The Rural Veterans Health Access Project presents Dr. Amy Murphy

Certified Brain Injury SpecialistAssessment, Diagnosis and Treatment of Brain Injurywith a focus on Mild TBI

The RVHAP is part of the Health Planning and Systems Development Section, Division of Public Health, Alaska Department of Health and Social Services. Funded

by the HRSA Office of Rural Health Policy Grant # H3GRH26369-02-00

Tenakee Springs-One of the SE Alaska rural communities served by RVHAP

The objective of the Rural Veterans Health Access Project (RVHAP) is to increase access to and quality of health care to Veterans and other rural residents in South East Alaska through the development of a demonstration Telehealth network (TH) including behavioral health and primary care

RVHAP Sponsored TBI WebinarTraumatic Brain Injuries are a risk

for Veterans who are the primary focus of the RVHAP and rural veterans have less access to services

Alaska has a higher rate of TBI than the national average among the general community which is the secondary focus for the RVHAP’s telehealth services

Training medical and behavioral practitioners in the diagnosis, assessment and treatment of TBI enhances the health care provided for Alaskans with TBI, in particular rural residents.

Polling Question:

Do you (or your organization) serve

Veterans?

For more information on the Rural Veterans Health Access Program contact the Program Director:

Susan Maley, MPH, Ph.D. susan.maley@alaska.gov, 907-269-

2084http://dhss.alaska.gov/dph/HealthPlanning/Pages/

veterans/default.aspx

Funding provided by the Health Resources and Services Administration’s Office of Rural Health

PolicyOffice for the Advancement of Telehealth

Grant number H3GRH26369

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Assessment, Diagnosis and Treatment of Brain Injurywith a focus on Mild TBI

Amy L. Murphy, DOBrain Injury Medicine Specialist

Providence Medical Group Brain Injury ServicesProvidence Alaska Medical Center

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Objectives• Assessment• Common issues• Treatment• Referrals• Discuss case

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Assessment• Misdiagnosed, misunderstood, mismanaged• Lack of education, increased psychosocial

stressors• Screening tools

• OSU screening tool• Rivermead

• Sports versus non-sports concussion• Return to play versus return to school/work

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Assessment• Complete history- especially risk factors,

previous treatments• Full exam- focused neurologic and

musculoskeletal assessment, eye movements

• Gait evaluation• Balance evaluation (BESS)• Overview of laboratory studies, prior

radiologic studies, any other notes

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Common IssuesHeadache• #1 complaint• Post-

traumatic headache

• Treat as primary headache dx

• No great studies for PTH subtypes

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Common IssuesFatigue/Sleep

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Common IssuesCognition

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TreatmentFatigue and Cognition

• Medication list should be completed prior to initiating pharmacologic therapy, also any drug or alcohol use• Stopping sedating meds may remove the need for

medication, significantly decrease dose• Weaning benzodiazepines or alcohol, slowly• Work in combination with therapies- SLP, neuropsychology,

psychology• Check for mood!

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Treatment- Sleep• Non-pharmacologic management should be used as

much as possible after a brain injury.• Environment- adequate exposure to sunlight, reduced noise and

distractions at night.• Cognitive behavioral-cognitive therapies- later in course• Ensure that activating medications are reduced or given early

• If environmental and behavioral interventions are maximized and need for pharmacologic intervention is necessary, melatonin supplementation/agonists or trazodone should be considered for first line management to avoid cognitive sequelae

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Common IssuesMood• PTSD• Depression• Anxiety• Mania• Frustration• Anger• Overwhelm

ed

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TreatmentMood

• Therapy, neurofeedback, sleep, pain• Adjunct if medications are needed

• Benzodiazepines- decreased functional recovery in animals and extends post-traumatic amnesia

• Maximize treatment with multi-use medicines• Potential side effects should be considered carefully • Assess any recreational drug use and refer

accordingly for services• Drug use, alcohol, supplements- many can interfere

with medications- get an adequate history

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Common IssuesMusculoskeletal/Cervicogenic

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TreatmentMusculoskeletal/Cervicogenic

• Assess for injuries, imaging as needed• Referrals

• Orthopedics, Pain management• PT, OT• Naturopath, Osteopath, Acupuncturist

• Non-pharmaceutical management• Trigger point management• Nerve blocks• Appropriate stretching and exercise

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Common IssuesVestibular/Ocular

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TreatmentVestibular/Ocular

• Referrals• Optometry- specializing in vision rehab• PT- specializing in vestibular therapy

• Medications• Meclizine- hallucinations, blurred vision, drowsiness• Scopolamine- dizziness, dry mouth/eyes, restlessness• Dimehydrinate- dizziness, drowsiness, dry mouth

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Treatment planning• Further work-up

• Imaging• Laboratory Studies

• Referrals• PT, OT, SLP• Optometry• Behavioral health- counseling, neurofeedback• Other medical specialty- pain, sleep, primary

care, orthopedics

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Summary• Education and Prevention are KEY!• Working as an interdisciplinary team-

communication!• Initially schedule close follow-up care

• Return to play• Return to school• Return to work

• Work on most debilitating symptoms first- headache, sleep, mood

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References• Watanabe, T.K. et al. Systematic Review of Interventions for Post-traumatic Headache. PM

R. 4, 129-140. (2012).• Hou, L. et al. Risk Factors Associated with Sleep Disturbance following Traumatic Brain

Injury: Clinical Findings and Questionnaire Based Study. PLoS One. 8(10), e76087. (2013)• Thiagarajan, P & Ciuffreda, K. Effect of oculomotor rehabilitation on vergence responsivity

in mild traumatic brain injury. JRRD. 50(9), 1223-1240. (2013)• Giacino J, Whyte J, Bagiella E et al. Placebo-Controlled Trial of Amantadine for Severe

Traumatic Brain Injury. N Eng J Med. 366(9), 819-826 (2012).• Jha A, Weintraub A, Allshouse A et al. A Randomized Trial of Modafinil for the Treatment of

Fatigue and Excessive Daytime Sleepiness in Individuals with Chronic Traumatic Brain Injury. J Head Trauma Rehabil. 23(1), 52-63 (2008).

• Ponsford J, Ziino C, Parcell D et al. Fatigue and Sleep Disturbance Following Traumatic Brain Injury- Their Nature, Causes and Potential Treatments. J Head Trauma Rehabil. 27(3), 224-233 (2012).

• Shekleton JA, Parcell DL, Redman JR et al. Sleep disturbance and melatonin levels following traumatic brain injury. Neurology. 74, 1732-1738 (2010).

• Larson E, Zollman F. The Effect of Sleep Medications on Cognitive Recovery From Traumatic Brain Injury. J Head Trauma Rehabil. 25(1), 61-67 (2010).

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References• Perna R. Brain Injury: Benzodiazepines, Antipsychotics, and Functional Recovery. J

Head Trauma Rehabil. 21(1), 82-84 (2006).• Mysiw WJ, Bogner J, Corrigan J et al. The impact of acute care medications on

rehabilitation outcome after traumatic brain injury. Brain Injury. 20(9), 905-911 (2006). • Willmott C, Ponsford J. Efficacy of methylphenidate in the rehabilitation of attention

following traumatic brain injury: a randomised, crossover, double blind, placebo controlled inpatient trial. J Neurol Neurosurg Psychiatry. 80, 552-557 (2009).

• Erickson JC, Neely ET, Theeler BJ. Posttraumatic Headache. Continuum Lifelong Learning Neurol. 16(6), 55-78 (2010).

• Rizzoli P. Acute and Preventive Treatment of Migraine. Continuum Lifelong Learning Neurol. 18(4), 764-782 (2012).

• Kaniecki R. Tension-type headache. Continuum Lifelong Learning Neurol. 18(4), 823-834 (2012).

• Simon O, Yelnik AP. Managing spasticity with drugs. Eur J Phys Rehabil Med. 46, 401-410 (2010).

• Petraglia, A.L. et al. From the Field of Play to the Field of Combat: A Review of the Pharmacological Management of Concussion. Neurosurgery. 70:1520-1533 (2012).

Assessment, Diagnosis and Treatment of Brain Injurywith a focus on Mild TBI

Questions?