TBI Presentation

Neuropsychological Assessment Neuropsychological Assessment and Rehabilitation: Person and Rehabilitation: Person

Centered PrinciplesCentered Principles

Presented at the Pennsylvania Psychological Association Continuing Presented at the Pennsylvania Psychological Association Continuing Education and Ethics Conference, Pittsburgh PA., October 9, 2009Education and Ethics Conference, Pittsburgh PA., October 9, 2009

PresentersPresenters

Mick Sittig , Ph.D. Rehabilitation Psychologist, ReMed of PittsburghMick Sittig , Ph.D. Rehabilitation Psychologist, ReMed of Pittsburgh

Tad T. Gorske, Ph.D. Assistant Professor, Physical Medicine and Tad T. Gorske, Ph.D. Assistant Professor, Physical Medicine and Rehabilitation, University of PittsburghRehabilitation, University of Pittsburgh

““The presentation of brain facts about specific The presentation of brain facts about specific damages is meaningless to patients unless they damages is meaningless to patients unless they can begin to understand how the changes in can begin to understand how the changes in their brains are lived out in everyday their brains are lived out in everyday experiences and situations”experiences and situations”

(Varella, 1991 as stated in McInerney and Walker, 2002)(Varella, 1991 as stated in McInerney and Walker, 2002)

Definition of Traumatic Brain InjuryDefinition of Traumatic Brain Injury

Closed head injury (CHI) – Skull intact, brain Closed head injury (CHI) – Skull intact, brain not exposed.not exposed.

Penetrating head injury (PHI) – Open head Penetrating head injury (PHI) – Open head injury where skull and dura are penetrated injury where skull and dura are penetrated by an object. by an object.

Vascular insults (due to stroke, anoxia, etc. Vascular insults (due to stroke, anoxia, etc. will also be included for today’s purposes.)will also be included for today’s purposes.)

Centers for Disease Control TBI DefinitionCenters for Disease Control TBI Definition– Craniocerebral trauma, specifically, an occurrence of Craniocerebral trauma, specifically, an occurrence of

injury to the head (arising from blunt or penetrating injury to the head (arising from blunt or penetrating trauma or from acceleration/deceleration forces) that is trauma or from acceleration/deceleration forces) that is associated with any of these symptoms attributable to associated with any of these symptoms attributable to injury: decreased level of consciousness, amnesia, injury: decreased level of consciousness, amnesia, other neurologic or neuropsychological abnormalities, other neurologic or neuropsychological abnormalities, skull fracture, diagnosed intracranial lesions, or death.skull fracture, diagnosed intracranial lesions, or death.

– Thurman DJ, Sniezek JE, Johnson D, et al., Guidelines for Surveillance of Central Nervous Thurman DJ, Sniezek JE, Johnson D, et al., Guidelines for Surveillance of Central Nervous System Injury. Atlanta, GA: National Center for Injury Prevention and Control, Centers for System Injury. Atlanta, GA: National Center for Injury Prevention and Control, Centers for

Disease Control and Prevention, US Department of Health and Human Services, 1995.Disease Control and Prevention, US Department of Health and Human Services, 1995.

Prevalence of TBIPrevalence of TBI

Associated w/Associated w/– 50,000 – 75,000 deaths annually;50,000 – 75,000 deaths annually;– 230,000 – 373,000 hospitalizations – nonfatal 230,000 – 373,000 hospitalizations – nonfatal

TBITBI– 80,000 = long term disability80,000 = long term disability– 1,975,000 individuals attended to medically1,975,000 individuals attended to medically

US StatisticsUS Statistics– Incidence average 220/100,000Incidence average 220/100,000

Rates of TBI hospitalization and death by age groupRates of TBI hospitalization and death by age group

0

50

100

150

200

250

0-4 5--14 15-24

25-34

35-44

45-54

55-64

65-74

75+

Rates per 100,000

AgeGroup

Proportion of TBI related hospitalizations and deathsProportion of TBI related hospitalizations and deaths

Transportation

Falls

Firearms

Other Assaults

Other

Unknown

Transportation

Falls

Firearms

Assaults

Other

Estimated cost of TBI was $260 billion spent Estimated cost of TBI was $260 billion spent in the United Statesin the United States

Mechanism of Brain InjuryMechanism of Brain Injury

Primary InjuryPrimary Injury– Damage that results from shear forces; seen in Damage that results from shear forces; seen in

the initial minutes/hours after the insultthe initial minutes/hours after the insult– Cortical disruptionCortical disruption– Axonal InjuryAxonal Injury– Vascular InjuryVascular Injury– HemorrhageHemorrhage

Closed Head InjuryClosed Head Injury

Resulting from falls, motor vehicle crashes, Resulting from falls, motor vehicle crashes, etc.etc.

Focal damage and diffuse damage to axonsFocal damage and diffuse damage to axons Effects tend to be broad (diffuse)Effects tend to be broad (diffuse) No penetration to the skullNo penetration to the skull

Open Head InjuryOpen Head Injury

Results from bullet wounds, etc.Results from bullet wounds, etc. Largely focal damageLargely focal damage Penetration of the skullPenetration of the skull Effects can be just as seriousEffects can be just as serious

TBI: A TBI: A biologicalbiological event within the event within the brainbrain

Tissue damageTissue damage Bleeding Bleeding SwellingSwelling

Subdural hematoma - Emergency neuroradiology. Axial CT scan though the level of the lateral ventricles shows right-sided subdural hematoma Subdural hematoma - Emergency neuroradiology. Axial CT scan though the level of the lateral ventricles shows right-sided subdural hematoma along the convexity (red arrow) and falx (green arrow), with severe midline shift from right to left.along the convexity (red arrow) and falx (green arrow), with severe midline shift from right to left.

Emergency NeuroradiologyEmergency Neuroradiology Author: M Tyson Pillow, MD, Assistant Director of Medical Education, Ben Taub General Hospital Emergency Center; Assistant Author: M Tyson Pillow, MD, Assistant Director of Medical Education, Ben Taub General Hospital Emergency Center; Assistant

Professor, Baylor College of MedicineProfessor, Baylor College of MedicineCoauthor(s): Robert A Mulliken, MD, Medical Director, Adult Emergency Department, University of Chicago and the University of Coauthor(s): Robert A Mulliken, MD, Medical Director, Adult Emergency Department, University of Chicago and the University of Chicago Hospitals; Christopher M Straus, MD, Assistant Professor, Department of Radiology, University of ChicagoChicago Hospitals; Christopher M Straus, MD, Assistant Professor, Department of Radiology, University of Chicago

TBI: Changes in TBI: Changes in functioningfunctioning

Loss of consciousness/comaLoss of consciousness/coma Other changes due to the TBIOther changes due to the TBI Post-traumatic amnesia (PTA)Post-traumatic amnesia (PTA)

Injured BrainInjured Brain

Does not mend fullyDoes not mend fully Leads to problems in functioningLeads to problems in functioning

What Do We Mean by What Do We Mean by Severity of InjurySeverity of Injury

Amount of brain tissue damageAmount of brain tissue damage

How to measure “severity”?How to measure “severity”?

Duration of loss of consciousnessDuration of loss of consciousness Initial score on Glasgow Coma Scale (GSC)Initial score on Glasgow Coma Scale (GSC) Length of post-traumatic amnesiaLength of post-traumatic amnesia Rancho Los Amigos Scale (1 to 10)Rancho Los Amigos Scale (1 to 10)

Mild injury0-20 minute loss of consciousness GCS = 13-15

PTA < 24 hours

Moderate injury

20 minutes to 6 hours LOC GCS = 9-12

Severe injury> 6 hours LOC GCS = 3-8

What Happens as the Person What Happens as the Person with Moderate or Severe with Moderate or Severe

Injury Begins to Recover After Injury Begins to Recover After Injury?Injury?

Recovery and PlasticityRecovery and Plasticity

Plasticity refers to the ability of the brain to Plasticity refers to the ability of the brain to recover and regenerate. recover and regenerate.

Controversial idea; definition and Controversial idea; definition and mechanisms are not clearmechanisms are not clear

Idea that the CNS is a dynamic system Idea that the CNS is a dynamic system capable of reorganization in response to capable of reorganization in response to injuryinjury

Determining Recovery PotentialDetermining Recovery Potential

Some guidelinesSome guidelines– Lower Glascow Coma Scale (GCS) Score;Lower Glascow Coma Scale (GCS) Score;– Longer coma duration (greater than 4weeks);Longer coma duration (greater than 4weeks);– Longer duration of Post Traumatic Amnesia (PTA)(good Longer duration of Post Traumatic Amnesia (PTA)(good

recovery unlikely when >3months)recovery unlikely when >3months)– Older age assoc. with worse outcomesOlder age assoc. with worse outcomes– Neuroimaging features (presence of SAH, cisternal Neuroimaging features (presence of SAH, cisternal

effacement, significant midline shift, EDH or SDH on effacement, significant midline shift, EDH or SDH on acute care CT = worse outcomes). acute care CT = worse outcomes).

Cognitive Impairments after TBICognitive Impairments after TBI

Cognitive Impairments after TBICognitive Impairments after TBI

Post Traumatic AmnesiaPost Traumatic Amnesia Information processing and attention;Information processing and attention; Anosognosia (unawareness of deficits);Anosognosia (unawareness of deficits); Intellectual functioningIntellectual functioning MemoryMemory Confabulation and delusionsConfabulation and delusions Spatial CognitionSpatial Cognition Chemical Senses (Olfaction and Taste)Chemical Senses (Olfaction and Taste) Executive FunctionsExecutive Functions Social Cognition and BehaviorSocial Cognition and Behavior

Comprehensive RehabilitationComprehensive Rehabilitation

Physical TherapyPhysical Therapy Occupational TherapyOccupational Therapy Speech TherapySpeech Therapy Medical ManagementMedical Management Psychological/Neuropsychological Psychological/Neuropsychological Emotional/Psychiatric Management as appropriateEmotional/Psychiatric Management as appropriate Family SupportFamily Support Case ManagementCase Management

The Role of Neuropsychological The Role of Neuropsychological Assessment: Historical PerspectiveAssessment: Historical Perspective

Period of Neuropsychological LocalizationPeriod of Neuropsychological Localization

Period of Neurocognitive EvaluationPeriod of Neurocognitive Evaluation

Current Period??Current Period??

Technician / ArtistTechnician / Artist

Neuropsychologists are challenged to Neuropsychologists are challenged to expand their roles from a purely technical expand their roles from a purely technical endeavor to a more holistic perspective. endeavor to a more holistic perspective.

Cognitive theorist, functional anatomistCognitive theorist, functional anatomist

Technician / ArtistTechnician / Artist

Neuropsychologists are challenged to Neuropsychologists are challenged to expand their roles from a purely technical expand their roles from a purely technical endeavor to a more holistic perspective. endeavor to a more holistic perspective.

Cognitive theorist, functional anatomist, Cognitive theorist, functional anatomist, psychotherapist, family therapist, emotional psychotherapist, family therapist, emotional adjustment, viewing the person from a adjustment, viewing the person from a holistic perspective. holistic perspective.

Holistic Neuropsychological PrinciplesHolistic Neuropsychological Principles Empower patients and families to take an active role Empower patients and families to take an active role

in the treatment process;in the treatment process; Believe people with neurological disabilities are more Believe people with neurological disabilities are more

like people without neurological disabilities (ie. like people without neurological disabilities (ie. Go Go beyond the brainbeyond the brain) ;) ;

Convey honesty and caring in personal interactions Convey honesty and caring in personal interactions to form a foundation for a strong therapeutic to form a foundation for a strong therapeutic relationship;relationship;

Develop practical plans for rehabilitation; explain Develop practical plans for rehabilitation; explain rehabilitation techniques in understandable language;rehabilitation techniques in understandable language;

Holistic Neuropsychological PrinciplesHolistic Neuropsychological Principles

Help patients and families understand Help patients and families understand neurobehavioral sequelae of brain injury and neurobehavioral sequelae of brain injury and recovery;recovery;

Recognize change is inevitable and help families Recognize change is inevitable and help families cope with change;cope with change;

Every patient is important, treat with respect;Every patient is important, treat with respect; Remember that patients and families have Remember that patients and families have

different perspectives regarding treatment different perspectives regarding treatment approaches;approaches;

Be willing to refer if appropriate. Be willing to refer if appropriate.

Collaborative Therapeutic Neuropsychological Collaborative Therapeutic Neuropsychological Assessment (Gorske and Smith)Assessment (Gorske and Smith)

A collaborative method of interviewing and A collaborative method of interviewing and providing feedback from neuropsychological providing feedback from neuropsychological assessment;assessment;

Enlists the patient/family as an active Enlists the patient/family as an active collaborator;collaborator;

Empowers patients/families to be caretakers Empowers patients/families to be caretakers of their own cognitive health. of their own cognitive health.


1.1. Comprehensive Neuropsychological Comprehensive Neuropsychological AssessmentAssessment

2.2. Referral question, records review, Referral question, records review, behavioral observations, clinical interview, behavioral observations, clinical interview, quantitative and qualitative assessment. quantitative and qualitative assessment.


The Information Gathering / The Information Gathering / Medical Model Medical Model – Clinician knows best;Clinician knows best;– Fragile patients;Fragile patients;– Knowledge is dangerousKnowledge is dangerous

Collaborative ModelCollaborative Model

– Clinician is an expert in Clinician is an expert in neuropsychology; the neuropsychology; the patient/family is the patient/family is the expert on themselvesexpert on themselves

– Patients are resilientPatients are resilient– Knowledge is powerKnowledge is power

CTNACTNA

The spirit of the CTNA lies in Collaborative The spirit of the CTNA lies in Collaborative and Therapeutic Assessment Modelsand Therapeutic Assessment Models– Open sharing; explore results contextually; use Open sharing; explore results contextually; use

results to facilitate empathic understandingresults to facilitate empathic understanding

The framework for conducting the CTNA is The framework for conducting the CTNA is drawn from Motivational Interviewing.drawn from Motivational Interviewing.

The CTNA adopts and adapts the MI The CTNA adopts and adapts the MI Personalized Feedback ReportPersonalized Feedback Report

CTNA Feedback SessionCTNA Feedback Session

Two primary componentsTwo primary components

1.1. Provide information from Provide information from neuropsychological test resultsneuropsychological test results

2.2. Interact with clients in a collaborative Interact with clients in a collaborative manner consistent with TA and MI.manner consistent with TA and MI.

CTNA Personalized FeedbackCTNA Personalized Feedback

1.1. IntroductionIntroduction• Provide feedback report; explain session purpose; Provide feedback report; explain session purpose;

facilitate collaboration and empathic understandingfacilitate collaboration and empathic understanding

2.2. Develop QuestionsDevelop Questions• Develop 2 or 3 well defined questions the client hopes Develop 2 or 3 well defined questions the client hopes

the results can answerthe results can answer

3.3. Explain how strengths and weaknesses are Explain how strengths and weaknesses are determineddetermined

• Percentiles, determine criteria for strength or Percentiles, determine criteria for strength or weaknessweakness


4.4. Feedback about strengths and Feedback about strengths and weaknessesweaknesses

• ElicitElicit: What skills did the client use : What skills did the client use to complete the test.to complete the test.

• ProvideProvide: Therapist provides : Therapist provides information on the cognitive skill information on the cognitive skill test(s) examine.test(s) examine.

• ElicitElicit: Therapist elicits reactions : Therapist elicits reactions from the clients and applies results from the clients and applies results to their real life. to their real life.


5.5. Summarize results and provide Summarize results and provide recommendationsrecommendations

Summary and key questionSummary and key question Ask permission to provide recommendationsAsk permission to provide recommendations Make recommendationsMake recommendations

Pilot Study ResultsPilot Study Results

NAFI NAFI (Neuropsychological Assessment Feedback Intervention) vs. (Neuropsychological Assessment Feedback Intervention) vs.

TAUTAU (Treatment As Usual) (Treatment As Usual)

NAFITAU

S1

71%

48%

0102030405060708090

100

Adherence Ratesp = .042, cohen's d = .78 (.02-1.55)

NAFI (n = 14); TAU (n = 14)

Pilot Study Results: D&A UsePilot Study Results: D&A UseNAFI = 6; TAU = 5NAFI = 6; TAU = 5

30 Day Alcohol Use

0

3.4

5.46

7.13

0

12

34

5

67

89

10

Baseline 30 Day

NAFI

TAU

Pilot Study Results: D&A UsePilot Study Results: D&A Use

30 Day Drug Use

0.66

3.43

0.40

4.73

0

1

2

3

4

5

6

7

Baseline 30 Day

NAFI

TAU

Pilot Study Results: DepressionPilot Study Results: DepressionNAFI = 7; TAU = 5NAFI = 7; TAU = 5

30 Day DepressionHRSD-25

20.21

11.4

22.221.2

0

5

10

15

20

25

Baseline 30 Day

NAFI

TAU

Patient ResponsesPatient Responses

““The assessment was helpful to me. I learned a lot about myself…I The assessment was helpful to me. I learned a lot about myself…I would have done it without being paid.”would have done it without being paid.”

““Allowed me to see why I may be reluctant to participate in groups.”Allowed me to see why I may be reluctant to participate in groups.”

““Helped me narrow in on specific steps I need to take with my therapist Helped me narrow in on specific steps I need to take with my therapist re: depression and addiction. Identified couple things we can work on.”re: depression and addiction. Identified couple things we can work on.”

““I am so pleased that I participated in the study. It was right on. M- I am so pleased that I participated in the study. It was right on. M- allowed me to share during the process, which really assisted with my allowed me to share during the process, which really assisted with my overall understanding of the feedback.” overall understanding of the feedback.”

Case of CECase of CE

Early 50’s Caucasian maleEarly 50’s Caucasian male TBI due to industrial accidentTBI due to industrial accident No LOC but combative/confusedNo LOC but combative/confused GCS = 7GCS = 7 Bifrontal subarachnoid hemorrhages,

tentorial/subfalcine subdural hematomas, contusions to the right and left temporal lobe and bilateral frontal lobes, and a left occipital epidural hematoma.

PTA cleared within 8 days. PTA cleared within 8 days.

Neuropsychological TestsNeuropsychological Tests

MMSE – Clock DrawingMMSE – Clock Drawing Wechsler Abbreviated Scale of IntelligenceWechsler Abbreviated Scale of Intelligence Digit Symbol – Coding – Incidental/Free RecallDigit Symbol – Coding – Incidental/Free Recall WAIS-IV- Digits, Letter Number Seq. WAIS-IV- Digits, Letter Number Seq. WMS-IV – Logical Memory – Visual ReproductionWMS-IV – Logical Memory – Visual Reproduction Rey Complex FigureRey Complex Figure CVLT-IICVLT-II COWACOWA BNTBNT Complex Ideational Material (BDAE)Complex Ideational Material (BDAE) Stroop C/W TestStroop C/W Test Wisconsin Card Sorting Test – 64Wisconsin Card Sorting Test – 64 Others as neededOthers as needed

Case of CE

0102030405060708090

100

ST Mem LT Mem Recog

Verbal Memory

Inpatient

Outpatient

Case of CE

0102030405060708090

100

VisuoSpatial ST Vis Mem LT Vis Mem

VisuoSpatial/Visual Memory

Inpatient

Outpatient

Case of CE

010203040506070

MentalFlexibility

ProblemSolving

ResponseSuppression

Executive Functioning

Inpatient

Outpatient

Case of CE

0102030405060708090

100

Attention Motor Speed ProcessingSpeed

Attention/Processing Speed

Inpatient

Outpatient

Case of CE

0102030405060708090

100

PhonemicFluency

SemanticFluency

Verbal Fluency

Inpatient

Outpatient

Neuropsychological TreatmentNeuropsychological Treatment

Education and ReferralEducation and Referral PsychotherapyPsychotherapy Family InterventionsFamily Interventions Support GroupsSupport Groups Behavior ManagementBehavior Management Cognitive RehabilitationCognitive Rehabilitation

Cognitive Recovery and Cognitive Recovery and RehabilitationRehabilitation

RecoveryRecovery.. A multi-stage process.A multi-stage process. Continues for years.Continues for years. Differs for each person.Differs for each person.

Long-term impact on Long-term impact on functioning.functioning.

Depends on severity of the injury, functions affected, Depends on severity of the injury, functions affected, personal meaning of the injury, resources available, and personal meaning of the injury, resources available, and areas not affected by the injury.areas not affected by the injury.

Cognition.Cognition. AttentionAttention ConcentrationConcentration MemoryMemory Speed of ProcessingSpeed of Processing

Long-term impact on Long-term impact on functioning.functioning.

Depends on severity of the injury, functions affected, Depends on severity of the injury, functions affected, personal meaning of the injury, resources available, and personal meaning of the injury, resources available, and areas not affected by the injury.areas not affected by the injury.

ConfusionConfusion PerseverationPerseveration ImpulsivenessImpulsiveness Language ProcessingLanguage Processing ““Executive functions”Executive functions”

The “Cognitive GridThe “Cognitive Grid

Strategy Development and Implementation.Strategy Development and Implementation. Best Learning Mode.Best Learning Mode. ““To-Do’s” To-Do’s”

Other Physical ChangesOther Physical Changes

Physical paralysis/spasticityPhysical paralysis/spasticity Chronic painChronic pain Sensory/Perceptual.Sensory/Perceptual. Seizures.Seizures. Control of bowel and bladderControl of bowel and bladder

Other Physical ChangesOther Physical Changes

Sleep disordersSleep disorders Loss of staminaLoss of stamina Appetite changesAppetite changes Regulation of body temperatureRegulation of body temperature Menstrual difficultiesMenstrual difficulties

Social-Emotional.Social-Emotional.

Dependent behaviorsDependent behaviors Emotional labilityEmotional lability Lack of motivationLack of motivation IrritabilityIrritability

Social-Emotional.Social-Emotional.

AggressionAggression DepressionDepression DisinhibitionDisinhibition Denial/lack of awarenessDenial/lack of awareness Spread-of-Effect.Spread-of-Effect. Deviance Disavowal.Deviance Disavowal. Stigma Management.Stigma Management. Sick-Role Retention.Sick-Role Retention.

““Recovery” –vs. Recovery” –vs. “Improvement”“Improvement”

Permanence of Change.Permanence of Change. Physical recoveryPhysical recovery Reeducation of the individualReeducation of the individual Environmental modificationsEnvironmental modifications

Generalization Issue(s)Generalization Issue(s)

DispositionDisposition ResidenceResidence Social milieuSocial milieu Productivity Productivity

Resource UtilizationResource Utilization

Resource BookResource Book Support GroupsSupport Groups ReferralsReferrals Follow-upsFollow-ups

Contact InformationContact Information

Mick Sittig, Ph.D.Mick Sittig, Ph.D.Rehabilitation PsychologistRehabilitation PsychologistReMedReMed5830 Ellsworth Avenue, Ste. 2015830 Ellsworth Avenue, Ste. 201Pittsburgh, PA 15232Pittsburgh, PA 15232412-661-0800 Direct 412-661-412-661-0800 Direct 412-661-0808 FAX0808 [email protected]@ReMed.comwww.remed.comwww.remed.com

Tad T. Gorske, Ph.D., Assistant ProfessorTad T. Gorske, Ph.D., Assistant ProfessorDivision of Neuropsychology andDivision of Neuropsychology andRehabilitation PsychologyRehabilitation PsychologyDepartment of Physical Medicine and Department of Physical Medicine and RehabilitationRehabilitationClinical Neuropsychology ServicesClinical Neuropsychology ServicesMercy Hospital-Building DMercy Hospital-Building DRoom G138Room G1381400 Locust Street1400 Locust StreetPittsburgh, PA 15219Pittsburgh, PA 15219Phone: 412-232-8901Phone: 412-232-8901Fax: 412-232-8910Fax: [email protected]@upmc.eduhttp://www.rehabmedicine.pitt.edu/http://www.rehabmedicine.pitt.edu/http://www.linkedin.com/in/tadgorskehttp://www.linkedin.com/in/tadgorske

http://www.remed.com/

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TBI Presentation