This document discusses traumatic brain injury (TBI) and the difficulties in discharging patients with TBI. It describes the various medical and non-medical treatments available for TBI and examines the newest evidence-based treatments. It also explains that due to shorter hospital stays, there are now multiple layers of post-acute care programs available including home care, day treatment programs, assisted living facilities, and independent living arrangements. However, choosing the appropriate next level of care can be challenging given differences in cost, availability of services, and levels of support across options. Family and medical input, insurance coverage, and individual needs must all be considered.

1. JamesA.Young, M.D.

2.  1. Describe the different medical and non-
medical treatments available to diagnose and
treatTBI
 2. Examine the newest evidence-based
treatments forTBI
 3. Explain the difficulty of discharging
patients withTBI

3.  None

4.  Predictability is fair at best
 Ten stages/patients for one diagnosis
 Limitless personality outcomes
 All organ systems involved
 Late problems
 Physical, mental, and emotional
disabilities
 Most behavioral problems are not the
patient’s fault
 Discharge complications at every level

8.  Occurs every 15 seconds with 500,000 requiring hospitalization
 It is the leading killer and cause of disability in children and young adults
 Motor vehicle crashes are a leading cause of death in the U.S. More than
2.5 million drivers and passengers were treated in emergency
departments as the result of being injured in motor vehicle crashes in
2012.The economic impact is also notable: in a one-year period, the cost
of medical care and productivity losses associated with injuries from
motor vehicle crashes exceeded $80 billion.
http://www.cdc.gov/injury/wisqars, 2010
 An estimated 2.4 million children and adults in the U.S. sustain a
traumatic brain injury (TBI) and another 795,000 individuals sustain an
acquired brain injury (ABI) from non-traumatic causes each year.
 Currently more than 5.3 million children and adults in the U.S. live with
a lifelong disability as a result ofTBI and an estimated 1.1 million have a
disability due to stroke.
 (Statistics courtesy of the Centers for Disease Control and the Stroke Fact
Sheet

10.  Few professionals in Medicine outside of Neurology,
Rehabilitation, Neurosurgery are knowledgeable aboutTBI
 Phases of recovery can be confusing (and permanent)
 Medicines used are frequently off-label and paradoxical
 Cause and effect from the environment plays a key role
 Behavioral and Cognitive issues predominate at all levels of
recovery
 Patients often look better than they are

11.  If a disability exists, all problems are somehow connected
with that disability
 ‘Not in my backyard’
 Basis for knowledge
 Readings
 Internet
 TV medical reporters
 TV and Movies
 Friends
 Sports (‘getting his bell rung’)

12.  Cognitive Difficulties
 Behavioral Difficulties
 Emotional complexities
 If you cannot see it, it doesn’t exist
 Head injury versus Brain injury
 Prior exposure toTBI
 “I (or someone else ) had an injury, and I
have no problems”

13.  Primary Injury
 Direct brain injury
 Acceleration, deceleration, rotational
components
 Shearing forces between tissue planes of different
densities
 Structural damage, disruptions in membrane
stability
 Intra-axonal cytoskeletal function changes
 Axonal transport mechanism change

14.  Secondary
 Changes due to
▪ Changes in cerebral metabolism
▪ Hypoxia
▪ Ischemia

16.  Focal
 Diffuse Axonal Injury
 Hypoxia
 Penetrating

17.  Any location
 Usually anterior and inferior surfaces of
frontal and temporal lobes
 Frequently acceleration/deceleration
 Sagittal plane of injury if after movement
 Occipital areas usually not involved unless a
direct blow

20.  The major type of diffuse traumatic cerebral
injury
 Shearing axotomy
 Lateral and oblique directional movements
 Coma lasts 6 hours or more

22.  Worst prognosis
 Seen with other types ofTBI
 Oxygen sensitive areas include the
hippocampus, basal ganglia and cerebellum
 Seen in about 1/3 of severeTBI
 Arterial hypotension in 15% of severeTBI
(<90mmHg)

24.  Diffuse perivascular damage and focal
disruption
 No axonal injury
 Diffusion of energy and formation of a cavity
which opens a and closes in milliseconds
 Changes in intracranial pressure

25.  Coma
 Acute
 Post-Acute
 Community

26.  No specific treatment or medicine shown effective
 On going monitoring to prevent primary and
secondary changes
 Many with normal BAER’s, with changes in heart
rate, ICP with auditory stimulation
 Talking to comatose patients
 Not time consuming and humane
 Not doing, may promote inappropriate care
 Those awakening from coma-comments

27.  Intermediate and developing medical and surgical
concerns
 Behavioral and medicine adjustments
 Ward/Rehab treatment goals
 PhysicalTherapy
 OccupationalTherapy
 Speech and language pathology
 Psychology
 Family Education
 Some Recreational and Cognitive remediation

28.  Rehabilitation treatment goals
 Independent living skills
 Cognitive therapies
 Recreational therapies
 Community skills
 Family education
 Behavioral and medicine adjustments

29.  Rehabilitation treatment goals
 Community independence
 Vocational services
 Cognitive retraining
 Transportation independence
 Behavioral and medicine adjustments
 Social reintegration
 Respite care

30.  Each level of injury and recovery has its own
idiosyncrasies and needs
 Tremendous variation in treatment styles and
approaches
 Important to differentiate PTSD from brain
injury
 Exaggeration and malingering are rare but
easier and easier to detect
 Lifetime disabilities.
 The majority of disabilities after brain injury are
cognitive and behavioral, not physical

31.  Vegetative versus minimally conscious
 Voluntary versus involuntary activity
 Role of psychiatry and neuropsychology
 Dependency issues and residential concerns
 Power of attorney
 Conclusive proof of injury
 Legal implications

32.  The goal is to systematically identify qualitative
and quantitative predictors of functional
outcome
 Although not the majority of injury, most
mapping studies look at the sensory and motor
regions
 Cognitive, behavioral, and language skills are
less precise in the their localization and more
diffusely distributed to various parts of the brain
 Structural and functional relationships are more
difficult to identify

33.  Which determines a “lesion” depends on the
imaging technique
 Most injuries are not seen with today’s
instruments
 Combining different techniques has potential
 The neuropsychological evaluation, history,
and those close to the patient are usually the
most helpful to corroborate story

34.  Glasgow Coma Scale with PostTraumatic
Amnesia Scale and the Disability Rating Scale
probably the most sensitive combination
 CTs performed commonly in the emergency
room grossly underestimates the injury
 MRIs correlate reasonably well with
neuropsychological evaluations.
 PET scans one third more sensitive than MRIs
 Brainstem lesions very predictive of a negative
outcome

35.  DiffusionTensor Imaging
 Detecting diffusion of water molecules in the tissue
 Software using using magnetic resonance imaging
 Tractography (an extension of DTI)
▪ Directional pattern of diffusion with colors representing
direction of white matter connectivitiy
▪ Green is anterior posterior
▪ Red represents left and right
▪ Blue represents head to foot or dorsal–ventral
 Potential for mild and moderate traumatic brain
injury, along with other disorders

38.  Unlimited causes for behavioral disturbances
 At all levels, behavioral concerns more disabling
than physical ones
 Difficulty predicting behaviors
 Right and left sided syndromes
 Frontal lobe syndromes rarely specific
 Neuroanatomy and psychology partly help
 Cortical/subcortical connections

39.  Agitation
 Anxiety
 Childishness
 Limited self-aware.
 Facetiousness
 Impatience
 Lability
 Phobias
 Social inappropriate
 Aggressiveness
 Apathy
 Denial
 Disinhibition
 Helplessness/Depen.
 Impulsivity
 Misperceptions
 Restless
 Suspicious
 Anger
 Depression
 Euphoria
 Indifference
 Paranoid
 Sexual interests
 Withdrawal

40.  Late neurological
sequelae
 Pain syndromes
 Iatrogenic (meds)
 Sleep/wake cycles
 Depression
 Situational conflicts
 Recurrent head injury
 Secondary medical
problems
 Vestibular dysfunctions
 Drug/Alcohol abuse
 Pre-morbid psycho
problems
 Learned maladaptive
behavior

41.  No test can accurately depict the mental
state at a specific past action or crime, only
provide the substrate that may have
contributed
 Present studies involve simple tasks and are
done in isolation and in sterile, stress-free
environments. Study numbers are also small
 It is likely that the neurosciences will
supplement not replace moral and legal
domains (Baskin, 2007)

42.  With the PPS system, and the growth of managed care, there has been a
steady outflow of the acute inpatient population and growth of the
outpatient, residential, subacute levels of care
 Continuation for inpatient care has changed because of
 High costs
 Few long-term effectiveness studies
 Few standards of performance among similar providers
 Industry influenced by negative press
 Few models of care and service

43.  Other factors
 Lack of education by the consumers in interpreting
marketing and advertising material
 Not knowing what to ask
 Limited sources of information for social workers, even
treaters
 Dependence on word of mouth
 Use of Internet to observe legal entanglements by
facilities

44.  Opinions of the primary treaters on present needs
▪ Medical stability
▪ Cognitive concerns
▪ Behavioral problems
▪ Anticipated problems requiring close follow-up care or emergency
attention
▪ Botox
▪ Baclofen fills
▪ Frequent adjustments of meds
▪ Seizures
▪ Specialty follow up

45.  Family concerns
 Distances
 Visits
 Personal involvement
 Sleeping arrangements
 Transportation
 Conferencing
 Staffing numbers
 Gyms, smells, roommates
 Restraint use, medications employed commonly
 Types of patients (numbers treated of each category)

46.  Financial concerns
 Type of insurance dictates much
▪ Services
▪ Duration
▪ After skilled services (i.e. after PT monies are used)
▪ Next level of care
▪ Follow-up visits
▪ Emergency visits or hospitalizations
▪ Surgical options
▪ ‘Experimental’ trials (ITB pumps)

47.  Usually with 3x a week of
▪ SP, PT, OT
 Nursing frequency depends on the needs
 Advantages
▪ Familiarity of surroundings
▪ Orientation assistance for many
▪ Own bed
▪ RehabWithoutWalls
▪ Local services or hospitals
▪ Insurance frequently covers

48.  Disadvantages
▪ Frequency of therapeutic visits
▪ Duration of visits
▪ Disruption of family life
▪ Dependency on family/caregiver to be around
▪ Experience of the caregivers, therapists withTBI
▪ Behavioral correction
▪ Supervision of therapists/nurses

49.  Advantages
▪ Level of medical acuity can be higher
▪ Insurance coverage
▪ Therapeutic coverage frequently adequate but
with 0.6-2.2 hours per day
▪ Rehabilitative milieu
▪ 24 hour care

50.  Disadvantages
▪ Nursing ratios can be as high as 14:1 for CNA:RN
▪ Number of beds per room
▪ Mixing of populations and ages
▪ Experience of facility forTBI
▪ May not accept patients with any behavioral problems
▪ Frequency of medical visits
▪ Interaction with a non-treater can be problematic
▪ Follow-up in the specialist’s office
▪ Programmatic limitations (possible)

51.  Advantages
▪ Less acute dollars spent due to earlier discharge
▪ Picks the patient up from home
▪ Allows the family ‘down time’
▪ Intensity of services
▪ 3-6 hours per day with routine set
▪ Frequently involves all services
▪ Nursing services usually available
▪ Can be daily, not on weekends
▪ Possibilities of therapeutic outings
▪ Facilities usually specialize

52.  Disadvantages
▪ Cost
▪ Sites may not be close and the ride to the facility long
▪ Duration of services over time
▪ Numbers involved in the program
▪ May be too strenuous
▪ Milieu is reduced or minimized
▪ Privacy considerations

53.  Advantages
▪ 24 hour care
▪ Personal choices
▪ Room decor
▪ Roommate or not
▪ Home like
▪ Longer stays
▪ Focused on certain diagnoses
▪ Community events
▪ Outings
▪ Shopping
▪ Consistent orientation in facility

54.  Advantages
▪ Seven day a week structure (or not)
▪ Variable supervision
▪ Variable sizes of the house, apartment
▪ Vocational training
▪ Taking public transportation
▪ Socialization opportunities

55.  Disadvantages
▪ Cost
▪ Availability
▪ Openings in the facility
▪ Paucity of programs
▪ Distance
▪ Medical acuity issues
▪ Appointments

56.  Due to shorter lengths of stay in the acute
rehab setting, multiple layers of post-acute
programs are now available
 Significant differences regarding
 Cost
 Availability
 Support and professional help

57.  Prior to considering any of the options
 Visit the facilities
 Ask the treaters
 MSW
 Insurance agents
 Research
▪ Brain Injury Association
▪ CARF
 Family groups have significant data
 A true understanding which level of care is best for what type of
injury, at what point in the injury, and service outcomes is yet
unknown