Families of veterans with traumatic brain injury in Australia and the United States: Implications for rehabilitation counselors

Defense and Veterans Brain Injury Center: The First 25 Years

To investigate associations of lifetime history of traumatic brain injury (TBI) with prescription opioid use and misuse among noninstitutionalized adults. Ohio Behavioral Risk Factor Surveillance System (BRFSS) participants in the 2018 cohort who completed the prescription opioid and lifetime history of TBI modules (n = 3448). Secondary analyses of a statewide population-based cross-sectional survey. Self-report of a lifetime history of TBI using an adaptation of the Ohio State University TBI-Identification Method. Self-report of past year: (1) prescription pain medication use (ie, prescription opioid use); and (2) prescription opioid misuse, defined as using opioids more frequently or in higher doses than prescribed and/or using a prescription opioid not prescribed to the respondent. In total, 22.8% of adults in the sample screened positive for a lifetime history of TBI. A quarter (25.5%) reported past year prescription opioid use, and 3.1% met criteria for prescription opioid misuse. A lifetime history of TBI was associated with increased odds of both past year prescription opioid use (adjusted odds ratio [AOR] = 1.52; 95% CI, 1.27-1.83; P < .01) and prescription opioid misuse (AOR = 1.65; 95% CI, 1.08-2.52; P < .05), controlling for sex, age, race/ethnicity, and marital status. Results from this study support the "perfect storm" hypothesis-that persons with a history of TBI are at an increased risk for exposure to prescription opioids and advancing to prescription opioid misuse compared with those without a history of TBI. Routine screening for a lifetime history of TBI may help target efforts to prevent opioid misuse among adults.

Employment Interventions for Return to Work in Working Aged Adults Following Traumatic Brain Injury (TBI): A Systematic Review

ABSTRACTObjectives: Describe State-of-the-Art in practice and research in caregiving with individuals, specifically, Veterans with traumatic brain injury (TBI) and the implications for current practice and future research. Sources: Professional literature and personal experience of review panel.Main Outcomes: Unpaid caregiving for individuals with TBI is most often provided by a spouse, parent or other blood relative; the majority of caregivers are women. Although caregiving can be rewarding, it also may create financial burden and psychological stress. Depression among family caregivers occurs four times more frequently than in the general population. Positive coping can help reduce the impact of stress, and Department of Veterans Affairs (VA) programmes are available to ease financial burden. Group interventions show promise in reinforcing and improving positive coping for both family caregivers and Veterans with TBI.Conclusions: Identifying the specific needs of caregivers and families of Veterans with TBI and other traumatic injuries, including post-traumatic stress syndrome (PTSD), will require further longitudinal research. Currently available group interventions and programmes appear to benefit injured Veterans and their family caregivers financially and psychologically. Increased understanding of characteristics of quality family caregiving and its long term costs and benefits is likely to lead to additional improvements in these interventions and programmes.

Discourse Analyses: Characterizing Cognitive-Communication Disorders Following TBI

Military and Veteran Families and Children: Policies and Programs for Health Maintenance and Positive Development and commentaries

An epidemiologic profile of traumatic brain injury (TBI) in Australia and New Zealand was obtained following the publication of international evidence-based guidelines. Adult patients with TBI admitted to the intensive care units (ICU) of major trauma centers were studied in a 6-month prospective inception cohort study. Data including mechanisms of injury, prehospital interventions, secondary insults, operative and intensive care management, and outcome assessments 12-months postinjury were collected. There were 635 patients recruited from 16 centers. The mean (+/-SD) age was 41.6 years +/- 19.6 years; 74.2% were men; 61.4% were due to vehicular trauma, 24.9% were falls in elderly patients, and 57.2% had severe TBI (Glasgow Coma Scale score </=8). Secondary brain insults were recorded in 28.5% and 34.8% underwent neurosurgical procedures before ICU admission. There was concordance with TBI and ICU practice guidelines, although intracranial pressure monitoring was used in 44.5% patients with severe TBI. Twelve-month mortality was 26.9% in all patients and 35.1% in patients with severe TBI. Favorable outcomes at 12 months were recorded in 58.8% of all patients and in 48.5% of patients with severe TBI. In Australia and New Zealand, mortality and favorable neurologic outcomes after TBI were similar to published data before the advent of evidence-based guidelines. A high incidence of prehospital secondary brain insults and an ageing population may have contributed to these outcomes. Strategies to improve outcomes from TBI should be directed at preventive public health strategies and interventions to minimize secondary brain injuries in the prehospital period.

Neuropsychiatric Complications of Traumatic Brain Injury: A Critical Review of the Literature (A Report by the ANPA Committee on Research)

Using Telehealth to Treat Combat-Related Traumatic Brain Injury

The Neuroendocrine Effects of Traumatic Brain Injury

Neuroendocrine dysfunction after traumatic brain injury (TBI) is under-diagnosed, under-treated, and may adversely affect the rate of recovery. Single or multiple pituitary-target hormone disruption occurs in up to two-thirds of persons with TBI, most commonly affecting the gonadal and growth hormone axes. The time course of decline in and recovery of pituitary function in relation to cognitive dysfunction and rehabilitation progress are not well described. This article reviews the clinical spectrum of neuroendocrine deficits after TBI and their underlying mechanisms. Future studies of the effects of hormonal replacement on recovery are recommended.

Risk of pre-existing hyponatremia and mortality in patients with traumatic brain injury across age groups

The Public Health Approach to TBI.

Preface

You have accessThe ASHA LeaderFeature1 Dec 2002Traumatic Brain InjuryA Primer for Professionals Kathleen M. Youse, Karen N. Le, Michael S. Cannizzaro and Carl A. Coelho Kathleen M. Youse Google Scholar More articles by this author , Karen N. Le Google Scholar More articles by this author , Michael S. Cannizzaro Google Scholar More articles by this author and Carl A. Coelho Google Scholar More articles by this author https://doi.org/10.1044/leader.FTR1.07122002.4 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In First, the eye-opening demographics: In the United States, nearly 1.5 million individuals suffer traumatic brain injury (TBI) each year, 13,000 children receive services for TBI in the public schools, and it is estimated that nearly 5.3 million people live with TBI-related disabilities. Adolescents and young adults age 15–24 have the highest incidence of TBI, typically associated with motor vehicle accidents. Older adults over the age of 65 and children under the age of 5 have the next highest incidence of TBI, most commonly resulting from falls. Males are nearly twice as likely to experience a TBI than females, and individuals with TBI are three times more likely to incur a subsequent TBI. The financial consequences of TBI are staggering. It is estimated that over $48 billion is spent in the United States alone on acute medical and rehabilitation services each year for the treatment of TBI. For acute care, the average length of stay is 22 days, and the average cost is $98,000 per patient. For inpatient rehabilitation, the average length of stay is 32 days, and the average cost is $43,000 per patient. Definitions TBI may be thought of as a subset Definition of Mild Traumatic Brain Injury Trauma-induced physiological disruption of brain function as evidenced by at least one of the following: a period of loss of consciousness not greater than 30 minutes GCS score of at least 13 by 30 minutes following injury loss of memory for events before or after injury (PTA less than 24 hours) any alteration in mental state focal neurological deficits that may or may not be transient if standard radiological studies (e.g., CT scan or MRI) are done, they must be interpreted as normal From the Mild Traumatic Brain Injury Committee of the American Congress of Rehabilitation of acquired brain injury (ABI) and, although some individuals advocate for the use of the more generic term ABI, for the purposes of this article, the more specific term TBI will be used. TBI results from a variety of etiologic factors including motor vehicle accidents, falls, gunshot wounds, or other trauma involving a blow to the head. The extent of brain trauma following TBI is determined by a combination of primary damage ranging from large to microscopic brain lesions caused by impact to the head, and secondary damage resulting from such factors as infection, oxygen deprivation, brain swelling, and elevated intracranial pressure. TBI is classified into two broad categories: open (penetrating) and closed (non-penetrating), depending on whether or not the meninges remain intact. Open head injuries result when the scalp, skull, and meninges are penetrated, as in a gunshot wound. Primary damage associated with closed head injuries are the result of mechanical forces involving direct contact and inertia. The point of impact is referred to as “coup,” whereas the damage to a brain site opposite that of the point of impact is “contrecoup.” Forces of impact cause the brain to bounce around the rough, somewhat jagged inner surfaces of the skull, resulting in contusions and bruising. The inertial forces involved in closed head injuries are similar to whiplash injuries in which there is rapid acceleration and deceleration. Such rapid twisting movements strain delicate blood vessels and nerve fibers and lead to stretching, shearing, and tearing of these structures. This type of injury is referred to as diffuse axonal injury. There are a variety of indices of TBI severity. Some of the more commonly applied measures are the Glascow Coma Scale (GCS), duration of coma, and length of post-traumatic amnesia (see “Severity” sidebar on page 6). The GCS assesses severity of injury by rating the degree of eye opening, the best verbal response, and the best motor response. Coma is a prolonged period of unconsciousness, and in most instances a longer duration of coma is associated with greater severity at injury. Post-traumatic amnesia (PTA) refers to the length of time during which memories aren’t stored and thus new learning cannot occur. No two injuries are the same; consequently, TBI results in a diverse, idiosyncratic constellation of cognitive-communicative, physical, and psychosocial deficits. The most common sequela of TBI is a reduced capacity to pursue premorbid interests and daily activities at the same functional level. Such difficulties exist along a broad continuum that can range from needing additional time to complete tasks to near total dependence on others for all basic needs. It has been estimated that approximately 75% of all cases of TBI can be characterized as mild (see sidebar above for definition). The most characteristic features of TBI are the resulting cognitive disturbances that are often present after the injury. Multiple areas may be disrupted, including attention, memory, organization, reasoning, executive functioning, communication, and social skills. Recovery following TBI progresses through a series of predictable stages (see sidebar above). However, it is important to emphasize that recovery is specific to individual circumstances and therefore may vary in both extent and rate. Pre-injury abilities, personality of the individual, and severity of the injury all influence recovery. Evidence-Based Practice Guidelines Recently, a national trend of referencing research evidence to support clinical decision making for the management of medical conditions has surfaced. Consistent with this movement, the Academy of Neurologic Communication Disorders and Sciences—in conjunction with ASHA’s Special Interest Division 2, Neurophysiology and Neurogenic Speech and Language Disorders—established committees of experts to develop evidence-based practice guidelines (EBPGs). The guidelines cover the management of dysarthria, aphasia, dementia, apraxia of speech, and cognitive-communication disorders following traumatic brain injury. The committee developing the EBPGs for TBI identified several assumptions about the nature and management of cognitive-communication disorders following TBI (see sidebar on page 7). In addition, the committee delineated five modules for organizing the research evidence, including remediation of attention, memory, social skills, and metacognition/executive function, as well as assessment tools and procedures. Technical reports on EBPGs for each module will be compiled. To date the EBPG-TBI committee has submitted two reports that will be published in the Journal of Medical Speech-Language Pathology. A few reports from other EBPG committees have already appeared in that journal. Family Involvement Family involvement is important in all stages of recovery and rehabilitation. In the early stages of care, the family should be encouraged to participate in the development of the treatment plan with the rehabilitation team. The family may be instructed to assist with specific treatment activities and to promote carryover. Family education is an ongoing process with the primary goal of developing the skills necessary to assist the individual with TBI at home and in the community. The rehabilitation team also assists the family in planning for the future and becoming an advocate for the individua l with TBI. Caring for a person with a TBI can be an overwhelming responsibility. Many families and caregivers are unaware of the medical, financial, or social implications of brain injury and are uncertain how or where to find information. Although there are many sources that can be consulted, the Internet is often a good place to start. Many Web sites offer links to specific information regarding regional and local resources that may provide answers to questions families may not think to ask. Culturally and Linguistically Diverse Populations TBI occurs in all culturally and linguistically diverse populations. Cultural competence is integral to serving these populations. Cultural competence is the consonant set of behaviors, attitudes, and policies within an individual or organization that allows that person or group to interact effectively with individuals from different cultural backgrounds. The ability to function adeptly and actively in cross-cultural contexts is critical to delivering meaningful services to culturally and linguistically diverse populations. Clinicians must evaluate the individual’s cultural and linguistic context, selecting and implementing TBI assessments and intervention programs that are culturally relevant and meaningful. It is equally important for clinicians to understand how the cultural and linguistic background of individuals with TBI influences their feelings about health and health care. Clinicians also need to examine their own biases and value system and be aware of how their beliefs influence interactions with individuals with TBI. By identifying and addressing the cultural and linguistic factors that may hinder or foster intervention, clinicians can increase the chances for the success of services (see sidebar above). Through cultural competence, clinicians can provide better care for individuals with TBI from unique cultural backgrounds, laying the foundations for better outcomes. School Re-Entry Many children with TBI return to school and often experience difficulty learning new information, understanding abstract material, learning in the presence of distractions, and organizing information. In addition, their impaired social and pragmatic skills affect relationships with peers, teachers, and family members. Transitional planning must carefully address these issues to promote the student’s academic success, which will determine future social and vocational competency. Successful re-entry to school involves collaboration among the student, the parents, and staff from the school and medical facility in developing and conducting assessment and intervention procedures. Ongoing, authentic assessments of students with TBI are critical to providing effective intervention. The nature of the SLP’s intervention in the educational setting depends on the learning needs of the student. For students with less severe injuries, the clinician may provide services through consultation and offering instructional strategies to family members, classroom teachers, and support staff. A pullout or classroom-based program may be appropriate for students with more intensive cognitive-communicative needs. Along with the remediation of other cognitive abilities, effective intervention must address communication and social skills, necessitating the participation of family, peers, and teachers in functional situations. Community Reintegration Returning to the community following a TBI can be challenging. The literature emphasizes that persistent cognitive impairments frequently impede successful community reintegration. Even those individuals who make significant gains in rehabilitation may experience difficulty when returning to premorbid activities. Community reintegration should emphasize a multidisciplinary approach, which also includes peers and family, in the attempt to close the gap between treatment activities and functional competence in the individual’s natural environment. The primary focus of community reintegration should be on what the individual with TBI needs to achieve for returning to work, school, and avocational interests (see sidebar above). Ongoing assessment of progress and modification of goals is critical to the success of any community reintegration program. Strategies for Community Reintegration Community/Family Environment Assess family’s ability to facilitate cognitive remediation in the home Provide clear demonstrations and multiple opportunities for the individual with TBI and family to practice new skills Increase opportunities for socialization and recreation to reestablish social networks Allow the individual with TBI to systematically assume greater responsibility for planning and completing activities Work Environment Conduct assessment in the actual place of employment Evaluate social and physical obstacles Use a job coach to facilitate success on the job Integrate adaptation and compensatory strategies Working With Culturally and Linguistically Diverse Groups Identify the cultural and linguistic background of the individual with TBI Learn about the culture, beliefs, and values of the individual with TBI and how these affect attitudes toward injury and management of health Use culturally relevant and meaningful assessment and intervention tools. Seek thoughts and feelings of family members and involve them in clinical decision-making and intervention process Create and distribute culturally appropriate materials to promote awareness of TBI and available resources in the community Use interpreters and translators with appropriate training Conduct ongoing advocacy and outreach on TBI through community/cultural centers Conduct cultural competence assessment Managing Cognitive-Communication Disorders Following TBI Management of cognitive-communication disorders is an integral part of SLPs’ scope of practice. SLPs are uniquely trained to manage these disorders with clinical knowledge in the interaction between cognition and communication. Managing cognitive-communication disorders is an interdisciplinary endeavor. Cognitive-communication intervention does not include communication intervention for aphasia or motor-speech disorders following TBI. There are many approaches to cognitive-communication intervention—behavioral approaches, skill training, process-specific approaches, and multi-modal approaches. Numerous service delivery models exist—in-patient medical rehabilitation, long-term care, outpatient care, job coaching, school-based services, day-treatment, transitional living programs, or individual and group therapy. Improvements in impairments may or may not facilitate a change in an individual’s activity or participation level and vice versa. The ultimate goal of cognitive-communication intervention is to achieve the highest level of communicative participation in everyday living. TBI Prevention Motor Vehicles Using a seatbelt in combination with an airbag reduces the risk of head injury by 81%, compared to 60% for seatbelts alone Children should ride in age and size appropriate car seats; learn to use car seats properly (www.safekids.org) Children under the age of 12 years should never ride in the front seat of a car equipped with an airbag Never drink and drive—41% of individuals with TBI test positive for alcohol at time of injury Bicycles Always wear a helmet, even on short rides Wearing reflective clothing allows riders to be seen at dusk or at night Bicycles should have a headlight and reflectors Children should ride on sidewalks or paths until they are at least 10 years old or show the ability to follow basic rules of the road Motorcycles Wearing a motorcycle helmet reduces the risk of a brain injury by 67% Obey speed limits—40% of motorcyclists who die in crashes are speeding Turn headlight on every time you ride Don’t carry passengers until you are skilled at driving in all kinds of conditions Take a motorcycle safety course—call 800-446-9227 Playground Safety Supervise children at all times Children should always play on equipment that is age appropriate Choose playgrounds with soft under-surfaces that will cushion a fall Make sure there is fencing between the playground and the street Check playground equipment to be certain it is in good repair Preventing Falls Among Older Adults Begin an exercise program to increase strength and balance Use non-slip mats in the bathtub and on shower floors Remove things that can be easily tripped over Improve lighting in the home Wear shoes with good support and non-slip soles Stages of Recovery Coma: unresponsive; eyes closed Vegetative state: no cognitive responses; gross wakefulness; sleep-wake cycles Minimally conscious state: purposeful wakefulness; responds to some commands Confusional state: recovered speech; amnesic (PTA); severe attentional deficits; agitated; hypoaroused; possible labile behavior Postconfusional, evolving independence: resolution of PTA; cognitive improvement; achieving independence in daily self-care; improving social interaction; developing independence at home Social competence, community re-entry: recovering cognitive abilities; goal-directed behaviors; social skills; personality; developing independence in the community; returning to academic or vocational pursuits Reprinted with permission from: Sohlberg, M. M., & Mateer, C. A. (2001). Cognitive rehabilitation: An integrative neuropsychological approach. NY: Guilford Press. Severity Classification, GCS Score, Duration of Coma, Length of PTA Severe, 3–8, Over 6 hours, Over 24 hours Moderate, 9–12, Less than 6 hours, 1–24 hours Mild, 13–15, 20 minutes or less, 60 minutes or less Reprinted with permission from: Sohlberg, M. M, & Mateer, C. A. (2001). Cognitive rehabilitation: An integrative neuropsychological approach. NY: Guilford Press. Improving Cognitive-Communicative and Social Skills Cognitive-Communicative Present new material in an organized and sequential manner with clear explanations, using visual aids or other teaching aids Provide repetitions and multiple opportunities for practicing new skills Encourage responsiveness and allow adequate time for the client to respond Use alternative or augmentative communication where appropriate and functional Focus on attention and memory skills Promote the use of higher level thinking (i.e., problem-solving, reasoning) Social Skills Allow the client to participate in the selection and prioritization of target skills Facilitate acquisition and understanding of client’s social knowledge Create awareness of social settings, social interactions, and corresponding appropriate modes of behavior and communication Educate and train family members how to best interact with client Focus on self-monitoring and self-evaluating behavior and performance Use role-playing and scripting to practice social interactions Author Notes Kathleen M. Youse, is a doctoral student in the communication sciences department at the University of Connecticut and an SLP at Hartford Hospital, in Hartford, CT. Contact her by email at [email protected] Karen N. Le, is a graduate student and research assistant in the communication sciences department at the University of Connecticut. Contact her by email at [email protected] Michael S. Cannizzaro, is a doctoral student in the communication sciences department at the University of Connecticut. Contact him by email at [email protected] Carl A. Coelho, is an associate professor in the communication sciences department at the University of Connecticut and an SLP at the Hospital for Special Care in New Britain, CT. Contact him by email at [email protected] Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 7Issue 12December 2002 Get Permissions Add to your Mendeley library History Published in print: Dec 1, 2002 Metrics Downloaded 1,455 times Topicsasha-topicsleader_do_tagasha-article-typesCopyright & Permissions© 2002 American Speech-Language-Hearing AssociationLoading ...