I. Intro, overview, and etiology (EBIG 1 & 4) 13%

Question 1

What is an acquired brain injury?

Answer 1

An injury to the brain that is not hereditary, congenital, degenerative, or induced by birth trauma

Question 2

What is a TBI?

Answer 2

An alteration in brain function, or other evidence of brain pathology, caused by an external force

Question 3

What are the characteristics of a mild TBI?

Answer 3

Can have either brief or no loss of consciousness and its presentation may demonstrate vomiting, lethargy, dizziness, and inability to recall what just happened

normal structural imaging

LOC=0-30 minutes

AOC=from a moment up to 24 hours

PTA=0-1 day

GCS=13-15

Question 4

What are the characteristics of a moderate TBI?

Answer 4

Normal or abnormal structural imaging

LOC >30 minutes and <24 hours

PTA >1 day and <7 days

GCS=9-12

Question 5

What are the characteristics of a severe TBI?

Answer 5

Normal or abnormal structural imaging

LOC>24 hours

PTA>7 days

GCS=3-8

Question 6

what is the Incidence of TBI

Answer 6

2.5 million people sustained a TBI. TBI is a contributing factor to 1/3 of all injury related deaths in the US.

Question 7

What percentage of TBIs are concussions/mild TBIs?

Answer 7

~75%

Question 8

Of the 2.5 million new TBIs per year, how many of them result in deaths, hospitalizations, and ED visits?

Answer 8

2% deaths (53,000)

11% hospitalizations (284,000)

87% ED visits (2, 214, 000)

TBIs annually receiving no other care or no medical care at all is unknown

Question 9

What is the prevalence of ABI?

Answer 9

2nd most prevalent disability in the US

estimated at 13.5 million americans

4.5% of the U.S. population

Question 10

What chronic conditions can be caused or accelerated by TBI?

Answer 10

epilepsy

alzheimers disease

CTE

neuro-endocrine disorders

incontinence

psychiatric disease

sexual dysfunction

musculoskeletal dysfunction

skeletal dsyfunction

Question 11

Describe epilepsy in relation to TBI?

Answer 11

cause of 5% of all epilepsy in the general population

Leading cause of epilepsy in adults.

TBI survivors are 1.5-17x more likely (depending on the severity of the injury) than the general population to develop seizures

Question 12

Describe alzheimer’s disease in relation to TBI

Answer 12

History of head injury more than doubled the risk of AD

as well as the chances of developing non-alzheimer’s dementia

the worse the head injury, the increased likelihood of dementia/AD

Question 13

Describe neuro-endocrine disorders in relation to TBI

Answer 13

dysfunction of the pituitary gland—in the chronic phase of TBI:27.5% across all levels of injury severity

growth hormone deficiency/insufficiency found in ~20% of mod-severe TBIs

Low thyroid function found in ~5% of people with TBI

Gonadotropin deficiency found in 10-15% of TBIs

Question 14

Describe incontinence in relation to TBI

Answer 14

may result in neurogenic bladder which can result in frequent UTIs and decubitus ulcers

may also result in fecal incontinence

Question 15

Describe psychiatric disease in relation to TBI

Answer 15

One of the most disabling consequences of TBI

many people with a mild TBI and overwhelming majority of mod-severe TBIs are left with significant long term neurobehavioral sequelae—may develop OCD, anxiety, psychotic disorders, mood disorders, and major depression

Question 16

Describe sexual dysfunction in r/t TBI

Answer 16

40-60% of people have complaints of sexual dysfunction s/p TBI

Question 17

Describe Musculoskeletal dysfunction in r/t TBI

Answer 17

spasticity can cause limitations in mobility and ADLs

requires life-long treatment and if left untreated can lead to muscle contractures, tissue breakdown, and skin ulceration

Question 18

What are standards for rehabilitation facilities?

Answer 18

services delivered for people with ABI are regulated by federal or state agencies, are licensed, and/or are accredited.

Question 19

What are benefits of accreditation?

Answer 19

person centered care

robust performance measurement, management, and improvement system that focuses on continuous improvement of clinical and business practice

delivery of quality services by competent and well-trained personnel, and accountability t persons served, payers, and regulators

Question 20

What are the accreditors of choice/gold standards?

Answer 20

Accreditation is typically voluntary, but some payers mandate accreditation for reimbursement

For hospitals, home care, or nursing care centers—Joint Commission accreditation is the gold standard

For brain injury rehab programs—CARF is the accreditor of choice

Question 21

What are the ramifications of the olmstead decision?

Answer 21

Has gradually challenged federal, state, and local governments to develop more opportunities for persons with disabilities to be served through cost-effective community-based services

The decision has resulted in several federal and state initiatives that will make living in the community a reality for more persons with disabilities

Question 22

What is the definition of mTBI?

Answer 22

traumatically indued physiologic disruption of brain function as manifested by at least one of the following: any period of LOC, any loss of memory for events immediately before/after injury, any Alteration in mental state (e.g., dazed, confused, uncertain with answering basic questions, etc).

Focal neurologic deficit that may or may not be transient but where the severity does not exceed the following: LOC of 30 minutes or less, an initial GCS of 13-15

PTA no greater than 24 hours

Normal CT/MRI—abnormal imaging = moderate to severe injury

most symptoms resolve within 2-4 weeks (85-90%) ; 10-15% of people experience persistent problems after that point

Question 23

what is the incidence of mTBI?

Answer 23

mTBI=75% of all TBIs that occur in the US which is 1.1 million people incurring mTBIs per year

true incidence however, is believe to be higher, given that 16-25% of those with mTBIs don’t seek medical treatment

Question 24

what are physical symptoms of mTBI?

Answer 24

Physical: headache, fatigue, seizure, nausea, numbness, poor sleep, light sensitivity, noise sensitivity, impaired hearing, blurred vision, dizziness/loss of balance, neurologic abnormalities

Question 25

What are cognitive symptoms of mTBI?

Answer 25

inattentiveness, diminished concentration, poor memory, impaired judgment, slowed processing speed, executive dysfunction

Question 26

What are behavioral/emotional symptoms of mTBI?

Answer 26

depression, anxiety, agitation, irritability, aggression, impulsivity

Question 27

What is PPCS?

Answer 27

persistence post concussion symptoms (AKA PCS)

Question 28

What is the incidence of PPCS?

Answer 28

10-15% of those who’ve sustained a concussion have a slow or incomplete resolution

Question 29

what are risk factors for PPCS?

Answer 29

pending litigation

over 40

hx of substance misuse

low SES

Traumatic injury

female

previous psych history

Question 30

Describe CTE

Answer 30

Typically sport-related caused by multiple concussions—seen in boxers, football players

Chronic Traumatic encephalopathy—aka dementia pugilistic

DAI causes release of Tau proteins-these pathologic proteins are changed structurally by the metabolic breakdown of cells following trauma and create a chronic inflammatory state leading to progressive
degeneration/dementia

Begins very slowly with deterioration in concentration, attention, memory, judgement, and insight, occasionally accompanied by dizziness and headaches

symptoms include apathy, impulsivity, suicidal thoughts

Severe cases of CTE show symptoms of Parkinsonism including disturbed coordination, slowed gait, slurred speech, masked facies, difficulty swallowing, and tremors

no way to predict which athlete will get CTE—best treatment is prevention