Eduardo Lopez, MD - PowerPoint Presentation

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Eduardo Lopez, MD

Associate Professor Clinical Rehabilitation MedicineNew York Medical College School of MedicineChief of Service Department Physical Medicine & RehabilitationNYCH&H Metropolitan

Mild Brain Injury

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Long-term RehabilitationSlide2

Objectives:IntroductionDefinition

Diagnosis and Assessment Mild Traumatic Brain Injury (mTBI)Long-term effects/ Rehabilitation of mTBIMultidisciplinary Rehabilitation ApproachSlide3

Introduction

Silent EpidemicAnnual incidence: 1.7-3.8 million estimatedPathophysiology: Axonal Injury at cellular levelWorking memory deficits at the behavioral levelConcussion/Mild Traumatic Brain Injury (mTBI) represent a separate disease/injury state Concussion is an important cause of m TB I and at times used interchangeably with m TBISlide4

DefinitionsMild TBI is an acute brain injury resulting from mechanical energy to the head from external physical forces.

Operational criteria for clinical identification include: (a) one or more of the following: confusion or disorientation, loss of consciousness for 30 minutes or less, post traumatic amnesia for less than 24 hours, and/ or other transient neurological abnormalities such as focal signs, seizure, and intracranial lesion not requiring surgery; (b) Glasgow Coma Scale score of 13-15 after 30 minutes post injury or later upon presentation for Health Care. These manifestations of mild TBI must not be due to drugs, alcohol, medications; caused by other injuries or treatment for other injuries; caused by other problems; or caused by penetrating craniocerebral injury. World Health Organization (WHO) Collaborative Center Task Force on mild TBISlide5

DefinitionsClassification

is based on initial severity indicators, not outcome.Three primary severity indicators are Duration of unconsciousness, Glasgow coma scale (GCS) scoreDuration of posttraumatic amnesia (PTA)Some research have differentiated complicated from uncomplicated mild TBI. Slide6

ClassificationsSlide7

Diagnostic criteria for mild TB I American Congress of Rehabilitation Medicine (ACRM)

Any period of loss of consciousness (LOC) for up to 30 minutesAny loss of memory for the events immediately before or after the accident for as much as 24 hoursAny alteration of mental states at the time of the accidents (e.g., feeling dazed, disoriented, or confused)Focal neurological deficit(s) that may or may not be transientSlide8

Diagnosis and Assessment mild TBI

The first critical step in successful managementHigh level of suspicion is required particularly when there is no evidence of direct trauma to the head or mechanism of injury that is frequently associatedUsually No Loss of ConsciousnessPatients may present in post traumatic amnesia (PTA)They may have a GCS score of 13-15Formal evaluation with a standardized toolSlide9

Diagnosis and Assessment mild TBISlide10

Risk Factors Influencing Recovery Post mild TBIMedical factors:

Posttraumatic amnesia (PTA)History of previous traumatic brain injuryHistory of previous physical limitationsHistory of previous neurological or psychiatric problemsHigher number of symptoms reported early after injurySkull fractureEarly onset of pain and in particular headache within 24 hours after injuryReduced balance or dizziness during acute phaseConfounding effects of other health related issues, e.g., Pain medications, disabling effects of associated injuries, emotional distressPresence of nausea after injuryPresence of memory problems after injurySlide11

Risk Factors Influencing Recovery Post mild TBIContextual factors:

Injuries sustained in a motor vehicle accidentThe potential influence of secondary gain issues related to litigation and compensationNot returning to work or significant delays in returning to work following the injuryBeing a studentPresence of life stressors the time of the injuryHigher levels of symptom reporting is associated with mood symptoms and heightened self awareness of deficits Older ageLack of social supportsLess education/lower social economic statusSlide12

Common Symptoms of mild TB IPhysicalHeadache

Nausea/vomitingBlurred or double visionBalance problems/ dizzinessTinnitusSensitivity to light/ seeing stars or lightsBehavioral/emotionalDrowsinessFatigue/lethargyDepression/anxietyIrritabilitySleep disturbanceSlide13

Common Symptoms of mild TB IPhysical

Behavioral/emotionalCognitiveFeeling “in a fog” or “dazed”Feeling “slowed down”Difficulty concentratingDifficulty remembering Slide14

Long-term Rehabilitation in Mild TBIMild TBIs are self-limiting and follow a predictable course

Permanent cognitive, psychological, or psychosocial problems caused by the biological effects of this injury are relatively uncommon in mild trauma patients and rare in athletes.Slow or incomplete recovery from mild TBI is poorly understood despite decades of researchSocietal burden resulting from mild TBI is at least equivalent to the resulting from severe TBI, given it higher prevalence.Slide15

Sports-Related ConcussionsIncidence: 3.8 million

annually in USAIncrease reporting in Youth SportsSlide16

Estimates that contact sport results in 300,000 m TBI every year in the USA Differences in outcome have been noted: minority of individuals (1-3 %) experiencing persistent symptoms higher estimates (10-15 %) among the broad range of m TB I patients of varying etiologies

Diagnoses of Sport-Related concussion should include assessment of several different domainsPhysicalBehaviorBalanceCognitionSports-Related ConcussionSlide17

Sports-Related ConcussionSports-Related concussion is an important cause of m TB I and at times used interchangeably with m TBI

Results from the effects of traumatic biomechanical forces on the brainSuch injuries tend to lie on the milder end of the m TBI spectrumLess often associated with concurrent extra cranial injuriesTypically occur in population with unique characteristics:YoungerHealthyHighly motivated and Often anticipating the blow or impactSlide18

Loss of/impaired consciousness. Confusion, such as slow to answer questions or follow directions. Feeling stunned or ‘dazed’. Slurred speechInappropriate playing behavior-e.g., running in the wrong direction. Appreciable decrease play abilityAmnesia: unaware of period, opposition, score of games; or unaware of time, date, place

Headache; nausea/vomiting. SeizuresUnsteadiness/loss of balance and/or poor coordination. DizzinessRinging in the ears. Double VisionEasily distracted, poor concentrationOthers symptoms, such as sleepiness, sleep disturbance and a subjective feeling of slowness and fatigue and the setting out on an impactPersonality changesSports-Related Concussion: SignsSlide19

Post concussion syndrome (PCS)

Traditionally defined as the presence of signs and symptoms directly related to a head injury that last longer than three months. PCS in the athletic population has been described as symptoms that last for more than a month.In Sports Return to-play activities should be deferred until all signs and symptoms have resolved, first at rest with progressive exertion of two maximal activities, and until all the diagnostic testing, including neurocognitive and neuropsychiatric testing, has returned to baseline or above. In cases of severe or prolonged PCS, retirement, especially from collisions sports, should be considered.Slide20

Neuropsychological OutcomeSevere acute symptoms and problems during the first 72 hours following injury

Acute adverse effect of sport-related concussion on objectively-measured cognition is large (Hedge‘s g=-0.81), adverse affects on balance (g=-2.56) and subjective symptoms (g=-3.31) are very large.Similar symptoms and problems are likely present in adults who sustain mild TBIs in daily lifeNatural recovery, neurocognitive deficits are typically not seen in athletes after 1-3 wks. And in trauma patients after 1-3 months in prospective group studiesSlide21

Diagnostic Criteria for Post-Concussion Syndrome [(ICD-10) F07.81]A. History of Head Trauma with loss of consciousness preceding symptom onset by a maximum of 4 weeks

B. Symptoms in 3 or more of the following symptom categories:Headache, dizziness, malaise, fatigue, noise toleranceIrritability, depression, anxiety, emotional labilitySubjective concentration, memory or intellectual difficulties without neuropsychological evidence of marked impairmentInsomniaReduced alcohol intolerancePreoccupation with above symptoms and fear of brain damage with hypochondriacal concern and adoption of sick roleSlide22

Long-term Rehabilitation in mTBI

Second impact syndrome occurs when an individual sustains a second impact that happens while the brain is in a vulnerable condition after an initial impact, usually a concussionSecond impact syndrome occurs when the brain loses autoregulation of blood flow, which leads to cerebral vascular congestion, increases intracranial pressure, and results in brain herniationThe condition results in 50% mortality and 100% morbidity. Participating in sports again after second impact syndrome is contraindicated and most likely is not possible, because rarely does an athlete fully recover from this event.Slide23

Long-term Rehabilitation in mTBI

Chronic Traumatic Encephalopathy (CTE)First clinically described in boxers in 1928 by Martland, who used the term “dementia pugilistica”. Historically described as a progressive neurodegenerative syndromeIts first neuropathologic description was published in 1954 by Brandenburg and Hallervorden. It is characterized by the diffuse tauopathy with Tau-immunoreactive neurofibrillary tangles and neuropil threads.In 2005, Omalu et al reported the first case report in a retired 17-year NFL. Created a causal link. Controversy caused secondary to other possible contributing factors.Slide24

Chronic Traumatic Encephalopathy (CTE)Prior to 2015, there were no agreed upon neuropathological criteria for the postmortem diagnosis of CTE

At preset, there are no agreed upon clinical criteria for diagnosing CTEEvidence that some former athletes in contact, collision and combat sports suffer from depression and cognitive deficits later in life, and an association between these deficits and a history of multiple concussionsIncreased risk of neurodegenerative disease in American football players is suggested in one study but not Alzheimer's disease.Slide25

DepressionSlide26

DepressionTBIs alter brain physiology, and/or create a psychological burden, precipitating the development of depression.

It is well established in the literature that people who sustain a TBI are at increased risk for developing depression with prevalence rates varying widely (i.e., 11% - 77%)Rates of depression in the first three months following mild TBI have ranged from 12%-44%.People who suffered TBIs have higher rates of preinjury psychiatric disorders, such as depression and substance abuse. Bombardier BH; et al.,JAMA 2010It is established that the number of prior episodes of depression is predictive of the likelihood of developing a future episode of depression. Slide27

DepressionMoreover, there should be at increased risk for developing depression, at some point post injury, yet for reasons unrelated to the injury.

Some overlap in symptoms of depression and that of brain injury (e.g., concentration problems, memory problems, irritability, amotivation/apathy, and fatigue)Theoretical underpinnings for trauma-related neurobiological factors being causally related to the onset of depression.Contusions to frontal lobes or damage to frontal-subcortical pathways could precipitate depression. microstructural disintegrative changes to white matter tracts (or more purely functional cellular changes)Complex narrow metabolic crisis, serotonin and dopamine transmitter systemsSlide28

Early Diagnosis and Assessment mTBISlide29

Diagnosis and Assessment Mild TBI

Hourly clinical observations should occur until at least 4 hours post injuryAt 4 hours post injury, if a patient has a GCS score of 15, is clinically improving and has a normal CT scan or there is no indication for CT and their Abbreviated Westmead Posttraumatic Amnesia Scale (A-WPTAS) is greater or equal to 18 -consider dischargeWith the risk to the patient low enough to warrant discharge to own care or home and there are appropriate support structures for safe discharge as for subsequent care (e.g., competent supervision at home)Recommendations for Emergency Department cliniciansSlide30

Recommendations for Emergency Department clinicians

All patients with any degree of brain injury who are deemed safe for appropriate discharge should receive valuable advice with written information. This information should be discussed with the patient and their care providers in their preferred languageReadmissions to ER with symptoms related to the initial injury will require a full reassessment; GCS; A-WPTAS and CT scan of the head if indicated and encouragement to attend specialized brain injury clinic or their Family Physician for follow-upDiagnosis and Assessment Mild TBISlide31

1) Information about common symptoms2) Reassurance that it is normal to experience some symptoms and that a positive outcome is expected3) Typical time (allowing for individual differences) and course of recovery

4) advice about how to manage or cope with symptoms5) advice about gradual reintegration to regular activities6) information on how to access further support if needed7) advice on stress managementElements that can be included in educational sessionSlide32

Minor problems should be manage symptomatically through reassurance and information on symptom management strategies.Symptomatic patients should be followed every 2 to 4 weeks from the time of initial contact until no longer symptomatic or until another re-assessment procedure has been put in placePerson who sustains a mild TBI should not drive for at least 24 hours.

General Recommendations for Management of mild TB ISlide33

Education after mild TBIResearch on interventions delivered post mild TB I are scantConsistent evidence to support the effectiveness of patient education interventions (Borg et al., 2004;

Comper et al., 2005). Several studies demonstrating brief, single session education-oriented treatment is superior to standard procedures (Alves et al.,1993; Mittenberg et al., 1996; Wade et al., 1997-98) and even as effective as more intensive interventions Paniak et al.,1998, 2000)Slide34

Long-term Rehabilitation in mTBI

Multi-disciplinary Rehabilitation Patients with relatively minor traumatic brain injury will recover without routine specialists follow up and rehabilitation Expert neurological rehabilitation services improve outcomes after acute brain injury in adults of working age Greater intensity is likely to lead to a faster and possibly greater level of recovery.There is the need for further research to investigate to confirm conclusions, cost effectiveness and to investigate which components of rehabilitation package are of particular importanceThe Cochrane Library 2011, Turner-Stokes,LSlide35

QUESTIONS

Long-term Rehabilitation after mild TBI