Not all Bells are Meant to be Rung September 29, 2011 Kirk Leininger, MD
Head injuries in the workplace
<ul><li>CDC calls head injury the  “silent epidemic” </li></ul>
TRAUMATIC BRAIN INJURY <ul><li>2 million TBI  </li></ul><ul><li>annually in US </li></ul><ul><li>80% of all TBI are mild (...
ANNUAL INCIDENCE RATES OF  MEDICAL CONDITIONS IN US <ul><li>2 million TBI </li></ul><ul><li>1.5 million heart attacks </li...
Concussion is a Latin word meaning  “collision.” <ul><li>Also called “bell ringer”, “ding”, “mild TBI” </li></ul>
NATURE OF BRAIN INJURY
COUP-CONTRECOUP
OPEN vs CLOSED  BRAIN INJURY <ul><li>Open indicates an object has penetrated the skull, (e.g. bullet, nail) </li></ul><ul>...
VISIBLE BRAIN LESIONS <ul><li>Specific lesion seen on brain imaging is usually associated with a specific neurological def...
CASE STUDY #1 <ul><li>49 year old police officer with gun shot wound to head, while on duty. </li></ul><ul><li>+ loss of c...
OPEN WOUND BRAIN INJURY
CASE STUDY #1 cont. <ul><li>Neurosurgery removed the bullet the same day of injury. </li></ul><ul><li>Medically stabilized...
BULLET WOUND 2 YRS LATER
CLOSED HEAD INJURY MAY CAUSE FRACTURE OR BLEED <ul><li>Epidural hematoma </li></ul><ul><li>Subdural hematoma </li></ul><ul...
SKULL FRACTURE
EPIDURAL HEMATOMA
SUBDURAL HEMATOMA
SUBARACHNOID HEMORRHAGE
INTRACEREBRAL BLEED
DIFFUSE AXONAL INJURY
CONCUSSION
YOU CANNOT SEE A CONCUSSION <ul><li>There is NOT a strong correlation between imaging and physical or cognitive deficits. ...
CONCUSSION <ul><li>Def. - An immediate and transient impairment of neural function, including alteration of consciousness,...
PATHOPHYSIOLOGY OF CONCUSSION <ul><li>- METABOLIC injury more than a structural </li></ul><ul><li>- Release of excitatory ...
 
CONCUSSION CRITERIA <ul><li>Closed head injury or sudden acceleration/deceleration injury </li></ul><ul><li>Glasgow Coma S...
GLASGOW COMA SCALE
CONCUSSION EVAL <ul><li>May not have signs of head trauma </li></ul><ul><li>May not have had LOC </li></ul><ul><li>Imaging...
SYMPTOMS OF CONCUSSION <ul><li>- Headache </li></ul><ul><li>- Nausea </li></ul><ul><li>- Dizzy </li></ul><ul><li>- Feels “...
FREQUENCY OF SYMPTOMS
SIGNS OF CONCUSSION <ul><li>- slow response time (questions/instructions) </li></ul><ul><li>- poor concentration (easily d...
ASSESSMENT OF CONCUSSION <ul><li>- Ask specific questions. Have someone verify the information. </li></ul><ul><li>“ How di...
ASSESSMENT OF CONCUSSION
PREDICTING OUTCOMES AFTER CONCUSSION <ul><li>- First TBI vs. previous TBI  </li></ul><ul><li>- Loss of consciousness vs. A...
PREDICTING OUTCOMES <ul><li>Multiple concussions – each subsequent injury has more severe and longer lasting symptoms. </l...
PREDICTING OUTCOMES <ul><li>Presence of amnesia is a more important predictor of severity and long-term problems than LOC....
PREDICTING OUTCOMES <ul><li>Research with TBI suggest that age <21 or >45 undergo more prolonged and diffuse cerebral swel...
PREDICTING OUTCOMES <ul><li>Premorbid history of depression, ADD, learning disability or substance abuse usually do worse ...
CASE STUDY #2 <ul><li>18 yr old man, crashes motorcycle without a helmet. </li></ul><ul><li>Neighbor witnessed crash, came...
HEAD CT NORMAL
CASE STUDY #2 <ul><li>3 weeks after TBI he graduated from HS with a 4.0 GPA </li></ul><ul><li>2 months later he left on an...
CASE STUDY #2 <ul><li>Patient complains of: </li></ul><ul><ul><li>Difficulty concentrating </li></ul></ul><ul><ul><li>Forg...
CASE STUDY #2 <ul><li>Neuropsych eval showed: </li></ul><ul><ul><li>Severe impairment of auditory attention </li></ul></ul...
CASE STUDY #2 <ul><ul><li>Treatment: </li></ul></ul><ul><ul><li>Speech therapy </li></ul></ul><ul><ul><li>Ritalin 10 mg da...
THE CHALLENGE WITH CONCUSSION <ul><li>Absence of obvious neuro deficit </li></ul><ul><li>Initial period of confusion may r...
 
VULNERABILITY OF BRAIN AFTER INJURY <ul><li>Brain is in a weakened state </li></ul><ul><li>It fatigues more easily during ...
 
SECOND IMPACT SYNDROME <ul><li>- Rapid, massive brain swelling occurs if a second concussion happens while symptomatic fro...
EXPECTED RECOVERY FROM CONCUSSION <ul><li>Benefit from complete rest for 1 st  few days after TBI to promote brain healing...
POST CONCUSSIVE SYNDROME <ul><li>When symptoms  </li></ul><ul><li>of head injury  </li></ul><ul><li>persist, affecting  </...
POST CONCUSSIVE SYMPTOMS <ul><li>- Headache </li></ul><ul><li>- Dizzy </li></ul><ul><li>- Poor memory </li></ul><ul><li>- ...
PCS – 4 AREAS OF INVOLVEMENT <ul><li>Cognitive Symptoms </li></ul><ul><ul><li>Attention, memory, executive function </li><...
COGNITIVE <ul><li>Reduced attention and being easily distracted are common after TBI </li></ul><ul><li>- Goal is to improv...
COGNITIVE <ul><li>Poor short-term memory/forgetful: </li></ul><ul><li>- No way to give back memory </li></ul><ul><li>- Mem...
SOMATIC <ul><li>Headaches  - Caused by:  </li></ul><ul><li>- muscle tension (cranial or cervical) </li></ul><ul><li>- sens...
SOMATIC <ul><li>Headaches </li></ul><ul><li>- Treatment, nonpharmacologic: </li></ul><ul><li>- manual therapy </li></ul><u...
SOMATIC <ul><li>Headaches - Treament, medication: </li></ul><ul><li>- NSAIDs </li></ul><ul><li>- muscle relaxants </li></u...
HEADACHE MEDICATIONS <ul><li>Ibuprofen 600 – 800 mg bid-tid prn HA </li></ul><ul><li>Tizanidine 4 mg tid prn tension HA </...
HEADACHE MEDS CONT. <ul><li>Opioids (hydrocodone or oxycodone) avoid use where possible, limit to 2x/wk for severe headach...
MOOD <ul><li>Irritability, impatience, anger: </li></ul><ul><li>- behavioral strategies </li></ul><ul><li>counseling, rela...
MOOD <ul><li>Depression: </li></ul><ul><li>- SSRI, e.g. citalopram 20-60 mg daily </li></ul><ul><li>- SNRI, e.g. venlafaxi...
SLEEP ALTERATION <ul><li>- Difficulty falling asleep </li></ul><ul><li>- Difficulty staying asleep </li></ul><ul><li>- Too...
SLEEP ALTERATION: Adverse effects <ul><li>- Difficulty concentrating </li></ul><ul><li>- Higher risk of accidents </li></u...
SLEEP ALTERATION: Causes <ul><li>- Brain injury itself </li></ul><ul><li>- Pre-existing sleep disorders </li></ul><ul><li>...
SLEEP ALTERATION: Treatment <ul><li>- Behavioral stratagies </li></ul><ul><ul><li>- Sleep hygiene education </li></ul></ul...
 
RETURN TO WORK/SCHOOL <ul><li>Multidisciplinary approach: </li></ul><ul><li>- speech therapist who is familiar with TBI  f...
RETURN TO WORK/SCHOOL <ul><li>Benefit of a few days of complete rest </li></ul><ul><li>Most brain recovery occurs in 1 st ...
RETURN TO WORK/SCHOOL <ul><li>Attempts at returning to normal activities too quickly can lead to frustration, feeling over...
 
RETURN TO WORK/SCHOOL <ul><li>Lasting problems can occur: </li></ul><ul><li>- memory  </li></ul><ul><li>- complex problem ...
IS POST-CONCUSSIVE SYNDROME REAL? <ul><li>Many physicians and lay people believe that if you can’t see a lesion on brain i...
DTI: Diffusion Tensor Images <ul><li>A diffusion MRI that produces images of brain tissue by following flow of water along...
 
YES, POST CONCUSSION SYNDROME IS REAL <ul><li>Take these patients seriously. </li></ul><ul><li>They can have a successful ...
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Leininger physiatric approach to concussion

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Leininger physiatric approach to concussion

  1. 1. Not all Bells are Meant to be Rung September 29, 2011 Kirk Leininger, MD
  2. 2. Head injuries in the workplace
  3. 3. <ul><li>CDC calls head injury the “silent epidemic” </li></ul>
  4. 4. TRAUMATIC BRAIN INJURY <ul><li>2 million TBI </li></ul><ul><li>annually in US </li></ul><ul><li>80% of all TBI are mild (concussion) </li></ul><ul><li>Cost of treatment in US = $17 billion/yr </li></ul>
  5. 5. ANNUAL INCIDENCE RATES OF MEDICAL CONDITIONS IN US <ul><li>2 million TBI </li></ul><ul><li>1.5 million heart attacks </li></ul><ul><li>800 thousand strokes </li></ul><ul><li>400 thousand deaths from heart attack </li></ul><ul><li>200 thousand new cases of breast cancer </li></ul><ul><li>48 thousand new cases of AIDS </li></ul>
  6. 6. Concussion is a Latin word meaning “collision.” <ul><li>Also called “bell ringer”, “ding”, “mild TBI” </li></ul>
  7. 7. NATURE OF BRAIN INJURY
  8. 8. COUP-CONTRECOUP
  9. 9. OPEN vs CLOSED BRAIN INJURY <ul><li>Open indicates an object has penetrated the skull, (e.g. bullet, nail) </li></ul><ul><li>Closed head injury results from blunt trauma to skull or severe jarring of brain against the inside of the skull from shaking </li></ul>
  10. 10. VISIBLE BRAIN LESIONS <ul><li>Specific lesion seen on brain imaging is usually associated with a specific neurological deficit seen on exam. </li></ul><ul><li>(e.g. Left brain contusion on CT scan in a patient with right hemiplegia and speech difficulty) </li></ul>
  11. 11. CASE STUDY #1 <ul><li>49 year old police officer with gun shot wound to head, while on duty. </li></ul><ul><li>+ loss of consciousness </li></ul><ul><li>Taken to ED by EMS </li></ul>
  12. 12. OPEN WOUND BRAIN INJURY
  13. 13. CASE STUDY #1 cont. <ul><li>Neurosurgery removed the bullet the same day of injury. </li></ul><ul><li>Medically stabilized and sent to inpatient rehab. </li></ul><ul><li>Rapid recovery of physical strength and balance. </li></ul><ul><li>Severe expressive and receptive aphasia, improving with ST. </li></ul>
  14. 14. BULLET WOUND 2 YRS LATER
  15. 15. CLOSED HEAD INJURY MAY CAUSE FRACTURE OR BLEED <ul><li>Epidural hematoma </li></ul><ul><li>Subdural hematoma </li></ul><ul><li>Subarachnoid hemorrhage </li></ul><ul><li>Intracerebral bleed </li></ul><ul><li>Diffuse axonal injury </li></ul>
  16. 16. SKULL FRACTURE
  17. 17. EPIDURAL HEMATOMA
  18. 18. SUBDURAL HEMATOMA
  19. 19. SUBARACHNOID HEMORRHAGE
  20. 20. INTRACEREBRAL BLEED
  21. 21. DIFFUSE AXONAL INJURY
  22. 22. CONCUSSION
  23. 23. YOU CANNOT SEE A CONCUSSION <ul><li>There is NOT a strong correlation between imaging and physical or cognitive deficits. </li></ul>
  24. 24. CONCUSSION <ul><li>Def. - An immediate and transient impairment of neural function, including alteration of consciousness, disturbance of vision and/or other symptoms. </li></ul><ul><li>Simply put – altered mental state after head trauma with or without loss of consciousness. </li></ul>
  25. 25. PATHOPHYSIOLOGY OF CONCUSSION <ul><li>- METABOLIC injury more than a structural </li></ul><ul><li>- Release of excitatory amino acids that induce chemical shifts in the brain </li></ul><ul><li>- Reduced cerebral blood flow </li></ul><ul><li>- Disruption of brain function </li></ul><ul><li>- Nerve cell vulnerability </li></ul><ul><li>Giza and Hovda, 2001 </li></ul>
  26. 27. CONCUSSION CRITERIA <ul><li>Closed head injury or sudden acceleration/deceleration injury </li></ul><ul><li>Glasgow Coma Scale (GCS) score 13-15 within first 24 hours </li></ul><ul><li>Normal brain imaging (CT scan) </li></ul><ul><li>Altered mental status </li></ul>
  27. 28. GLASGOW COMA SCALE
  28. 29. CONCUSSION EVAL <ul><li>May not have signs of head trauma </li></ul><ul><li>May not have had LOC </li></ul><ul><li>Imaging studies are normal (CT brain) </li></ul><ul><li>Look for symptoms and signs of brain injury </li></ul>
  29. 30. SYMPTOMS OF CONCUSSION <ul><li>- Headache </li></ul><ul><li>- Nausea </li></ul><ul><li>- Dizzy </li></ul><ul><li>- Feels “foggy” or slow </li></ul><ul><li>- Blurry or double vision </li></ul><ul><li>- Sensitive to light/noise </li></ul><ul><li>- Fatigue </li></ul>
  30. 31. FREQUENCY OF SYMPTOMS
  31. 32. SIGNS OF CONCUSSION <ul><li>- slow response time (questions/instructions) </li></ul><ul><li>- poor concentration (easily distracted) </li></ul><ul><li>- unsteady on feet (clumsy) </li></ul><ul><li>- disoriented (confused about the situation) </li></ul><ul><li>- personality change (irritable) </li></ul><ul><li>- poor memory (asking questioned recently answered) </li></ul><ul><li>- AMNESIA, retrograde vs. anterograde </li></ul>
  32. 33. ASSESSMENT OF CONCUSSION <ul><li>- Ask specific questions. Have someone verify the information. </li></ul><ul><li>“ How did you get hurt?” </li></ul><ul><li>“ Who helped you when you first got hurt?” </li></ul><ul><li>“ What did you have for lunch today?” </li></ul><ul><li>- Ask the same questions every 5 minutes for 20 minutes to see if they remember. </li></ul>
  33. 34. ASSESSMENT OF CONCUSSION
  34. 35. PREDICTING OUTCOMES AFTER CONCUSSION <ul><li>- First TBI vs. previous TBI </li></ul><ul><li>- Loss of consciousness vs. Amnesia </li></ul><ul><li>- Age </li></ul><ul><li>- Premorbid conditions </li></ul>
  35. 36. PREDICTING OUTCOMES <ul><li>Multiple concussions – each subsequent injury has more severe and longer lasting symptoms. </li></ul><ul><li>Guskiewicz et al, 2003: Iverson et al, 2004 </li></ul>
  36. 37. PREDICTING OUTCOMES <ul><li>Presence of amnesia is a more important predictor of severity and long-term problems than LOC. </li></ul><ul><li>Amnesia on day 3 correlates with long-term deficits. </li></ul><ul><ul><li>Collins et al, 2003; Erlanger et al, 2003 </li></ul></ul>
  37. 38. PREDICTING OUTCOMES <ul><li>Research with TBI suggest that age <21 or >45 undergo more prolonged and diffuse cerebral swelling after TBI and less chance of a good outcome. </li></ul><ul><ul><li>Field et al, 2003 </li></ul></ul>
  38. 39. PREDICTING OUTCOMES <ul><li>Premorbid history of depression, ADD, learning disability or substance abuse usually do worse after traumatic brain injury. </li></ul>
  39. 40. CASE STUDY #2 <ul><li>18 yr old man, crashes motorcycle without a helmet. </li></ul><ul><li>Neighbor witnessed crash, came to scene, where victim was having seizure. </li></ul><ul><li>Upon EMS arrival he is awake, conversing, but very disoriented. </li></ul><ul><li>In ED he was fully oriented. CT brain normal. D/C home. No follow up. </li></ul>
  40. 41. HEAD CT NORMAL
  41. 42. CASE STUDY #2 <ul><li>3 weeks after TBI he graduated from HS with a 4.0 GPA </li></ul><ul><li>2 months later he left on an LDS mission –English speaking </li></ul><ul><li>Post-mission he attended BYU on scholarship </li></ul><ul><li>GPA at end of 1 st year was 1.6 </li></ul>
  42. 43. CASE STUDY #2 <ul><li>Patient complains of: </li></ul><ul><ul><li>Difficulty concentrating </li></ul></ul><ul><ul><li>Forgetful </li></ul></ul><ul><ul><li>Can’t retain any information he studies </li></ul></ul><ul><ul><li>No motivation to do anything </li></ul></ul><ul><ul><li>Sleeps all day </li></ul></ul><ul><ul><li>Admits that he struggled his whole mission </li></ul></ul>
  43. 44. CASE STUDY #2 <ul><li>Neuropsych eval showed: </li></ul><ul><ul><li>Severe impairment of auditory attention </li></ul></ul><ul><ul><li>Severe impairment of visual attention </li></ul></ul><ul><ul><li>Slow processing speed </li></ul></ul><ul><ul><li>Low endurance </li></ul></ul>
  44. 45. CASE STUDY #2 <ul><ul><li>Treatment: </li></ul></ul><ul><ul><li>Speech therapy </li></ul></ul><ul><ul><li>Ritalin 10 mg daily </li></ul></ul><ul><ul><li>Change school to UVU </li></ul></ul><ul><ul><li>Limit class load to 2 classes per term </li></ul></ul><ul><ul><li>Apps in iPhone that help with taking notes in class </li></ul></ul><ul><ul><li>Outcome: Keeping up with school work. </li></ul></ul>
  45. 46. THE CHALLENGE WITH CONCUSSION <ul><li>Absence of obvious neuro deficit </li></ul><ul><li>Initial period of confusion may resolve quickly and patient appears “fine” </li></ul><ul><li>Common for patient to minimize or deny problem </li></ul><ul><li>Patient and family believe everything will be the same as before the accident </li></ul><ul><li>Often no follow up </li></ul>
  46. 48. VULNERABILITY OF BRAIN AFTER INJURY <ul><li>Brain is in a weakened state </li></ul><ul><li>It fatigues more easily during everyday life </li></ul><ul><li>Extra effort required to do formerly routine activity </li></ul><ul><li>Impaired cognitive performance leads to anger, frustration and depression </li></ul>
  47. 50. SECOND IMPACT SYNDROME <ul><li>- Rapid, massive brain swelling occurs if a second concussion happens while symptomatic from the first one </li></ul><ul><li>- Less impact required on 2 nd hit </li></ul><ul><li>- Only found in children/adolescents </li></ul><ul><li>- Intracranial vasodilation </li></ul><ul><li>- Brainstem herniation within 2-5 min </li></ul><ul><li>- Morbidity is 100%, Mortality up to 50% </li></ul><ul><li>Zasler, Katz, Zafonte, Brain Injury Medicine, 2007 </li></ul>
  48. 51. EXPECTED RECOVERY FROM CONCUSSION <ul><li>Benefit from complete rest for 1 st few days after TBI to promote brain healing </li></ul><ul><li>Most recover in 1 st week to 1 month (80%) </li></ul><ul><li>Persistent symptoms at 1 year is reported as 6-15% </li></ul><ul><li>If patients don’t get adequate follow up or get advice about future activity, may develop long-term condition (post concussive syndrome) </li></ul>
  49. 52. POST CONCUSSIVE SYNDROME <ul><li>When symptoms </li></ul><ul><li>of head injury </li></ul><ul><li>persist, affecting </li></ul><ul><li>other aspects </li></ul><ul><li>of life </li></ul>
  50. 53. POST CONCUSSIVE SYMPTOMS <ul><li>- Headache </li></ul><ul><li>- Dizzy </li></ul><ul><li>- Poor memory </li></ul><ul><li>- Limited attention </li></ul><ul><li>- Poor sleep </li></ul><ul><li>- Slow thinking </li></ul><ul><li>- Moody </li></ul><ul><li>- Feeling overwhelmed </li></ul>
  51. 54. PCS – 4 AREAS OF INVOLVEMENT <ul><li>Cognitive Symptoms </li></ul><ul><ul><li>Attention, memory, executive function </li></ul></ul><ul><li>Somatic Symptoms </li></ul><ul><ul><li>Headache, nausea, dizziness </li></ul></ul><ul><li>Mood Disruption </li></ul><ul><ul><li>Irritability, depression, anxiety </li></ul></ul><ul><li>Sleep Alterations </li></ul><ul><ul><li>Too much, too little, general fatigue </li></ul></ul>
  52. 55. COGNITIVE <ul><li>Reduced attention and being easily distracted are common after TBI </li></ul><ul><li>- Goal is to improve alertness and focus </li></ul><ul><li>- Minimize distractions </li></ul><ul><li>- CNS stimulants increase dopamine and norepinephrine in frontal lobe </li></ul><ul><li>- methyphenidate </li></ul><ul><li>- dextroamph/amphetamine </li></ul>
  53. 56. COGNITIVE <ul><li>Poor short-term memory/forgetful: </li></ul><ul><li>- No way to give back memory </li></ul><ul><li>- Memory aids </li></ul><ul><li>Repeat info </li></ul><ul><li>Write things down </li></ul><ul><li>Keep a day planner – written or on phone </li></ul><ul><li>Computer games (lumosity.com) </li></ul><ul><li>Word/number games </li></ul><ul><li>- Meds: donepezil may help </li></ul>
  54. 57. SOMATIC <ul><li>Headaches - Caused by: </li></ul><ul><li>- muscle tension (cranial or cervical) </li></ul><ul><li>- sensitivity of scalp laceration/contusion </li></ul><ul><li>- vascular </li></ul><ul><li>- occipital neuralgia </li></ul><ul><li>- trigeminal neuralgia </li></ul><ul><li>- cognitive fatigue </li></ul><ul><li>- medication rebound </li></ul><ul><li>- TMJ dysfunction </li></ul>
  55. 58. SOMATIC <ul><li>Headaches </li></ul><ul><li>- Treatment, nonpharmacologic: </li></ul><ul><li>- manual therapy </li></ul><ul><li>- stretching/exercise </li></ul><ul><li>- modalities </li></ul><ul><li>- injections </li></ul><ul><li>- acupuncture </li></ul><ul><li>- supplemental oxygen </li></ul>
  56. 59. SOMATIC <ul><li>Headaches - Treament, medication: </li></ul><ul><li>- NSAIDs </li></ul><ul><li>- muscle relaxants </li></ul><ul><li>- antiepilepticts </li></ul><ul><li>- antidepressant – TCA, SSRI, SNRI </li></ul><ul><li>- beta blockers/calcium channel blocker </li></ul><ul><li>- triptans </li></ul><ul><li>- metaclopramide </li></ul><ul><li>- opioids and butalbital </li></ul>
  57. 60. HEADACHE MEDICATIONS <ul><li>Ibuprofen 600 – 800 mg bid-tid prn HA </li></ul><ul><li>Tizanidine 4 mg tid prn tension HA </li></ul><ul><li>Topiramate 25 – 100 mg qhs </li></ul><ul><li>Nortriptyline 10 -150 mg qhs </li></ul><ul><li>Propranolol 20 – 80 mg bid </li></ul><ul><li>Metoclopramide 10 mg q8 hrs, w/an NSAID </li></ul><ul><li>Sumatriptan 25 – 50 mg at onset of headache </li></ul>
  58. 61. HEADACHE MEDS CONT. <ul><li>Opioids (hydrocodone or oxycodone) avoid use where possible, limit to 2x/wk for severe headache </li></ul><ul><li>Butalbital w/aspirin/caffeine, 1-2x/day prn, commonly used. May help with tension HA. </li></ul><ul><li>Tramadol – cautious use, due to lowering seizure threshold in patients with TBI </li></ul>
  59. 62. MOOD <ul><li>Irritability, impatience, anger: </li></ul><ul><li>- behavioral strategies </li></ul><ul><li>counseling, relaxation, limit caffeine </li></ul><ul><li>- meds (avoid benzos – delay recovery of TBI) </li></ul><ul><li>valproic acid 250-500 mg tid </li></ul><ul><li>propranolol 20 -80 mg bid-tid </li></ul><ul><li>nortriptyline 25-150 mg qhs </li></ul><ul><li>quetiapine 25-200 mg qhs-bid </li></ul><ul><li>methylphenidate 5 – 20 mg bid </li></ul>
  60. 63. MOOD <ul><li>Depression: </li></ul><ul><li>- SSRI, e.g. citalopram 20-60 mg daily </li></ul><ul><li>- SNRI, e.g. venlafaxine 75-225 mg daily </li></ul><ul><li>- TCA, e.g. nortriptiline 50-150 mg daily </li></ul><ul><li>- antiepileptic, valproic acid 250-500 tid </li></ul><ul><li>Anxiety: </li></ul><ul><li>- buspirone 7.5 – 15 mg bid </li></ul>
  61. 64. SLEEP ALTERATION <ul><li>- Difficulty falling asleep </li></ul><ul><li>- Difficulty staying asleep </li></ul><ul><li>- Too much sleep </li></ul><ul><li>- Too little sleep </li></ul>
  62. 65. SLEEP ALTERATION: Adverse effects <ul><li>- Difficulty concentrating </li></ul><ul><li>- Higher risk of accidents </li></ul><ul><li>- Decreased quality of life </li></ul><ul><li>- Higher rates of chronic pain </li></ul><ul><li>- Independent risk factor for poor physical and mental health </li></ul><ul><li>Morin et al. Therapeutic options for sleep maintenance and sleep-onset insomnia. Pharmacotherapy. 2007; 21(1):89-110 </li></ul>
  63. 66. SLEEP ALTERATION: Causes <ul><li>- Brain injury itself </li></ul><ul><li>- Pre-existing sleep disorders </li></ul><ul><li>- Pain </li></ul><ul><li>- Pharmacologic effects </li></ul><ul><ul><li>“ energy drinks” </li></ul></ul><ul><ul><li>CNS stimulants </li></ul></ul><ul><li>- Drug withdrawal </li></ul>
  64. 67. SLEEP ALTERATION: Treatment <ul><li>- Behavioral stratagies </li></ul><ul><ul><li>- Sleep hygiene education </li></ul></ul><ul><ul><li>- Relaxation therapies </li></ul></ul><ul><ul><li>- Sleep restriction </li></ul></ul><ul><li>- Pharmacology </li></ul><ul><ul><li>- Trazadone 50-200 mg qhs </li></ul></ul><ul><ul><li>- TCA – nortriptyline 50-150 mg qhs </li></ul></ul><ul><ul><li>- Non-benzodiazepine hypnotics – zolpidem 10 mg qhs </li></ul></ul><ul><ul><li>Morin, et al, 2007. </li></ul></ul>
  65. 69. RETURN TO WORK/SCHOOL <ul><li>Multidisciplinary approach: </li></ul><ul><li>- speech therapist who is familiar with TBI for cognitive rehab </li></ul><ul><li>- OT – community reintegration </li></ul><ul><li>- psychology for coping strategies </li></ul><ul><li>- pharmacology – the brain is a chemical machine </li></ul><ul><li>- vocational rehab for job evaluation/retrain </li></ul><ul><li>- family support </li></ul><ul><li>- RN case manager </li></ul>
  66. 70. RETURN TO WORK/SCHOOL <ul><li>Benefit of a few days of complete rest </li></ul><ul><li>Most brain recovery occurs in 1 st month </li></ul><ul><li>Gradual transition back to work/school </li></ul><ul><li>Reduced work load to start </li></ul><ul><li>Structured environment </li></ul><ul><li>Pacing activities </li></ul><ul><li>Accommodations/accessibility </li></ul><ul><li>Neuropsych eval to determine problem areas </li></ul>
  67. 71. RETURN TO WORK/SCHOOL <ul><li>Attempts at returning to normal activities too quickly can lead to frustration, feeling overwhelmed and depressed </li></ul><ul><li>Research shows 34% still not back to work at 3 months Rimel 1981 </li></ul><ul><li>Reschedule events that may be stressful until able to manage everyday life (moving, taking exams, travel – applies to work and personal life) </li></ul>
  68. 73. RETURN TO WORK/SCHOOL <ul><li>Lasting problems can occur: </li></ul><ul><li>- memory </li></ul><ul><li>- complex problem solving </li></ul><ul><li>- difficulty handling stress </li></ul><ul><li>- feeling overwhelmed </li></ul><ul><li>- social interactions </li></ul><ul><li>More likely to manifest during fatigue or stress </li></ul><ul><li>Important: 1 thing at a time and breaks </li></ul>
  69. 74. IS POST-CONCUSSIVE SYNDROME REAL? <ul><li>Many physicians and lay people believe that if you can’t see a lesion on brain imaging studies, then the patient with persistent symptoms must be malingering. </li></ul>
  70. 75. DTI: Diffusion Tensor Images <ul><li>A diffusion MRI that produces images of brain tissue by following flow of water along functioning axons.    </li></ul><ul><li>The top two images represent normal  corpus callosal water diffusion. </li></ul><ul><li>The bottom two images are following what was classified as a mild TBI.  </li></ul>
  71. 77. YES, POST CONCUSSION SYNDROME IS REAL <ul><li>Take these patients seriously. </li></ul><ul><li>They can have a successful recovery after brain injury with a little insight into their problem. </li></ul>

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