TBI                                  Basics                                  VA/DoD                                  CPG  ...
PURPOSE OF THIS GUIDEThe purpose of this Mild Traumatic Brain Injury (TBI) PocketGuide is to provide primary care provider...
2
TBI             TBI             Basics             BasicsTBI BASICS
TBI BASICSDoD Definition (2007)A traumatically induced structural injury and/or physiologicaldisruption of brain function ...
6Severity Ratings for TBI  Criteria                                    Mild               Moderate             Severe     ...
VA/DoD             CPGVA/DoD CPG
The following clinical recommendations contained in the VA/DoD CPG for the Management of Concussion/  Mild TBI (2009) and ...
SUMMARY OF DEPARTMENT OF VETERANSAFFAIRS/DEPARTMENT OF DEFENSE (VA/DoD)CLINICAL PRACTICE GUIDELINE (CPG) FOR THEMANAGEMENT...
10Summary of Algorithm A: Initial Presentation Step One: Identify urgent or emergent conditions Indicators for immediate e...
Step Four: Determine if symptoms are related to mild TBISymptoms present, related and          Refer to Algorithm C: Follo...
12Summary of Algorithm B:Management of Symptoms Step One: History and Physical Exam                 Evaluate signs and sym...
Step Two: Clarify Symptoms Durationyy                                                  Impact on functioning              ...
14Step Seven: Consider Case Management Consider case management if all symptoms not sufficiently resolved within days. Ass...
Summary of Algorithm C: Follow-up of PersistentSymptoms (persistent symptoms beyond four to sixweeks not responding to tre...
16Return to Duty Guidance When to Return to Duty/Activity                    When to Apply Duty Restrictions  Provide peri...
ManagementMANAGEMENT     of HeadachesOF HEADACHES
MANAGEMENT OF HEADACHESBackground Headaches Prevalence in mild TBI      yy (post-traumatic) headaches                     ...
20Assessment, Referral and Treatment, cont. Post-traumatic Headaches (Includes Tension and Migraine), cont. Patient       ...
Tension, cont.     Migraine, cont.           Chronic Daily, cont.                                                    ––Sum...
22                                 All Headaches                                  Relaxation training and biofeedback in c...
MANAGEMENT OF       OTHER SYMPTOMS                                               Management                               ...
MANAGEMENT OF DIZZINESS ANDDISEQUILIBRIUMBackground Dizziness Prevalence in mild TBI                 30%                  ...
26  Dizziness and Disequilibrium, cont.                             yy Nose and Throat (ENT)/                             ...
Assessment, Referral and Treatment               Fatigue                            Sleep Disturbances                Pre/...
28                Fatigue, cont.                      Sleep Disturbances,                                                 ...
Fatigue, cont.                      Sleep Disturbances,                                                                 co...
30Assessment, Referral and Treatment                          Vision                   Hearing               Olfactory    ...
MANAGEMENT OF IRRITABILITY*Background  Irritability                             Anger                            yy       ...
32MANAGEMENT OF APPETITE CHANGESAND NAUSEABackground                  Appetite Changes                    Nausea Prevalenc...
ICD-9 CODING               ICD-9               Coding
DoD ICD-9 CODING GUIDANCE FOR TBI(JANUARY 2010)Special rules apply to the coding of brain injuries, specifically to DoDext...
DoD ICD-9 Coding Guidance for TBI(January 2010)Special rules apply to the coding of brain injuries, specifically to DoDext...
36Coding Subsequent TBI Encounters (Listed in order of precedence)                       Symptom codes are used that best ...
COMMONLY USED TBI CODESTBI Screening CodeSeries Code     DescriptionV80.01          Special Screening for TBI800-804 and 8...
38                 Injury                              Level of Severity, cont.V-Code,          Relatedcont.            to...
Common Symptoms Associated with TBI, cont.Code          Description              Psychiatric308.9         Acute Stress Rea...
40E&M Coding for TBI CareSeries Code   Description99203         New Outpatient – level 399204         New Outpatient – lev...
COGNITIVEREHABILITATION                 Cognitive                 Rehab
COGNITIVE REHABILITATION FOR MILD TBICONSENSUS CONFERENCE (2009): SUMMARYOF CLINICAL RECOMMENDATIONS*``Goal: To provide gu...
44Assessment (Part Two): ComprehensiveCognitive Evaluation``Purpose: To determine 1) the primary factor contributing  to s...
––Identification of individualized cognitive rehabilitation     goals that target symptom reduction through restoration   ...
46COGNITIVE REHABILITATION PROCESS                                     Initial Evaluation Description of injury eventyy Du...
Determine the Treatment Plan Upon Completion of the                     Comprehensive Cognitive Assessment  Primary factor...
48
DRIVINGFOLLOWING TBI                Driving                Following                TBI
DRIVING FOLLOWING TBI CONFERENCE (2009):SUMMARY OF CLINICAL RECOMMENDATIONSThis fact sheet summarizes the clinical recomme...
52Mild TBI Symptoms that may affect                  Moderate and Severe TBI Symptoms thatDriving (not all-inclusive)     ...
What is a driver rehabilitation specialist?A driver rehabilitation specialist is one who plans, develops,coordinates and i...
54
PATIENT EDUCATIONHeadache....................................................... 57Dizziness.................................
Provision of TBI education early after diagnosis of mild TBI hasbeen shown to decrease symptom prevalence (Ponsford, 2002)...
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
Mild traumatic brain injury pocket guide
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Mild traumatic brain injury pocket guide

  1. 1. TBI Basics VA/DoD CPG Management of Headaches Management of Other Symptoms ICD-9 CodingMild Traumatic Brain InjuryPocket Guide (CONUS) Cognitive Rehab Driving Following TBI Patient Education Clinical Tools and Resources 1
  2. 2. PURPOSE OF THIS GUIDEThe purpose of this Mild Traumatic Brain Injury (TBI) PocketGuide is to provide primary care providers in the ContinentalUnited States (CONUS) with an all-encompassing, quickreference that includes clinical guidance in assessing and treatingservice members and veterans who have sustained a mild TBI.Mild TBI is also known as concussion. The term “mild TBI(mTBI)” will be used throughout this guide.TBI Basics. .........................................................................................................5 .Summary of Department of Veterans Affairs/Department ofDefense (VA/DoD) Clinical Practice Guideline (CPG) for theManagement of Concussion/Mild TBI.............................................................9 .Management of Headaches............................................................................19Management of Other Symptoms..................................................................25 Management of Dizziness and Disequilibrium......................................................... 25 Management of Fatigue and Sleep Symptoms........................................................ 26 Management of Vision, Hearing and Olfactory Symptoms....................................... 29 . Management of Irritability........................................................................................ 31 Management of Appetite Changes and Nausea...................................................... 32DoD ICD-9 CM Coding Guidance for TBI .......................................................35Cognitive Rehabilitation for Mild TBI Consensus Conference:Summary of Clinical Recommendations.......................................................43Driving Following TBI Conference: Summary ofClinical Recommendations.............................................................................51Patient Education............................................................................................57Clinical Tools and Resources. ........................................................................71 .This pocket guide was developed by the Defense Centers of Excellence for Psychological Health andTraumatic Brain Injury (DCoE) and the Defense and Veterans Brain Injury Center (DVBIC). 1
  3. 3. 2
  4. 4. TBI TBI Basics BasicsTBI BASICS
  5. 5. TBI BASICSDoD Definition (2007)A traumatically induced structural injury and/or physiologicaldisruption of brain function as a result of an external force that isindicated by new onset or worsening of at least one of the followingclinical signs immediately following the event:`` Any period of loss of or a decreased level of consciousness (LOC)`` Any loss of memory for events immediately before or after the injury [post-traumatic amnesia (PTA)]`` Any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.)`` Neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/plegia, sensory loss, aphasia, etc.) that may or may not be transient`` Intracranial lesionExternal forces may include any of the following events:``Head being struck by an object``Head striking an object``Brain undergoing an acceleration/deceleration movement without direct external trauma to the head``Foreign body penetrating the brain``Forces generated from events such as blast or explosion, or other force yet to be definedCausesIn the military the leading causes of TBI are:`` Blasts `` Motor vehicle crashes`` Fragments `` Falls`` Bullets 5
  6. 6. 6Severity Ratings for TBI Criteria Mild Moderate Severe Normal or Normal or Structural Imaging Normal Abnormal Abnormal > 30 min and Loss of Consciousness (LOC) 0–30 min < 24 hrs > 24 hrs Alteration of Consciousness/ ≤ 24 hrs > 24 hrs > 24 hrs Mental State (AOC) > 24 hrs and > seven Post-traumatic Amnesia (PTA) ≤ 24 hrs < seven days days Glasgow Coma Scale (GCS) Score Score Score (best available score in first 13–15 9–12 3–8 24 hours)** GCS is not part of the official DoD definition for TBI but is commonly used in practice
  7. 7. VA/DoD CPGVA/DoD CPG
  8. 8. The following clinical recommendations contained in the VA/DoD CPG for the Management of Concussion/ Mild TBI (2009) and the Updated DoD mild TBI Clinical Guidance (2008) document are based on the best information available at the time of publication. They are designed to provide information and assist in decision- making. They are not intended to define a standard of care and should not be construed as one. In addition,they should not be interpreted as prescribing an exclusive course of management. Every health care professional making use of these guidelines is responsible for evaluating the appropriateness of applying them.
  9. 9. SUMMARY OF DEPARTMENT OF VETERANSAFFAIRS/DEPARTMENT OF DEFENSE (VA/DoD)CLINICAL PRACTICE GUIDELINE (CPG) FOR THEMANAGEMENT OF CONCUSSION/MILD TBI (2009)ScopeThis guideline is relevant to all healthcare professionals providing ordirecting treatment services to patients with mild TBI in any VA orDoD healthcare setting, including both primary and specialty care.The guideline DOES apply to the following:1. Adult patients (18 years or older) and2. Diagnosed with mild TBI and3. Complaining of symptoms related to the injury and4. Treated in a VA or DoD clinical setting for these symptoms at least seven days after the initial head injuryThe guideline DOES NOT address the following:1. Management of mild TBI in the acute phase (< seven days post injury)2. Management of moderate or severe TBI3. Mild TBI presented as polytrauma and managed in an inpatient setting4. Mild TBI in childrenThere are three algorithms contained in the CPG: 1) InitialPresentation, 2) Management of Symptoms and 3) Follow-up ofPersistent Symptoms. The information within each algorithm,summarized in the following pages, helps identify the bestinterventions and timing of services for patients in order to optimizequality of care and clinical outcomes. The full CPG can be accessedat http://www.healthquality.va.gov/mtbi/concussion_mtbi_full_1_0.pdf. 9
  10. 10. 10Summary of Algorithm A: Initial Presentation Step One: Identify urgent or emergent conditions Indicators for immediate emergency evaluation and treatment: yy Current altered consciousness yy Cannot recognize people or disoriented yy Progressively declining neurological exam to place yy Pupillary asymmetry yy Behaves unusually or confused yy Seizures and irritable yy Repeated vomiting yy Slurred speech yy Double vision yy Unsteady on feet yy Worsening headache yy Weakness or numbness in arms/legs Note: yy person is currently deployed, follow guidance for management of mild TBI in deployed setting If yy person presents immediately after injury (< seven days), then follow local guidance or If emergency department (ED) protocols Step Two: Evaluate for diagnosis of mild TBI yy of or decreased level of consciousness (< 30 minutes) Loss yy of memory for events immediately before or after injury (≤ 24 hrs) Loss Alteration of consciousness/mental state (≤ 24 hrs) yy Normal structural computerized axial tomography (CT) imaging yy yy Score: 13–15 (best value within first 24 hours if available) GCS Note: if diagnosis is moderate or severe TBI, exit this algorithm Step Three: Identify if related symptoms are present Physical Cognitive Behavioral/Emotional Headache yy Difficulties with: Depression yy Dizziness yy yy Attention Anxiety yy Balance disorder yy yy Concentration Agitation yy Nausea yy yy Memory Irritability yy Fatigue yy yy Processing speed Impulsivity yy Sleep disturbance yy yy Judgment Aggression yy Blurred vision yy yy Executive control yy sensitivity Light Hearing loss yy Noise sensitivity yy Seizures yy Transient neurological yy abnormalities Numbness and tingling yy
  11. 11. Step Four: Determine if symptoms are related to mild TBISymptoms present, related and Refer to Algorithm C: Follow-up of yyon treatment Persistent SymptomsSymptoms present, related and Refer to Algorithm B: Management yynot on treatment of Symptoms Provide education and access information yy Screen for yy –– Stress disordersSymptoms present but unrelated –– Substance use disorders –– Mental health conditions Follow up as indicated yy 11
  12. 12. 12Summary of Algorithm B:Management of Symptoms Step One: History and Physical Exam Evaluate signs and symptoms indicating potential for neurosurgical yy emergencies that require immediate referrals Confirm diagnosis of mild TBI yy Characterize initial injury and identify detailed information of the yy injury event –– Mechanism of injury –– Duration and severity of alteration of consciousness Complete –– Immediate symptoms History Patient’s symptoms and health concerns yy –– Symptom course –– treatment Prior Determine if symptoms are related to the mild TBI yy Pre-morbid conditions, potential co-occurring conditions, other yy psychosocial risk factors Assess danger to self or others yy Focused neurological examination yy ––Mental Status Examination (MSE) ––Cranial nerve testing ––Extremity tone testing ––Deep tendon reflexes ––Strength ––Sensation ––Postural stability (Romberg’s Test, dynamic standing) Physical Focused vision examination yy Exam ––Gross visual acuity –– movement Eye ––Binocular function ––Visual fields/attention testing Focused musculoskeletal examination of head and neck yy ––Range of motion of neck and jaw ––Focal tenderness ––Referred pain yy necessary for mild TBI (may consider lab tests for evaluating other Not Lab Tests causes of symptoms) yy recommended for patients who sustained mild TBI beyond 72 Not hours post-injury (emergency phase) unless condition deteriorates or red flags noted Imaging yy scan CT –– Modality of choice for acute mild TBI –– Absence of abnormal findings does not preclude presence of mild TBI
  13. 13. Step Two: Clarify Symptoms Durationyy Impact on functioning yy Frequencyyy Assess exacerbating factors: yy Onset and triggersyy ––Prescribed and over-the-counter (OTC) Locationyy medications Previous episodesyy ––Caffeine, tobacco and other stimulants Intensity or severityyy (energy drinks) Previous treatment and responseyy ––Sleep patterns and sleep hygiene Patient perception of symptomsyy ––Co-existing illnessesStep Three: Evaluate and Treat Co-occurring DisordersComorbid psychiatric problems, whether or not regarded as etiologically related to the mildTBI, should be treated aggressively using appropriate psychotherapeutic and pharmacologicinterventions. Comorbid psychiatric problems may include, but are not limited to:yy Major depressive episodeyy Anxiety disorders [including post-traumatic stress disorder (PTSD)]yy Substance use disorderStep Four: Determine Treatment Plan Document summary of patient’s problemsyy Develop treatment plan that includes severity and urgency for treatment interventionsyy Discuss with patient the general concept of mild TBI sequelae, treatment options (andyy associated risks/benefits) and prognosis to determine patient’s preferences Emphasize good prognosis and empower patient for self-managementyy Referral to specialty care is not required in majority of patients with mild TBI. Most patientsyy with symptoms following a single mild TBI of recent onset can be successfully managed in the primary care setting Treatment should be coordinated and may include consultation with rehabilitation therapists,yy pharmacy, collaborative mental health and social supportStep Five: Educate Patient and Family Early and Often (Written and Verbal) Review potential symptoms of mild TBIyy Review expected outcomes and recoveryyy –– Reassurance on positive expectation of recovery Educate about prevention of further injuriesyy Techniques to manage stress (see “Step Six” below, refer to Patient Education tab andyy DVBIC’s educational materials available for download at http://www.dvbic.org )Step Six: Provide Early (Non-pharmacologic) Interventions Sleep hygiene education (refer to Patient Education Tab, “Healthy Sleep”)yy Relaxation techniquesyy Limiting use of caffeine, tobacco and alcoholyy Graded return to exercise with close monitoringyy Monitored progressive return to normal duty, work or activityyy 13
  14. 14. 14Step Seven: Consider Case Management Consider case management if all symptoms not sufficiently resolved within days. Assign caseyy manager to: ––Follow up and coordinate (remind) future appointments ––Reinforce early interventions and education ––Address psychosocial issues (financial, family, housing or school/work) ––Connect to available resourcesStep Eight: Initiate Symptom-based TreatmentSee specific symptom tabs for symptom management (starting on page 19)Step Nine: Follow Up and Reassess Follow up and reassess in four to six weeks, sooner if clinically indicatedyy Encourage and reinforce positive expectation of recoveryyy Monitor for comorbid conditionsyy Address:yy –– Return to work, duty or activity –– Community participation –– Family/social issuesStep Ten: If Symptoms Are Not Sufficiently Resolved Continue to Algorithm C: Follow-up of Persistent Symptomsyy
  15. 15. Summary of Algorithm C: Follow-up of PersistentSymptoms (persistent symptoms beyond four to sixweeks not responding to treatment) Reassess symptom severity and functional status and complete psychosocial evaluation Are symptoms and functional status improved? NO YES Are any behavioral health disorders Initiate/continue established? symptomatic treatment Assess for possible alternative and provide patient causes for persistent symptoms: and family education - Sleep disorder - Mood disorder - Depression - Traumatic stress - Anxiety - Substance use disorder NO YES Manage comorbidity according to theAre any persistent physical, appropriate VA/DoD clinical practice cognitive or emotional guideline for behavioral health conditions symptoms present? and consider referral to mental health NO YES Consider referral to Refer for further specialty occupational/vocational evaluation and treatment therapy and community integration programs andcontinue case management Encourage, reinforce and monitor for comorbid conditions Follow up and reassess in three to four months 15
  16. 16. 16Return to Duty Guidance When to Return to Duty/Activity When to Apply Duty Restrictions Provide period of rest for individuals with yy yy duty specific task cannot be safely A post-injury symptoms or competently completed based on Encourage gradual return to normal activity yy symptoms as clinically appropriate yy work/duty environment cannot be The Suggest exertional testing if a person’s yy adapted to the patient’s symptom-based normal activity involves significant limitation physical activity yy deficits cannot be accommodated The yy exertional testing results in a return of If Symptoms reoccur yy symptoms, recommend additional rest until symptoms resolveReferral Guidance When to Refer to Specialists Symptoms cannot be linked to an event (suspicion of another diagnosis) yy yy atypical symptom pattern or course is present An Findings indicate an acute neurological condition requiring urgent intervention yy Presence of other major comorbid conditions requiring special evaluation yy
  17. 17. ManagementMANAGEMENT of HeadachesOF HEADACHES
  18. 18. MANAGEMENT OF HEADACHESBackground Headaches Prevalence in mild TBI yy (post-traumatic) headaches 90% Tension-type (including cervicogenic component) yy Manifestations Migraine yy Combined migraine and tension-type yyAssessment, Referral and Treatment Post-traumatic Headaches (Includes Tension and Migraine) Characterize headaches yy Pre-existing headache disorder yy History Assess sleep/wake cycles (lack of sleep is an exacerbating factor and yy mild TBI is also associated with impaired sleep) Head and neck yy Gait yy Physical Cranial nerve, fundoscopic yy Upper and lower extremity yy Examination and pupil exam coordination Muscle strength and tone yy Chronic daily use of non-steroidal anti-inflammatory drugs (NSAIDs) yy or acetaminophen (alone or combined with caffeine) may lead to Medication rebound headaches Review Excessive use or rapid withdrawal of caffeine or tobacco can yy trigger headaches Emergency Department yy Neurology yy ––Fever ––Worsening headache –– neck Stiff ––Seizures Referral* ––Blackouts –– abnormality found Any during neurological or musculoskeletal exam Perform series of neck stretches yy Review sleep posture and make adjustments to ensure neck and spine yy Patient are in a neutral position Education Consult with healthcare professional regarding any OTC medications or yy if interventions are not effective after two to four weeks 19
  19. 19. 20Assessment, Referral and Treatment, cont. Post-traumatic Headaches (Includes Tension and Migraine), cont. Patient Awareness and avoidance of migraine triggers yy Maintain regular exercise, sleep and meal schedules yy Education, Recognize warning signs (aura) yy cont. Headache diary yy Tension Migraine Chronic Daily Typically given for more Abortive agents typically Prevention of chronic daily mild tension headache: given for more mild headache:* yy Ibuprofen 400-600mg migraine headache: yy Propanolol 10–240mg TID-QID yy Ibuprofen 400-600mg (Causes decrease in yy Naproxen 500mg BID TID-QID blood pressure and may yy Acetaminophen yy Naproxen 500mg BID reduce PTSD symptoms) yy Aspirin yy Amitriptyline or yy Choline-magnesium- Abortive agents typically Nortriptyline 10–100mg trisalisylate given for more moderate/ QHS (may also assist severe migraine headache:* with sleep) Typically given for more yy Ibuprofen 600-800mg yy Paroxetine moderate/severe tension yy Naproxen (antidepressant with headache:* yy Compazine possible headache yy Ibuprofen 600-800mg yy Phenergan benefit) yy Naproxen yy Triptans yy Fluoxetine yy Compazine –– Zolmitriptan oral (antidepressant with Pharmacologic Treatment yy Phenergan 5–10mg at onset, possible headache may repeat once benefit) Note: Medications for if headache not yy Gabapentin 300–900mg tension-type headaches resolved in two hours QHS to BID should be given PRN at yy Sodium valproate onset, no more than three Note: VA/DoD mild 500–1500mg (draw days/week. Persistent TBI CPG recommends levels) usage can lead to initiating dosing of yy Topirimate 25–100mg rebound headaches. Zolmitriptan oral at QDAY to BID 5–10mg. While this may occur in practice, official drug manufacturer dosing recommendations suggest initiation with 2.5–5mg. Maximum dosing: 10mg/24 hours ––Zolmitriptan nasal one spray of 5mg, may repeat once if headache not re- solved in two hours. Maximum daily dose should not exceed 10mg/day
  20. 20. Tension, cont. Migraine, cont. Chronic Daily, cont. ––Sumatriptan oral 50–100mg at onset, may repeat once if headache not resolved in two hours ––Sumatriptan nasal one spray of 10mg, may repeat in two hours. Maximum daily dose should not exceed 40mg/day ––Sumatriptan inject- able 6mg SQ, may repeat in one hour.Pharmacologic Treatment, cont. Maximum daily dose not to exceed 12mg/day Note: Abortive agents for migraine headaches should be given PRN at onset, no more than three days/week. Persistent usage can lead to rebound headaches. Prophylactic agents: yy Divalproex sodium extended release 250mg BID. May increase by 250mg/ day every week to maximum of 1000mg/ day (draw levels) yy Topiramate 25–100mg BID yy Metoprolol 25mg BID. May increase every three to four weeks up to 100mg BID if needed 21
  21. 21. 22 All Headaches Relaxation training and biofeedback in combination with medication yy Non-pharmacologic Treatment Physical therapy to exercise neck muscles and maintain appropriate range yy of motion Increased physical activity may help to reduce frequency and intensity of yy headaches Visualization yy Extracranial pressure yy Regular exercise and maintenance of regular meal schedule (may be more yy effective as preventatives than as treatments) yy compress or alternate ice and heat on neck and head two to three times per Cold day for about 20 minutes Therapeutic massages to help with headaches from neck tension yy* Updated DoD mild TBI Clinical Guidance (2008)
  22. 22. MANAGEMENT OF OTHER SYMPTOMS Management of Other SymptomsManagement of Dizziness andDisequilibrium................................................ 25Management of Fatigue andSleep Symptoms............................................ 26 .Management of Vision, Hearingand Olfactory Symptoms. ............................... 29 .Management of Irritability............................... 31Management of Appetite Changesand Nausea.................................................... 32
  23. 23. MANAGEMENT OF DIZZINESS ANDDISEQUILIBRIUMBackground Dizziness Prevalence in mild TBI 30% yy Impaired balance yy Manifestations Altered coordination yyAssessment, Referral and Treatment Dizziness and Disequilibrium Neurological examination yy Vestibular yy Vision yy –– Dynamic acuity –– Acuity –– Positional testing –– Tracking Evaluation of functional and yy –– Saccades balance activities –– Nystagmus –– Sitting and standing Auditory yy ‚‚ Romberg with eyes –– Hearing screen open and closed Physical –– Otoscopic exam ‚‚ Single leg stance Assessment Sensory yy –– Transfers –– Sharp ‚‚ Supine-sit –– Light touch ‚‚ Sit-stand –– Proprioception –– Gait –– Vibration ‚‚ Walking Motor yy ‚‚ Tandem walking –– Power ‚‚ Turning –– Coordination Dizziness Handicap yy Inventory (DHI) Dizziness included as potential side effect for the following medications: Stimulants yy Neuroleptics yy Medication Benzodiazepines yy Anticonvulsants yy Review * Tricyclics yy Selective serotonin agonists yy Monoamine oxidase inhibitors yy yy blockers Beta Tetracyclics yy Cholinesterase inhibitors yy Emergency Department yy Neurology yy ––Cerebrospinal Fluid ––Lateral abnormality Referral* (CSF) leak ––Nystagmus ––Abnormal Romberg 25
  24. 24. 26 Dizziness and Disequilibrium, cont. yy Nose and Throat (ENT)/ Ear, Audiology/Vestibular rehabilitation (dependent on local resources) Referral, cont.* –– Positive Dix Hallpike –– score > 1 or DHI persistent dizziness complaints yy shown to be effective in Not Scopolamine 0.5mg patch yy chronic dizziness after mild TBI Q3 days Consider only if symptoms are yy Dimenhydrinate 50mg PO yy severe enough to significantly Q4-6 hours Pharmacologic limit functional activities and Lorazepam 0.5mg PO BID yy Treatment should be limited to two weeks Clonazepam 0.25–0.5mg yy yy be helpful during May PO BID acute period Diazepam 2–10mg PO, yy Meclizine 12.5–50mg Q4–6 hrs yy IM or IV Non- Vestibular and balance rehabilitation yy pharmacologic Treatment Perform neck stretches yy Patient Modify activity and change positions slowly yy Education Change sleep position yy Perform vestibular rehabilitation exercises yy* Updated DoD mild TBI Clinical Guidance (2008)MANAGEMENT OF FATIGUE ANDSLEEP SYMPTOMSBackground Fatigue Sleep Disturbances Prevalence in yy most common Third yy occur acutely after injury Can mild TBI symptom Primary effect (central nervous yy Circadian rhythm sleep yy system-related) disorders Manifestations Secondary effect yy Delayed sleep pattern syndrome yy (co-existing depression or Irregular sleep-wake pattern yy sleep disturbances)
  25. 25. Assessment, Referral and Treatment Fatigue Sleep Disturbances Pre/post-injury level of yy Evaluate for: –– Physical activity yySleep routine –– Cognitive function yySleep activity –– Mental health yyNightmares and frightened Identify and treat underlying yy arousal medical and psychological yyOther current health History disorders conditions that might contribute (i.e., chronic pain) yyPotential cormorbid psychiatric conditions including depression and anxiety Multidimensional Assessment yy Examine neck size, airway, yy of Fatigue (MAF) height, weight Fatigue Impact Scale (FIS) yy Administer Epworth yy Fatigue Assessment yy Sleepiness Scale (ESS) Instrument (FAI) Consider administering yy Laboratory tests yy Pittsburgh Sleep Quality Physical –– Complete blood Index (PSQI) Assessment count (CBC) –– Metabolic panel –– Vitamin B12 and folate –– Thyroid function test –– Erythrocyte Sedimentation Rate (ESR) yy medication appears If Medication and yy Medication contributory, perform Applied supplement use Review * Behavioral Analysis (ABA) trial to determine the association Sleep study referral yy –– Apnea Referral* Not included in guidance –– >12 ESS –– Body Mass Index (BMI) >30 27
  26. 26. 28 Fatigue, cont. Sleep Disturbances, cont. Address modifiable factors prior yy Zolpidem 5mg QHS. If poor yy to initiating pharmacotherapy results after three nights, Persistent symptoms ( > four yy may increase to 10mg QHS weeks) without improvement Zolpidem 5–10mg QHS yy with management of sleep, max duration 10 days* pain, depression and lifestyle, Trazodone 25–50mg QHS yy may consider neurostimulant max dose 150mg (sleep (contraindicated if history of maintenance)* substance abuse): Amitriptyline 25mg yy –– Methylphenidate QHS max dose 100mg 5mg Q 0800 and Q (headache benefit)*Pharmacologic 1300. Increase totalTreatment daily dose by 5mg Q 2 weeks to maximum dose of 20mg BID –– Modafanil 100mg QAM. Increase by 100mg, using split daily dosing up to maximum of 400mg/day Amantadine 100–400mg QD yy Medication trial for at least yy three months yy balanced meals Well Sleep hygiene yy Sleep hygiene yy Cognitive behavioral yy Regular exercise yy therapy focused on sleepNon- Cognitive behavioral therapy yy with additional behavioral and physical therapy to improve interventions to includepharmacologic functional performance sleep restriction, stimulusTreatment control, and relapse prevention techniques Reduce stimulation before yy bedtime Identify factors contributing yy yy caffeine, heavy exercise, No to fatigue alcohol, nicotine, power yy well-balanced meals Eat drinks, stimulants or heavy Practice sleep hygiene yy meals three hours prior to Maintain regular exercise yy bedtimePatient Avoid bright light exposure yyEducation near bedtime yy regular bedtime and Keep wakeup hours Foster quiet, pleasant sleep yy environment
  27. 27. Fatigue, cont. Sleep Disturbances, cont. yy work or TV viewing Stop at least one hour before bedtime yy bed only for sleep Use and sex Reduce or eliminate yy daytime naps Consult with healthcare yy professional before taking any OTC medications or Patient supplements Education, cont. Restrict nighttime sleep yy period to eight hours Engage in daytime physical yy and mental activities (within limits of individual’s capacity) yy to another room if sleep Go does not come within 20–30 minutes yy a relaxing bedtime Have routine* Updated DoD mild TBI Clinical Guidance (2008)MANAGEMENT OF VISION, HEARING ANDOLFACTORY SYMPTOMSBackground Vision Hearing Olfactory Prevalence in 50% yy yy (blast- 75% yy 25% < mild TBI (approximately) related mild TBI) Sensitivity to yy Sensitivity to yy Post-traumatic yy Manifestations light, diplopia noise, decreased olfactory deficits and blurring auditory acuity (anosmia) 29
  28. 28. 30Assessment, Referral and Treatment Vision Hearing Olfactory Pre-injury visual yy Pre-injury hearing yy Pre-injury causes yy History deficits deficits (common) of anosmia Ophthalmologic yy Otologic yy Perform yy examination examination nasal and –– Extraocular Bedside hearing yy oropharyngeal movements test examination Physical –– Pupils Audiogram (if yy Perform yy Assessment –– Visual fields by available) depression confrontation screen –– Fundoscopic exam –– Visual acuity Review yy Medication Not included in Not included in medications for Review guidance ototoxicity guidance Optometry (request yy Audiology (if no yy yy (if needed) ENT ocular testing) other cause is and Ophthalmology found) Neurology yy ENT* yy ––Papilledema (Hemotympanum, ––Cranial nerve foreign body, Referral deficit tympanic membrane perforation) Initial use of yy Reassurance yy Reassurance and yy sunglasses followed yy management Pain monitoring by formal weaning Control yy Increase spicing yy program (decrease environmental of foods (+/- Non- by 15 minutes noise dietary referral) every two hours) White noise yy Monitor weight yy pharmacologic Control yy generators Treatment environmental light Intermittent patching yy for double vision Provide reassurance yy Manage pain yy* Updated DoD mild TBI Clinical Guidance (2008)
  29. 29. MANAGEMENT OF IRRITABILITY*Background Irritability Anger yy Anxiety yy Manifestations Depression yy Tension yy Mood swings yy Easily overwhelmed yyAssessment, Referral and Treatment Management of Irritability Evaluate specific history and symptoms: yy ––Physical fighting ––Suicidal History ––Alcohol intake ––Homicidal ––Relationship problems Administer PTSD Checklist – Military Version (PCL-M) yy screening questionnaire Physical Assessment Consider Patient Health Questionnaire (PHQ-9) or other yy depression inventory Psychiatry, psychology and social work Referral Outward violence yy Suicidal ideation yy Excessive alcohol intake yy Homicidal ideation yy Sertraline 25–50mg daily. Titrate Q7–10 days. Max yy dose 150mg/day Pharmacologic Citalopram 10mg /day. Titrate to max dose 40mg/day yy Treatment Allow three to four week therapeutic trial of each drug yy Refer to psychiatry, psychology or social work for yy treatment failure of two medications Understand that it is normal to have feelings of anxiety, yy depression, agitation and feeling overwhelmed Replace negative thoughts and actions with positive ones yy Refrain from negative self talk (putting oneself down) yy Patient yy to someone you love and trust about these concerns Talk Education yy emergency care for thoughts or feelings of hurting Seek self or others yy psychological support if these feelings are causing Seek problems at work or home* Updated DoD mild TBI Clinical Guidance (2008) 31
  30. 30. 32MANAGEMENT OF APPETITE CHANGESAND NAUSEABackground Appetite Changes Nausea Prevalence in Occasionally after acute injury yy yy 5% < mild TBI Usually seen in combination yy with dizziness (as secondary effect of medications or Manifestations Change in appetite yy due to exacerbation of gastroesophageal reflux disease/gastrointestinal (GERD/GI) dysfunctionAssessment and Treatment Appetite Changes Nausea Pre-injury causes of appetite yy Define triggers and patterns yy History issues of nausea Perform nasal and yy Perform oropharyngeal yy oropharyngeal examination examination Physical Review neurovegetative yy Assessment signs (assess for depressed affect or clinical depression) Assess medication list yy Assess medication list for yy for agents that can cause agents that may cause or olfactory or gustatory worsen G I symptoms Medication abnormalities (centrally Review acting medications, in particular anti-epileptics, some antibiotics) Non- Reassurance and monitoring yy Reassurance and monitoring yy Increase spicing of foods yy Encourage rapid management yy pharmacologic (+/- dietary referral) of dizziness if contributing to Treatment Monitor weight yy cause of nausea
  31. 31. ICD-9 CODING ICD-9 Coding
  32. 32. DoD ICD-9 CODING GUIDANCE FOR TBI(JANUARY 2010)Special rules apply to the coding of brain injuries, specifically to DoDextenders for capturing data on TBI. This guidance is intended for codingTBI occurring both in theater and at all military treatment facilities (MTFs).TBI is coded based on documentation contained within the medical recordand in accordance with Military Health System (MHS) and ICD-9-CMcoding guidelines. In all cases of TBI encounters, at least two codesare necessary to capture the required elements. In the case of the initialencounter these two codes are the 8XX series code and the personal historyof TBI code (V15.52_X). In the case of subsequent encounters, these twocodes are the appropriate symptom code(s) and the personal history of TBIcode (V15.52_X). Other codes may apply, e.g., deployment codes, E codes,to encounters and should be used in accordance with general coding guidance. Coding Initial TBI Encounter (Listed in order of precedence) yy time the patient is seen by ANY medical professional for TBI (regardless of First when the injury occurred) Does not refer to the first time the patient is seen by each clinician for that particular TBI yy Code from the 8XX series yy yy series code used only once and for initial encounter 8XX Clinical documentation must support that the encounter coded is yy 8XX Series the initial encounter for that particular injury yy fourth digit is required that further describes the 8XX series A yy fifth digit is required to describe the level of consciousness A associated with the TBI V15.52_X codes (personal history of TBI) are used to assist the yy Personal History DoD in tracking TBI occurrences of TBI Code yy appropriate V15.52_X code should be utilized at all The encounters associated with the TBI Symptom Code(s) Representative of patient’s presenting complaint(s) yy Deployment V70.5_5 (during deployment encounter) yy Status Code V70.5_6 (post-deployment encounter) yy yy V80.01 Code TBI Screening yy be coded if screening occurs at a visit Must (if applicable) yy TBI diagnosis code should not be entered for a positive screen A since a positive TBI screen does not equal a TBI diagnosis 35
  33. 33. DoD ICD-9 Coding Guidance for TBI(January 2010)Special rules apply to the coding of brain injuries, specifically to DoDextenders for capturing data on TBI. This guidance is intended for codingTBI occurring both in theater and at all military treatment facilities (MTFs).TBI is coded based on documentation contained within the medical recordand in accordance with Military Health System (MHS) and ICD-9-CMcoding guidelines. In all cases of TBI encounters, at least two codesare necessary to capture the required elements. In the case of the initialencounter these two codes are the 8XX series code and the personal historyof TBI code (V15.52_X). In the case of subsequent encounters, these twocodes are the appropriate symptom code(s) and the personal history of TBIcode (V15.52_X). Other codes may apply, e.g., deployment codes, E codes,to encounters and should be used in accordance with general coding guidance. Coding Initial TBI Encounter (Listed in order of precedence) yy time the patient is seen by ANY medical professional for TBI (regardless of First when the injury occurred) Does not refer to the first time the patient is seen by each clinician for that particular TBI yy Code from the 8XX series yy yy series code used only once and for initial encounter 8XX Clinical documentation must support that the encounter coded is yy 8XX Series the initial encounter for that particular injury yy fourth digit is required that further describes the 8XX series A yy fifth digit is required to describe the level of consciousness A associated with the TBI V15.52_X codes (personal history of TBI) are used to assist the yy Personal History DoD in tracking TBI occurrences of TBI Code yy appropriate V15.52_X code should be utilized at all The encounters associated with the TBI Symptom Code(s) Representative of patient’s presenting complaint(s) yy Deployment V70.5_5 (during deployment encounter) yy Status Code V70.5_6 (post-deployment encounter) yy yy V80.01 Code TBI Screening yy be coded if screening occurs at a visit Must (if applicable) yy TBI diagnosis code should not be entered for a positive screen A since a positive TBI screen does not equal a TBI diagnosis 35
  34. 34. 36Coding Subsequent TBI Encounters (Listed in order of precedence) Symptom codes are used that best represent the patient’s yySymptom Code(s) presenting complaint, e.g., headaches, insomnia and vertigo, as the primary code V15.52_X codes (personal history of TBI) are used to assist the yyPersonal History DoD in tracking TBI occurrencesof TBI Code yy appropriate V15.52_X code should be utilized at all The encounters associated with the TBI yy for all follow-up visits related to TBI UsedLate Effect Code 905.0 (late effect of intracranial injury with skull or facial fracture) yy 907.0 (late effect of intracranial injury without skull or facial fracture) yyDeployment V70.5_5 (during deployment encounter) yyStatus Code V70.5_6 (post-deployment encounter) yyMiscellaneousInpatient or yy first code entered is taken from the V57.XX series TheOutpatient Guidance for coding subsequent TBI encounters is then followed yyRehabilitation 799-series codes allow providers to code emotional/behavioral yyEmotional/ symptoms without using mental health diagnosis codesBehavioral yy not replace mental health diagnosis codes DoSymptom Codes yy when providers observe symptoms but a mental health Used diagnosis is not established Assigned when appropriate, e.g., E979.2—terrorism involving yy other explosions/fragmentsE-Code Refer to Health Information Management Coding Department for yy further guidance yy code 96116 is used if the Psychomotor Neurobehavioral CPT Status Exam is completed Includes the time for testing, interpreting and preparing the report yy Coding is completed in one hour units. Anything less than one yy hour is claimed as one unit Documentation must include clinically indicated portions of an yyProcedure Coding assessment of thinking, reasoning and judgment, e.g., attention,for TBI Care acquired knowledge, language, memory and problem solving. The areas most often affected by TBI include attention, memory and problem solving so these areas should be screened if there are cognitive complaints Other areas may be assessed as clinically indicated and may be yy completed in follow-up visits as long as the documentation is supportive (history and documented screening examination)
  35. 35. COMMONLY USED TBI CODESTBI Screening CodeSeries Code DescriptionV80.01 Special Screening for TBI800-804 and 850-854 Series CodesSeries Code Description (Note: All require a fourth and fifth digit)800 Fractures of vault of skull­801 Fractures of base of skull802 Fracture of face bones803 Other and unqualified skull fractures804 Multiple fractures involving skull or face with other bones850 Concussion851 Cerebral laceration and contusion852 Subarachnoid, subdural and extradural hemorrhage, following injury853 Other and unspecified intracranial hemorrhages following injury854 Intracranial injuries of other and unspecified nature Injury Level of SeverityV-Code Related(must be used to Globalwith all TBI Unknown Mild Moderate Severe Penetratingencounters) War on TerrorismV15.52_0 Personal history of traumatic brain injury NOT otherwise specifiedV15.52_1 Yes XV15.52_2 Yes XV15.52_3 Yes XV15.52_4 Yes XV15.52_5 Yes X 37
  36. 36. 38 Injury Level of Severity, cont.V-Code, Relatedcont. to Global (must be used War on Unknown Mild Moderate Severe Penetratingwith all TBIencounters) Terrorism, cont.V15.52_6 No XV15.52_7 No XV15.52_8 No XV15.52_9 No XV15.52_A No XV15.52_B Unknown XV15.52_C Unknown XV15.52_D Unknown XV15.52_E Unknown XV15.52_F Unknown XLate Effect Code (must be used with all follow-up TBI encounters)905.0 Late effect of intracranial injury with skull or facial fracture907.0 Late effect of intracranial injury without skull or facial fractureCommon Symptoms Associated with TBICode Description Hearing389.9 Hearing Loss, Unspecified388.42 Hyperacusis (oversensitivity to certain sound frequencies)388.3 Tinnitus Neurologic780.4 Dizziness, Lightheadedness784.0 Headache780.93 Memory Loss, Not Otherwise Specified (NOS)438.85 Vertigo
  37. 37. Common Symptoms Associated with TBI, cont.Code Description Psychiatric308.9 Acute Stress Reaction, Unspecified300 Anxiety/Irritability311 Depression Sleep780.5 Sleep Disturbance780.52 Insomnia Vision368.8 Blurred Vision, NOS368.13 Photophobia Other/General780.7 Malaise and Fatigue787.02 NauseaEmotional / Behavioral Symptom CodesSeries Code Description799.21 Nervousness799.22 Irritability799.23 Impulsiveness799.24 Emotional Lability799.25 Demoralization and Apathy799.29 Other Signs and Symptoms Involving Emotional State 39
  38. 38. 40E&M Coding for TBI CareSeries Code Description99203 New Outpatient – level 399204 New Outpatient – level 499213 Established Outpatient – level 399214 Established Outpatient – level 4Procedure Code for TBI CareSeries Code Description96116 Neurobehavioral Status Exam
  39. 39. COGNITIVEREHABILITATION Cognitive Rehab
  40. 40. COGNITIVE REHABILITATION FOR MILD TBICONSENSUS CONFERENCE (2009): SUMMARYOF CLINICAL RECOMMENDATIONS*``Goal: To provide guidance regarding cognitive rehabilitation of chronic post-concussive symptoms in service members and veterans receiving treatment within military medical settings``This guidance addresses the needs of the service member or veteran who is three months or more post-concussive injury and has persistent cognitive symptoms`` recommendations contained in the document are divided into The four areas: assessment (initial and comprehensive), interventions, outcome measures and program implementation`` term cognitive rehabilitation is used synonymously with The neurorehabilitation, neuropsychological rehabilitation, cognitive remediation and cognitive retrainingAssessment (Part One): Initial Evaluation``Purpose: To determine if the individual has a history of mild TBI with persistent cognitive symptoms or signs of cognitive impairment and to determine if any comorbidities exist that may affect cognitive function``Performed by a TBI-experienced provider in the primary care setting who is also familiar with other deployment-related health conditions``Referral to the initial evaluation can be made by any provider``Reasons for referral: cognitive symptoms observed by the provider or reported by the patient, family or leadership; referral may also be made even if the patient does not report cognitive symptoms but displays evidence of cognitive dysfunction in daily social or occupational functioning``Any suspicion of mild TBI with persistent cognitive symptoms warrants further cognitive evaluation* o-sponsored by the Defense Centers of Excellence for Psychological Health and Traumatic Brain C Injury (DCoE) and the Defense and Veterans Brain Injury Center (DVBIC)Available at: http://www.dcoe.health.mil/ForHealthPros/Resources.aspx 43
  41. 41. 44Assessment (Part Two): ComprehensiveCognitive Evaluation``Purpose: To determine 1) the primary factor contributing to symptoms, 2) cognitive deficits, 3) the need for cognitive rehabilitation, 4) the type of rehabilitation needed and 5) the short- and long-term goals``Performed by an interdisciplinary group (resource dependent): neuropsychologist, occupational therapist and speech- language pathologist``Includes a comprehensive neurological evaluation performed by a neurologist or physician with expertise in and knowledge of cognitive symptoms``Includes a review of the medical records to look for prior cognitive disordersInterventions``Interventions should target attention, memory, executive functioning and social pragmatics as these are the most common cognitive domains affected by TBI``Attention is the prerequisite for basic and complex behaviors involving memory, judgment, social perception and executive skills``Interventions should be based on a holistic approach and include individual and group therapies within an integrated therapeutic environment``Specific examples of empirically-supported interventions are contained in the full guidance document (http://www.dcoe.health. mil/ForHealthPros/Resources.aspx)Program Implementation``Ideal cognitive rehabilitation team: holistic, interdisciplinary team, including a designated team leader competent in brain injury rehabilitation and military culture and capable of developing a therapeutic alliance with patients``Core elements of a successful program: –– Assessment prior to treatment
  42. 42. ––Identification of individualized cognitive rehabilitation goals that target symptom reduction through restoration and compensation, functional improvements/gains, and a therapeutic alliance ––Development of an interdisciplinary individualized treatment plan ––Periodic cognitive reassessment and review of goals ––Development of a well-defined discharge planOutcome Measures``Cognitive rehabilitation programs must describe outcomes in order to advance the published science``Recommended outcome measures are outlined in the 2009 Consensus Conference on Cognitive Rehabilitation for Mild TBI report and include administrative performance metrics, pre- and post-assessment differences, pre- and post-functional differences, moderating variables, discharge criteria, consumer satisfaction and aggregate program outcome dataAvailable at: http://www.dcoe.health.mil/ForHealthPros/Resources.aspx 45
  43. 43. 46COGNITIVE REHABILITATION PROCESS Initial Evaluation Description of injury eventyy Duration of loss of consciousness or altered mental statusyy Confirmation of mild TBI diagnosisyy Evaluation of ongoing symptomsyy Mental health evaluationyy Evaluate for chronic pain, sleep disorders and substance abuseyy Measures of effortyy Possible Outcomes Following Initial Evaluation The patient does not have any cognitive symptoms; education and reassurance toOutcome #1 the referring provider and the patient There is no indication that the patient sustained a mild TBI but cognitiveOutcome #2 symptoms are present; refer the patient back to the primary care provider for further evaluation of a medical or mental health condition The patient has comorbidities or other symptoms that are too severe for him/her to undergo cognitive assessment yy referred to specialty clinic, assign case manager and re-evaluate in IfOutcome #3 four weeks yy referred to specialty clinic and all cognitive symptoms resolve, case manager If to follow via phone for six months to ensure symptoms remain resolved The patient sustained a mild TBI and has symptoms that warrant furtherOutcome #4 comprehensive cognitive evaluation Comprehensive Cognitive Evaluation Comprehensive neurological evaluation to occur prior to comprehensive cognitive evaluationyy Assessment domains:yy ––Attention –– Post-concussive syndrome ––Memory symptom rating ––Processing speed –– screen Pain ––Executive functioning (reasoning, –– Symptom validity test problem solving, organizing, –– Substance abuse screen planning, self-monitoring and –– Measures of effort emotional regulation) ––PTSD screen
  44. 44. Determine the Treatment Plan Upon Completion of the Comprehensive Cognitive Assessment Primary factor contributing to symptoms, e.g., is mild TBI the primary cause of the symptoms yy or is a comorbidity, such as major depression, considered the primary contributor Cognitive deficits associated with diagnosis of mild TBI yy Need for cognitive rehabilitation yy yy of rehabilitation needed Type Short- and long-term goals of rehabilitation yy Interventions Area of Cognitive Impairment Empirically-supported Interventions Attention yy Attention process training yy Working memory training yy Memory yy Various mnemonic techniques yy Visual imagery mnemonics yy Attention yy Memory notebook yy Memory yy External cuing yy Executive functioning yy Executive functioning yy Social communication skills training groups yy Social pragmatics yy Attention yy Problem solving training yy Memory yy yy management training Error Executive functioning yy Emotional regulation training yy Social pragmatics yy Integrated use of individual and group yy interventionsAvailable at: http://www.dcoe.health.mil/ForHealthPros/Resources.aspx 47
  45. 45. 48
  46. 46. DRIVINGFOLLOWING TBI Driving Following TBI
  47. 47. DRIVING FOLLOWING TBI CONFERENCE (2009):SUMMARY OF CLINICAL RECOMMENDATIONSThis fact sheet summarizes the clinical recommendations containedin the Driving Following Traumatic Brain Injury: Summary ofClinical Recommendations report that is a result of the DCoEDriving Evaluations After TBI Conference.``Goal: To ensure that those who have sufficiently recovered from all severities of TBI have the opportunity to safely drive government and privately owned vehicles in accordance with federal and state guidelines``Safe operation of a motor vehicle is a complex task requiring interaction of operational, cognitive and higher executive functions and perceptual abilities`` TBI can disrupt the complex interplay of functions A``Individuals with all severities of TBI may be at risk for developing symptoms that affect fitness to drive`` driving evaluation is a two-step process—Step One: A Driving Screening and Step Two: Driving Assessment`` driving screening should be considered for every individual A with a TBI`` driving screening may be performed by any qualified clinician A who has experience and knowledge to evaluate those domains listed on the next page in Step One: Driving Screening`` comprehensive driving assessment is usually reserved for A patients whose driving screening results raise concerns or based on clinical judgment, is warranted`` comprehensive driving assessment is performed by A clinicians with driver rehabilitation training and education and TBI experienceAvailable at: http://www.dcoe.health.mil/ForHealthPros/Resources.aspx 51
  48. 48. 52Mild TBI Symptoms that may affect Moderate and Severe TBI Symptoms thatDriving (not all-inclusive) may affect Driving (not all-inclusive) Attention/concentration difficultiesyy yy TBI symptoms in addition to Mild Memory difficultiesyy –– Visual impairment Irritabilityyy –– Paresis Challenges with executive functioningyy –– Plegia Reasoning and problem solvingyy –– Post-traumatic seizures –– Organizing, planning and self-monitoring –– Emotional regulationStep One: Driving ScreeningPerformed by any clinician with experience and knowledge to evaluate the following areas: Visual acuityyy Visuospatial skills yy Pain yy Visual fieldsyy Selective and divided yy Coordination yy Visual perceptionyy attention Motor and sensory yy Visual processingyy Executive skills yy function Fatigue yyA comprehensive driving assessment may be considered for those individuals whosedriving screening results raise concerns or is warranted based on clinical judgment.Step Two: Comprehensive Driving AssessmentPerformed by clinician with driver rehabilitation training and education and TBI experience,oftentimes, referred to as a driver rehabilitation specialist Medical and driving historyyy Cognitive yy ––Frequency of driving ––Orientation ––Usual location of driving ––Visual perception ––Driving history pre- and ––Constructional ability post-injury ––Memory ––Self-reported violations/crashes ––Calculation skills ––Verification of valid driver’s license ––Reasoning and judgment ––Visual attention Visionyy ––Visual scanning/search –– Visual fields ––Processing speed –– Visual acuity ––Mental flexibility –– Contrast sensitivity ––Executive functioning –– Depth perception ––Directed attention –– recognition/road knowledge Sign Motoryy ––Complex reaction time Performance yy ––Musculoskeletal screen –– the road On ––Simulation (if available)
  49. 49. What is a driver rehabilitation specialist?A driver rehabilitation specialist is one who plans, develops,coordinates and implements driving services for individuals withdisabilities. Driver rehabilitation specialists are often occupationaltherapists, physical therapists, kinesiotherapists, psychologists anddriver education specialists who undergo additional training indriver rehabilitation. While many driver rehabilitation specialistsmay hold a specific certification or are in the process of obtaining thenecessary education and experience, certification is not required topractice driver rehabilitation.Where are driver rehabilitation specialists located?Several military treatment facilities, hospitals and clinics throughoutthe VA and DoD have driver rehabilitation specialists on staff andmay offer driver rehabilitation services. To determine if your facilityoffers these services or if your patient needs a referral outside of yourfacility, contact your rehabilitation services department.Available at: http://www.dcoe.health.mil/ForHealthPros/Resources.aspx 53
  50. 50. 54
  51. 51. PATIENT EDUCATIONHeadache....................................................... 57Dizziness........................................................ 59Healthy Sleep................................................. 61Mood Changes............................................... 62 .Improving Memory......................................... 63 .Non-Acute Concussion/mild TBI...................... 64Acute Concussion/mild TBI............................. 66 . Patient Education
  52. 52. Provision of TBI education early after diagnosis of mild TBI hasbeen shown to decrease symptom prevalence (Ponsford, 2002). Patient education focused around the natural history of mild TBI recovery that provides recommendations to facilitate sleep hygiene, coping strategies, stress management and avoidance of excessive alcohol and drug use would be most useful. — Updated DoD mTBI Clinical Guidance (2008)Ponsford J, Willmott C, Rothwell A, et al. Impact of early intervention on outcome following mild headinjury in adults. J Neurol Neurosurg Psychiatry 2002: 73(3): 330–332

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