaint.
If somebody says they have triplevision after an injury like a patient told me the other day, that is highly not likely and more likely to be what we call nonorganic or not real. So understand what is a reasonable complaint versus one that may be fabricated; that is important.
Understanding the natural history of recovery in the context of what we do as rehabilitation clinicians is critical, and understanding what you can do to effectuate improvement in that, whether greater expediency or greater outcome in the longterm. Also, it is part and parcel of what falls under our responsibility.
When patients get worse, you need to know that is something important to make the treating clinician aware of. So if you are seeing a patient coming in, presenting more fatigued, irritable or spacey cognitively, I will tell you your responsibility as a voc person is to let somebody know about that.
Certainly if somebody has a critical event like a seizure, that is something you immediately call paramedics for and inform the treating physician that this event occurred.
Treatment issues. I think it may be more the crux of what will be of interest to this called against. The thing we can do, yourself included, to help people in general and as it relates to vocational reentry, modulating physical impairments, including looking at ways within the workplace as to now you can look at the impairment.
If a standing device allows them to stand at the job for longer, something like that may want to be considered. Facilitating sleep, making sure somebody gets restorative sleep, that is something I look at when I look at a patient. We want to make sure that restorative sleep cycle persists on an ongoing basis. So if somebody complains to you about I'm getting poor sleep, that would be something you would want to let the treating clinician know about.
Modulating pain. If somebody tells you what they are doing in terms of your work activities with them, causing their back pain to go through the ceiling, and before that, they are worse, that would be a red flag to inform the treating clinician on.
My job and treating clinician's job with regard to the patient rehabilitation, find pain generators, treat them, decrease pain and make patient more functional even with persistent pain.
Modulating behavior, whether irritability, aggression, emotional ability, crying at the front of a hat, or anxiety or depression, after the form may be as far as the presentation.
We want that to be modulated as much as possible to allow that individual to function more for lack of a term which I don't love "normally" in the workplace, and interact with individuals in a more adaptive way.
Provide cognitive compensatory strategies. Cognitive remediation takes many forms. It can be attentional training in front of a computer, to treating somebody with cognitiveenhancing medications or teaching these strategies like using the Iphone like many of us doctors use to keep track of their schedule, have alarms for taking medication, et cetera.
Cognitive rehabilitation doesn't mean one thing, but it means a lot of different things. There are lots of things that can be offered to patients in terms of improving their functional acts when they present with cognitive deficits.
Fatigue is a common problem following traumatic brain injury. There are lots of different causes to say fatigue is caused by the brain injury is really an exclusion airy diagnosis. That is you rule out everything else, and then you can say it is due to the brain injury or neurogenic etiology.
Fatigue and poor sleep can cause pain. Fatigue can be caused by brain injury, resulting in anxiety and depression. In the general community, psychiatric disorders, that is depression and anxiety are the two most common causes of fatigue.
It is obviously important for reentry of the workplace to reassess driving skill. There are methodologies in place to objectively assess people's driving skills for reaction time, attention span, divided attention, multitasking, all interfacing in the context of driving, which is probably one of the most complex functional activities we do as humans, and also one of the most dangerous.