Posts Tagged Traumatic Brain Injury

[Abstract] Epilepsy after severe traumatic brain injury: frequency and injury severity

ABSTRACT

Objective

To estimate national frequency of posttraumatic epilepsy (PTE) after severe traumatic brain injury (TBI) and assess injury severity (Glasgow Coma Scale (GCS) and posttraumatic amnesia (PTA)) as prognostic factors for PTE.

Methods

Data on patients ≥18 years surviving severe TBI 2004–2016 were retrieved from the Danish Head Trauma Database (n = 1010). The cumulative incidence proportion (CIP) was estimated using death as competing event. The association between injury severity and PTE was assessed using multivariable competing risk regressions.

Results

CIP of PTE 28 days and one year post-TBI was 6.8% (95% confidence interval (CI) 5.4–8.5) and 18.5% (95% CI 16.1–21.1%), respectively. Injury severity was not associated with PTE within 28 days post-TBI but indicated higher PTE-rates in less severely injured patients. PTA-duration >70 days was associated with PTE 29–365 days post-TBI (Adjusted sub-hazard ratio 4.23 (95% CI 1.79–9.99)). GCS was not associated with PTE 29–365 days post-TBI.

Conclusion

The PTE frequency was higher compared to previous estimates. Increasing injury severity was associated with PTE 29–365 days post-TBI when measured with PTA, but not with GCS. Though nonsignificant, the increased PTE-risk within 28 days in lower severity suggests an underdiagnosing of PTE.

Source: https://www.tandfonline.com/doi/abs/10.1080/02699052.2020.1763467

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[WEB SITE] Brain Injury News – CNS

RESEARCH UPDATES, INDUSTRY NEWS, SURVIVOR STORIES

The world of advancements in brain injury knowledge and treatment is a rich composite of the progress being made by scores of dedicated people. The articles and reports below reflect current research, industry analysis, and stories of recovery. Innovations in patient care and the evolution of best practices in rehabilitation are among the subjects addressed by thought leaders, universities, and institutes noted here.

Categories:  Survivor  Stories  Traumatic Brain Injury  Concussion  Stroke  Aneurysm  Coma

NEWS & EVENTS ARCHIVES

via Brain Injury News

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[BLOG POST] What Is the Glasgow Coma Scale? – BrainLine

What Is the Glasgow Coma Scale?The Glasgow Coma Scale (GCS) is the most common scoring system used to describe the level of consciousness in a person following a traumatic brain injury. Basically, it is used to help gauge the severity of an acute brain injury. The test is simple, reliable, and correlates well with outcome following severe brain injury.

The GCS is a reliable and objective way of recording the initial and subsequent level of consciousness in a person after a brain injury. It is used by trained staff at the site of an injury like a car crash or sports injury, for example, and in the emergency department and intensive care units.

The GCS measures the following functions:

Eye Opening (E)

  • 4 = spontaneous
  • 3 = to sound
  • 2 = to pressure
  • 1 = none
  • NT = not testable

Verbal Response (V)

  • 5 = orientated
  • 4 = confused
  • 3 = words, but not coherent
  • 2 = sounds, but no words
  • 1 = none
  • NT = not testable

Motor Response (M)

  • 6 = obeys command
  • 5 = localizing
  • 4 = normal flexion
  • 3 = abnormal flexion
  • 2 = extension
  • 1 = none
  • NT = not testable

Clinicians use this scale to rate the best eye opening response, the best verbal response, and the best motor response an individual makes. The final GCS score or grade is the sum of these numbers.

Using the Glasgow Coma Scale

A patient’s Glasgow Coma Score (GCS) should be documented on a coma scale chart. This allows for improvement or deterioration in a patient’s condition to be quickly and clearly communicated.

Individual elements, as well as the sum of the score, are important. The individual elements of a patient’s GCS can be documented numerically (e.g. E2V4M6) as well as added together to give a total Coma Score (e.g E2V4M6 = 12). For example, a score may be expressed as GCS 12 = E2 V4 M6 at 4:32.

Every brain injury is different, but generally, brain injury is classified as:

  • Severe: GCS 8 or less
  • Moderate: GCS 9-12
  • Mild: GCS 13-15

Mild brain injuries can result in temporary or permanent neurological symptoms and neuroimaging tests such as CT scan or MRI may or may not show evidence of any damage.

Moderate and severe brain injuries often result in long-term impairments in cognition (thinking skills), physical skills, and/or emotional/behavioral functioning.

Limitations of the Glasgow Coma Scale

Factors like drug use, alcohol intoxication, shock, or low blood oxygen can alter a patient’s level of consciousness. These factors could lead to an inaccurate score on the GCS.

Children and the Glasgow Coma Scale

The GCS is usually not used with children, especially those too young to have reliable language skills. The Pediatric Glasgow Coma Scale, or PGCS, a modification of the scale used on adults, is used instead. The PGCS still uses the three tests — eye, verbal, and motor responses — and the three values are considered separately as well as together.

Here is the slightly altered grading scale for the PGCS:

Eye Opening (E)

  • 4 = spontaneous
  • 3 = to voice
  • 2 = to pressure
  • 1 = none
  • NT = not testable

Verbal Response (V)

  • 5 = smiles, oriented to sounds, follows objects, interacts
  • 4 = cries but consolable, inappropriate interactions
  • 3 = inconsistently inconsolable, moaning
  • 2 = inconsolable, agitated
  • 1 = none
  • NT = not testable

Motor Response (M)

  • 6 = moves spontaneously or purposefully
  • 5 = localizing (withdraws from touch)
  • 4 = normal flexion (withdraws to pain)
  • 3 = abnormal flexion (decorticate response)
  • 2 = extension (decerebrate response)
  • 1 = none
  • NT = not testable

Pediatric brain injuries are classified by severity using the same scoring levels as adults, i.e. 8 or lower reflecting the most severe, 9-12 being a moderate injury and 13-15 indicating a mild TBI. As in adults, moderate and severe injuries often result in significant long-term impairments.

Posted on BrainLine February 13, 2018. Reviewed July 25, 2018.

References

Teasdale G, Allen D, Brennan P, McElhinney E, Mackinnon L. The Glasgow Coma Scale: an update after 40 years. Nursing Times 2014; 110: 12-16

Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974,2:81-84. PMID 4136544.

The Glasgow Structured Approach to Assessment of the Glasgow Coma Scale. (n.d.). Retrieved February 13, 2018, from www.glasgowcomascale.org.

via What Is the Glasgow Coma Scale? | BrainLine

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[BLOG POST] Top tips for dating after receiving a traumatic brain injury – Jumbledbrain

Dating after receiving a traumatic brain injury

Guest Post: Top Tips For Dating After Receiving A Traumatic Brain Injury

Brandon Leuangpaseuth is a freelance copywriter from San Diego, CA. Brandon is an avid traveler, book enthusiast and loves animals. He loves exploring new places and going on long walks on the beach. You can connect with him on LinkedIn @ bleuangpaseuth.

Today he wants to share with you his personal experience of dating after receiving a traumatic brain injury, including his top tips for how to successfully settle down with the right person.

 


In 2015, I was hit by a car and I received a severe traumatic brain injury. A brain injury that left me without the ability to remember what I had done the day prior, constant fatigue, and the need to sleep more than usual. I have openly written and shared my journey to recovery since the incident on Jumbled Brain’s blog… From my struggles to graduating from college while dealing with the detrimental effects of my brain injury to struggling to work a full-time job (but finding a great career that worked with my TBI!) to coping with the everyday changes, my brain injury has had on my life.

Now, the next strenuous chapter I face while living with a brain injury is…dating (honestly, dating without a brain injury was already hard enough!) Dating with a brain injury opens up a slew of other obstacles that make it even more arduous. In this article, I want to spread how I learned to cope with the new obstacles my brain injury has had on my dating life.

The Importance of Communication

My doctor once told me a brain injury is only invisible to the outside world if I did not tell people about my head injury. What he meant by that other people will not know I suffer some negative effects from an unseen disability, unless I inform them of it.  It can definitely be a tough conversation to have. At first, I struggled with telling people about my brain injury because I was ashamed and I wanted nothing more than to be normal. As time passed, I’ve come to terms with my head injury.

I made it a point to tell everyone who I dated after the car accident about my brain injury. I want to let my partner know what they were getting into before they started to date me. That I do have a lingering invisible disability that would impact the relationship. I’ve had some partners that said it was not a big deal until they had to deal with some of the issues I faced when dealing with a brain injury.

I have to let them know that I can be quite forgetful and I get horrific TBI exhaustions that make me take an enormous amount of naps throughout a day. Sometimes I can’t drive for long hours or stay out too late because my body would get too fatigued and I would need to sleep.

After I communicated with my partner, they would understand that I needed a nap whenever I got brain fog.

Being honest with my partner about some of the hurdles I face and that the effects it would have on the relationship have been extremely helpful. Telling my partner ahead of time some situations where the effects of my brain injury would come into play has helped my partner understand me better.

Dealing With the Dreaded Fatigue and Brain Fog

Fatigue is the absolute biggest issue I face. Hands down it is the worst part of my brain injury. My partner would get mad at me when I would fall asleep watching a movie in every theater date we had or when I would say I could not stay out any longer because I was getting some serious brain fog. Of course, I want to spend time or being out late nights with my partner…but it is just harder with a brain injury. I would get pretty sad when I had to tell my partner that I can’t stay out late on some date nights because I was too tired.

The best solution for me was to plan ahead of time. I’m a freelance writer so I would write in the mornings and take my naps throughout the day if I had a big date that night or an outing. I would also pack some bottles of black teas to keep with me in case I needed to stay awake.

I would also make sure to use ride-sharing applications on some night outs because I know I’d be too exhausted to drive later.

I can’t stress it enough that preparation is key when you are dating with a brain injury.

Being Confident in Myself

Right after I received the brain injury, I had a lot of confidence issues. I used to pride myself on being a pretty academic and intelligent guy, but when I could not even remember what I did the day prior and I had difficulty forming cogent thoughts…I started to second guess that belief.

Thoughts of “who would date somebody with a TBI” started to pop into my head…

I felt like damaged goods.

–and my own thoughts and how I felt about myself flowed out into my dating life. People around me can sense my lack of confidence whenever I interacted with them.

If I didn’t even want to date myself, who would want to date me…

So, the first step was rebuilding some confidence in myself. I started to routinely hit the gym, cleaned up my diet and really worked on reframing how I thought about my brain injury. I realized that if someone didn’t completely accept me for who I was, a guy with a brain injury, why would I want to date that person? I had to learn how to be loved for who I was and accept all parts of me. If a girl was not interested in dating me because of my disability, then it was her loss! With this mindset, I started to be more confident with myself in my dating life.

Here’s to Dating With A Brain Injury

If you have a brain injury and you are struggling with dating, hang in there. Hopefully, my tips can make it a little bit easier to dating someone when you have a brain injury. Being honest with your partner, being prepared for dates and reframing how you think about your brain injury can go a long way.

I wish you the best of luck on your dating journey and I hope you stay safe!

via Guest post: Top tips for dating after receiving a traumatic brain injury | Jumbledbrain

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[Abstract] Pharmacological and Non-Pharmacological Interventions for Depression after Moderate-to-Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis

The objective of this study was to systematically review the literature and perform a meta-analysis of randomized controlled trials (RCTs) on the effectiveness of pharmacological and non-pharmacological interventions for depression in patients with moderate-to-severe traumatic brain injury.

Databases searched were: Embase, PubMed, PsycInfo, Cochrane Central, Web of Science, and Google Scholar. Depression score on a self-report questionnaire was the outcome measure. Outcomes were collected at baseline and at the first follow-up moment. Data extraction was executed independently by two researchers. Thirteen RCTs were identified: five pharmacological and eight non-pharmacological. Although not all individual studies had significant results, the overall standardized mean difference (SMD) was −0.395, p ≤ 0.001, indicating that interventions improved the depression scores in patients with TBI.

The difference in effectiveness between pharmacological interventions and non-pharmacological interventions was not significant (ΔSMD: 0.203, p = 0.238). Further subdivision into methylphenidate, sertraline, psychological, and other interventions showed a significant difference in effectiveness between methylphenidate (ΔSMD: −0.700, p = 0.020) and psychological interventions (reference). This difference was not found if other depression outcomes in four of the included studies were analyzed. The SMD of low-quality studies did not differ significantly from moderate- and high-quality studies (ΔSMD: 0.321, p = 0.050).

Although RCTs targeting interventions for depression after TBI are scarce, both pharmacological and non-pharmacological interventions appear to be effective in treating depressive symptoms/depression after moderate-to-severe TBI. There is a need for high-quality RCTs in which the add-on effects of pharmacological and non-pharmacological interventions are investigated.

via Pharmacological and Non-Pharmacological Interventions for Depression after Moderate-to-Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis | Journal of Neurotrauma

 

 

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[WEB PAGE] Traumatic Brain Injury | TBI – MedlinePlus

Summary

What is traumatic brain injury (TBI)?

Traumatic brain injury (TBI) is a sudden injury that causes damage to the brain. It may happen when there is a blow, bump, or jolt to the head. This is a closed head injury. A TBI can also happen when an object penetrates the skull. This is a penetrating injury.

Symptoms of a TBI can be mild, moderate, or severe. Concussions are a type of mild TBI. The effects of a concussion can sometimes be serious, but most people completely recover in time. More severe TBI can lead to serious physical and psychological symptoms, coma, and even death.

What causes traumatic brain injury (TBI)?

The main causes of TBI depend on the type of head injury:

  • Some of the common causes of a closed head injury include
    • Falls. This is the most common cause in adults age 65 and older.
    • Motor vehicle crashes. This is the most common cause in young adults.
    • Sports injuries
    • Being struck by an object
    • Child abuse. This is the most common cause in children under age 4.
    • Blast injuries due to explosions
  • Some of the common causes of a penetrating injury include
    • Being hit by a bullet or shrapnel
    • Being hit by a weapon such as a hammer, knife, or baseball bat
    • A head injury that causes a bone fragment to penetrate the skull

Some accidents such as explosions, natural disasters, or other extreme events can cause both closed and penetrating TBI in the same person.

Who is at risk for traumatic brain injury (TBI)?

Certain groups are at higher risk of TBI:

  • Men are more likely to get a TBI than women. They are also more likely to have serious TBI.
  • Adults aged 65 and older are at the greatest risk for being hospitalized and dying from a TBI

What are the symptoms of traumatic brain injury (TBI)?

The symptoms of TBI depend on the type of injury and how serious the brain damage is.

The symptoms of mild TBI can include

  • A brief loss of consciousness in some cases. However, many people with mild TBI remain conscious after the injury.
  • Headache
  • Confusion
  • Lightheadedness
  • Dizziness
  • Blurred vision or tired eyes
  • Ringing in the ears
  • Bad taste in the mouth
  • Fatigue or lethargy
  • A change in sleep patterns
  • Behavioral or mood changes
  • Trouble with memory, concentration, attention, or thinking

If you have a moderate or severe TBI, you may have those same symptoms. You may also have other symptoms such as

  • A headache that gets worse or does not go away
  • Repeated vomiting or nausea
  • Convulsions or seizures
  • Not being able to wake up from sleep
  • Larger than normal pupil (dark center) of one or both eyes. This is called dilation of the pupil.
  • Slurred speech
  • Weakness or numbness in the arms and legs
  • Loss of coordination
  • Increased confusion, restlessness, or agitation

How is traumatic brain injury (TBI) diagnosed?

If you have a head injury or other trauma that may have caused a TBI, you need to get medical care as soon as possible. To make a diagnosis, your health care provider

  • Will ask about your symptoms and the details of your injury
  • Will do a neurologic exam
  • May do imaging tests, such as a CT scan or MRI
  • May use a tool such as the Glasgow coma scale to determine how severe the TBI is. This scale measures your ability to open your eyes, speak, and move.
  • May do neuropsychological tests to check how your brain is functioning

What are the treatments for traumatic brain injury (TBI)?

The treatments for TBI depend on many factors, including the size, severity, and location of the brain injury.

For mild TBI, the main treatment is rest. If you have a headache, you can try taking over-the-counter pain relievers. It is important to follow your health care provider’s instructions for complete rest and a gradual return to your normal activities. If you start doing too much too soon, it may take longer to recover. Contact your provider if your symptoms are not getting better or if you have new symptoms.

For moderate to severe TBI, the first thing health care providers will do is stabilize you to prevent further injury. They will manage your blood pressure, check the pressure inside your skull, and make sure that there is enough blood and oxygen getting to your brain.

Once you are stable, the treatments may include

  • Surgery to reduce additional damage to your brain, for example to
    • Remove hematomas (clotted blood)
    • Get rid of damaged or dead brain tissue
    • Repair skull fractures
    • Relieve pressure in the skull
  • Medicines to treat the symptoms of TBI and to lower some of the risks associated with it, such as
    • Anti-anxiety medication to lessen feelings of nervousness and fear
    • Anticoagulants to prevent blood clots
    • Anticonvulsants to prevent seizures
    • Antidepressants to treat symptoms of depression and mood instability
    • Muscle relaxants to reduce muscle spasms
    • Stimulants to increase alertness and attention
  • Rehabilitation therapies, which can include therapies for physical, emotional, and cognitive difficulties:
    • Physical therapy, to build physical strength, coordination, and flexibility
    • Occupational therapy, to help you learn or relearn how to perform daily tasks, such as getting dressed, cooking, and bathing
    • Speech therapy, to help you to with speech and other communication skills and treat swallowing disorders
    • Psychological counseling, to help you learn coping skills, work on relationships, and improve your emotional well-being
    • Vocational counseling, which focuses on your ability to return to work and deal with workplace challenges
    • Cognitive therapy, to improve your memory, attention, perception, learning, planning, and judgment

Some people with TBI may have permanent disabilities. A TBI can also put you at risk for other health problems such as anxiety, depression, and post-traumatic stress disorder. Treating these problems can improve your quality of life.

Can traumatic brain injury (TBI) be prevented?

There are steps you can take to prevent head injuries and TBIs:

  • Always wear your seatbelt and use car seats and booster seats for children
  • Never drive under the influence of drugs or alcohol
  • Wear a properly fitting helmet when riding a bicycle, skateboarding, and playing sports like hockey and football
  • Prevent falls by
    • Making your house safer. For example, you can install railings on the stairs and grab bars in the tub, get rid of tripping hazards, and use window guards and stair safety gates for young children.
    • Improving your balance and strength with regular physical activity

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For more Visit —->  Traumatic Brain Injury | TBI | MedlinePlus

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[VIDEO] Traumatic Brain Injury: Understanding Fatigue – YouTube

The TBI Coach, Nathalie Kelly, explains cognitive fatigue in a way that everyone can understand. Brain fatigue is a huge debilitating issue for those with brain injuries and concusssions. See the full transcript below.

Hello my beautiful and courageous friends,

Do you find it hard to understand that at some moments someone with a TBI can appear to function pretty well, and a minute later they are stuttering and stumbling?

It’s called Cognitive Fatigue. Cognitive fatigue happens because the injured brain is working very hard . Since the old pathways are broken, your amazing brain is having to find new paths. when the brain is overloaded and it is like your brain switch being turned off. One minute you are there, and the next minute, it was too much, a fuse blew, and you are gone.

It can be so extreme of a contrast, that people get accused of faking their brain injury. That hurts!

The best explanation I have ever heard comes from Dr. Clark Elliott in his fabulous book “The Ghost in My Brain”. He came up with a great metaphor. It is as if we have 3 energy batteries, an A, B, C battery.

The most efficient battery is the A battery. For most people, it gets charged up each night with sleep,and lasts throughout the day. When the A battery gets used, we have to turn to our B battery. The B battery does not last as long and takes a lot longer to charge. When the B Battery runs down, we have to turn to our emergency battery, the C battery. The C battery should be for dire emergencies only. It only lasts a short while and it takes days to recharge. It’s kinda of like your laptop tells you you have 2% battery left. And then it shuts off and the screen goes black.

When you have a TBI, your A battery gets used up processing things that took no effort before. An enormous percentage of our brain’s energy goes toward processing vision. While it was no problem before, now Processing vision and sound, balance and motion, now takes most of your available energy. So your A batteries are always depleted.

You are now running on B batteries to do anything else, getting groceries, driving a car, going to work. They are not going to last long. And so you are dipping into the C batteries on a daily basis and not just during an emergency.

This is what it looks like when the C batteries are depleted. There will be days of sleep to pay for pushing it this far.

At the beginning of a brain injury when your brain is working really hard to find workarounds for the broken connections, you may be like this most of the time. Over time, as your brain slowly heals, your ability to process information improves and now your A battery has a little more capacity. As you get better you are tapping into you C battery less and less, perhaps only on rough days instead of everyday.

When you are fatigued, it is really important to sleep. That is the only way the batteries get charged again. And that is how our brain heals. New studies show that sleep is the process during which the brain dispels toxins so it can function at its best.

So, if someone you love has a Brain Injury and you can tell they are fatigued. What they need from you is an Immediate response. It takes less than a minute to go from one battery cell to the next, Take them out of the situation, the restaurant, the noise, and get them to quiet, dark, and rest ASAP. You do not want to linger. and You do not want to push the system into the C batteries.

Please share with our community your thoughts and experiences in the comment section below. What do you think of this A B C Battery metaphor? What helps you with cognitive fatigue?

Visit my website http://www.TheTBICoach.com for more helpful videos and tips and for my special report on 3 Things Everyone with a TBI Should Know.

via Traumatic Brain Injury: Understanding Fatigue – YouTube

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[BLOG POST] Interventions For Behavioral Problems After Brain Injury – BrainLine

by Carrie Beatty, CBIS, ResCare Premier
Interventions For Behavioral Problems After Brain Injury

Introduction

Behavior change is difficult for any individual to accomplish. The process, however, can be infinitely more difficult for those who suffer from a traumatic brain injury (TBI) due to physical, cognitive, and emotional impairments associated with an injury. Successful reintegration into the community and return to activities of choice is often dependent on the individual’s ability to modify maladaptive behaviors that may result from the injury. Behavioral challenges that frequently require intervention following brain injury include aggression, disinhibition, difficulty relating to others, and a host of other behaviors.

A total reversal of behavioral problems after a brain injury may not be possible. A more realistic goal is to modify behaviors. There are several interventions available to assist with the modification of those behaviors that negatively effect goal achievement, successful community reintegration, or quality of life for individuals with TBI. The intent of this article is to describe and provide examples of current options for therapeutic intervention and examine their effectiveness for individuals with TBI.

Proactive Measures

There are a number of steps that can be taken proactively to set the stage in developing effective plans for behavior change.

Developing Trusting Relationships

It is important to build a trusting relationship with an individual who has had a brain injury. Much of what occurs during rehabilitation is based on trust that the individuals providing services understand what is important to the person receiving services. There must be trust that the recommendations providers make and activities they encourage, are designed to help the individual achieve his/her goals.

Trust is developed through honest, caring, and consistent interactions. It is important to be realistic with the individual. You cannot promise to ‘make him/her better.’ We, as family members or professionals, do not have all the answers to the individual’s problems. We may be most helpful by providing a comfortable, nonjudgmental atmosphere in which the individual can discuss his/her concerns and preferences, even if the concerns and the accompanying behaviors do not appear to be logical. The knowledge gained from such discussions is invaluable when developing behavior plans or carrying out treatment.

The importance of relationships in behavior change goes beyond relationships between professionals and a person with brain injury. Following a brain injury, an individual may feel isolated and depressed (Denmark & Gemeinhardt, 2002). Success in coping with or adapting to changes after injury, as well as in modifying maladaptive behaviors, is highly dependent upon the feedback and support an individual receives from his/her social network. A supportive network may include professionals, family, old friends, new friends, and persons who have had similar experiences.

Understanding the Behavior

Developing adaptive behavior first requires recognizing what may be contributing to the problematic behavior. Triggers, antecedents, and precipitating factors are terms describing that which precedes the behavior. Triggers to acting-out behavior may be internal or external (Caraulia & Steiger, 1997). Examples of internal causes of behavioral problems can be fatigue, hunger, lowered self-esteem, etc. External triggers may include a frustrating task, interaction with certain individuals, change in structure/ routine, increased level of stimulation, etc. In addition to understanding what may trigger maladaptive behavior, it is important to understand what occurs following the behavior that may serve to reinforce and hence maintain the behavior. For example, if a given behavior consistently results in a rewarding experience such as increased attention, the frequency of the behavior will most likely increase. Modification of antecedents and consequences to change behavior is discussed in more detail under the heading Behavior Therapy.

Recognizing and Responding to Precursors

Individuals often provide non-verbal and verbal signs prior to displaying the behavior of concern. A person’s change in behavior can represent a negative internal state. There may be signs of anxiety such as pacing and fidgeting. The face may become flushed; he/she may have difficulty maintaining eye contact or may display decreased attention to a task. An individual may also exhibit verbal signs, such as muttering to him/herself or increasing the volume of speech. Clearly, it is important to be aware of sudden, often subtle, changes in behavior (both non-verbal and verbal) in order to effectively intervene. Intervening early in the sequence of behavioral escalation is one of the most effective strategies for behavior change.

General Guidelines

In order to select the most appropriate intervention for modifying behavior during rehabilitation, the following guidelines, outlined by White, Seckinger, Doyle, and Strauss (1997), need to be considered:

  • Include the individual with TBI when developing a strategy. If a plan is developed without client input, it is not likely to be effective.
  • Prioritize the functional needs of the individual. Consider his/her strengths and weaknesses.
  • Analyze the tasks required for goal achievement. Individuals have more success if they can incorporate what they have already learned and know.
  • Consider the learning style. Individuals can learn from written information, oral information, or a combination of both. Ensure the intervention is compatible with the learning style of the individual.
  • Consider the individual’s willingness to participate in the therapy or strategy.
  • Ensure that the strategy is practical. Time and funding constraints, family concerns, and environment limitations (i.e., in-patient vs. day-patient) should be considered.

Therapeutic Interventions

Several different approaches have been used to modify behavioral problems in individuals with TBI, some with more success than others. Most of the therapeutic intervention strategies were developed originally for individuals with learning disabilities, emotional dyscontrol, and psychiatric disorders. Studies have shown that with some adjustments or combination of approaches, these intervention strategies can benefit individuals with TBI (Alderman, 2003). However, most researchers agree that additional studies should be conducted to better measure the effectiveness of therapeutic interventions that have been adapted for use with persons with TBI (Denmark & Gemeinhardt, 2002; Kinney, 2001; Manchester & Wood, 2001; Schlund & Pace, 1999).

Insight Oriented Psychotherapy

Insight oriented psychotherapy can be defined as a process to gain more awareness and insight into our thoughts, feelings, and behaviors (Pologe, 2001). Theoretically, the more awareness one has of thoughts, feelings, and behaviors, the more one is able to change them. Therefore, insight oriented psychotherapy guides an individual to gain this awareness in order to change behavioral patterns. This type of therapy requires the individual to attend to task, maintain thought process, recall what is occurring (or occurred) during therapy, use reason, and develop insight. Considering these requirements, it is understandable that individuals with TBI, who may have problems with attention, memory, thought organization, or abstract processing, may not benefit from insight oriented psychotherapy. For this reason, Wood and Worthington (2002) concluded that insight oriented psychotherapy could only be implemented with individuals who have suffered mild or moderate debilitating effects.

For individuals with traumatic brain injuries who do not have severe cognitive deficits, insight oriented psychotherapy may be very beneficial. Prigatano (1986) suggested that a goal of psychotherapy for individuals with TBI should be to increase understanding of what has happened, the injury, and its effects. It should also help the person develop strategies for acceptance of injury, achieve self-acceptance, be realistic, and adjust to role and relationship changes. Finally, the process may be used to increase social appropriateness and develop behavioral strategies. Insight oriented psychotherapy for individuals with TBI is often conducted in a group in the rehabilitation setting. The group setting adds opportunities for feedback from peers that may enhance insight. Group therapy may not be productive, however, for individuals who are unable to filter out external stimuli and selectively attend to the task at hand, for those who become overly stimulated in a group setting, or for those who easily become frustrated or aggressive (Bennett & Raymond, 1997).

Cognitive Behavioral Therapy

Cognitive behavioral therapy is a specific form of psychotherapy that is concerned with how people’s behavior is shaped by their interpretation and perception of their experience (Alderman, 2003). It aims at assisting the individual in understanding the link between beliefs, thoughts, feelings, and behavior. That is, there is often a belief (realistic or not; adaptive or maladaptive) that underlies one’s thoughts and results in a pattern of behavior that is consistent with that belief. Needless to say, belief patterns that existed prior to the injury or those that are developed post-injury affect progress in rehabilitation.

In cognitive behavioral therapy, the individual is required to analyze maladaptive behavior in regard to any underlying beliefs that may be untrue, unrealistic, or counterproductive to meeting basic needs. The benefit of this approach is that one can alter behavior by changing beliefs or the way one thinks when it may not be possible to change the external situation (Albert Ellis Institute & Abrams, 2004). For example, a teenager may be suspended multiple times for fighting in school. She reveals to her counselor that she has the following belief: “the way to deal with hostility is to be hostile in return — an eye for an eye and a tooth for a tooth.” Her counselor suggests alternative beliefs that would alter her emotional response and help her to avoid fights in school. In this case, alternative beliefs might include, “ignoring or walking away from another person’s hostility keeps me out of trouble” or “being hostile in return doesn’t improve the situation in the long run.” The process requires that an individual take an active role in the application of techniques. Homework may be assigned so that techniques are practiced. Furthermore, the individual may be required to monitor his/her own behavioral responses (self-monitoring). This process builds awareness of behavioral patterns (including frequency, type of response, etc.), and leads to the individual taking more responsibility for altering his/her own behavior (Denmark & Gemeinhardt, 2002).

Effectiveness of cognitive behavioral therapy with individuals who have a TBI is dependent upon the individual’s level of cognitive functioning. For example, the following personal characteristics are required to participate in Rational Emotive Behavioral Therapy (REBT) which is a form of cognitive behavioral therapy: self-direction, good ability to tolerate frustration, flexibility, acceptance of uncertainty, self-acceptance, nonutopianism (accepting the fact that one will never achieve a utopian or ideal existence), and ability to take responsibility for one’s own emotional disturbances (Ellis & Dryden, 1997). Additionally, in REBT self-defeating thoughts and feelings are openly challenged. Discussion in either individual or group settings can be quite direct and demanding. Consequently, it has been suggested that a more flexible protocol of REBT be implemented for individuals with TBI. It should be more collaborative, less directive, and more flexible. In this sense, the therapist might adapt to the needs of the individual rather than the individual adapting to the REBT (Kinney, 2001). Manchester and Wood (2001) advocate that if REBT or another form of psychotherapy is used with persons with brain injury that the sessions be highly structured, repetitive, and include role play. They suggest that through procedural learning (repetition and structure), the likelihood will increase that cognitive behavioral therapy will be successful.

Behavior Therapy

The goal of behavior therapy is to manipulate the person’s environmental antecedents (that which consistently precedes a behavior) and consequences (that which follows or results from the behavior) in order to decrease the likelihood of maladaptive behaviors occurring and increase more positive, adaptive behaviors (Denmark & Gemeinhardt, 2002). Typically, individuals who are not appropriate for insight oriented psychotherapy or cognitive behavioral therapy are able to benefit from behavior therapy. Behavior therapy is currently accepted as an effective intervention for modifying behavior following TBI. For example, there is evidence suggesting that if behavior therapy intervention is properly implemented to meet the needs of the individual, outbursts significantly decrease in a group home setting for individuals with TBI (Denmark & Gemeinhardt, 2002). Traditionally, behavior therapy has focused on modification of maladaptive behaviors. However, it has also been effective in helping individuals to relearn other skills such as self-care, budgeting, etc.

Terms and Concepts in Behavior Therapy

Identifying and modifying antecedents

As mentioned previously, analyzing the environment for antecedents to problem behavior and adapting the environment in which the behavioral problems occur can be critical in decreasing the severity and frequency of the behavior. For instance, an outburst could be preceded by a lot of noise, too many people in the room, too many demands, or simply fatigue or hunger (Ponsford, 1995). In the initial stages of working with an individual with TBI and assessing reasons for undesirable behaviors, consider the environment’s comfort and pleasantness, level of stimulation, and adequacy in terms of privacy. Consider cultural issues that may contribute to behavioral problems. For instance, most Europeans prefer to bathe rather than shower. Attempting to impose a change in these cultural practices may, in fact, cause an undesirable behavior to occur. External expectations that do not take these issues into account may become a source of frustration for the individual and can contribute to behavioral problems.

Fluharty and Glassman (2001) examined the use of antecedent control to improve outcome for an individual with frontal lobe injury and intolerance for auditory and tactile stimuli. The individual suffered from profound memory, reasoning, and insight deficits. Therefore, traditional behavior modification using reinforcement and consequences was unsuccessful. The individual was unable to recall what behavior resulted in reward or consequence and had limited ability to understand the effects of his behavior. The treatment team made changes to the environment by eliminating noise and touch, which had previously served as triggers for problem behaviors. These changes were effective in reducing the problem behaviors. Clearly, understanding antecedents is a very important factor in the process of changing behavior.

Identifying and modifying consequences

Consequences serve to encourage or discourage a specific behavior or behavioral pattern. For example, others’ reaction to an unwanted behavior may impact the individual’s response resulting in the escalation (or de-escalation) of the behavior. This is referred to as an integrated experience — both individuals’ behavior and attitude affect each other (Caraulia & Steiger, 1997). Individuals who display maladaptive behaviors are the most challenging to rehabilitate and may be excluded from rehabilitation settings because staff members lack the skills to respond effectively. If participating in a program that does not specialize in the treatment of maladaptive behavior, there is a natural tendency for staff to intensify interactions with the individual during the crisis situation (or when maladaptive behavior is exhibited) and to provide less attention to the individual when he/she is not displaying the maladaptive behaviors. The attention paid to the maladaptive behavior becomes a rewarding or reinforcing consequence. According to Alderman (2003), a benefit of using behavior therapy techniques is that staff members are required to attend to the individual when he/she is displaying desired, productive behaviors, reversing the tendency to attend to undesirable behaviors.

Positive reinforcement

Positive reinforcement refers to the use of rewards, privileges, incentives, attention, and praise to increase a desired behavior. When positive things happen following a behavior, the behavior is likely to increase.

Negative reinforcement

Negative reinforcement refers to the removal of noxious stimuli in order to increase desired behavior. For example, when inappropriate or aggressive behavior successfully stops the continuation of an unpleasant or physically taxing physical therapy session (unpleasant stimuli), the inappropriate or aggressive behavior is likely to occur in the future (Braunling-McMorrow, Niemann, & Savage, 1998).

Punishment

Punishment consists of unpleasant consequences following undesirable behavior. When behavior leads to a negative consequence (punishment), it is less likely to occur (Braunling-McMorrow, et al., 1998). It should be noted that punishment is consistently found to be less effective than positive reinforcement for creating and maintaining behavioral change. When the threat of the punisher has been removed, the behavior may resume.

Differential reinforcement

Differential reinforcement refers to a variety of positive reinforcement strategies and is one of the most widely used concepts in behavior therapy. The primary focus of differential reinforcement is to positively reinforce a desirable behavior that will replace the undesirable behavior. Four categories of differential reinforcement are defined below with an example as described in the American Academy for the Certification of Brain Injury Specialists (AACBIS) Training Manual for Certified Brain Injury Specialists (Braunling-McMorrow et al., 1998).

  • Differential Reinforcement of Other Behavior (DRO) – In using DRO, the individual receives a reward for specified periods of time in which there has been no occurrence of the undesirable behavior. For example, someone who has a verbal outburst twice per hour would receive a reward for each 30-minute interval in which no verbal outbursts occur.
  • Differential Reinforcement of Incompatible Behavior (DRI) — In DRI, a behavior that is incompatible with the undesirable behavior is identified and reinforced. For example, if one touches others repetitively when asked not to do so, an incompatible behavior would be keeping one’s hands in one’s pockets. The individual would receive positive reinforcement when engaging in the incompatible behavior.
  • Differential Reinforcement of Alternative Behavior (DRA) — DRA involves identifying an alternative behavior that is not necessarily incompatible with the target behavior and reinforcing it. For example, if one is overly talkative during vocational activities, an alternative behavior (e.g., remaining on task) is reinforced, while the undesirable behavior (e.g., talking) is ignored.
  • Differential Reinforcement of Low-Rate Behavior (DRL) — DRL involves the reinforcement of the reduction of undesirable behavior. For example, if someone displays 20 verbal outbursts per day, it is unrealistic to implement a plan that requires zero verbal outbursts to earn reinforcement. Rather, implementing a plan in which a lower frequency of the undesirable behavior, (i.e., displaying no more then 15 verbal outbursts per day), is more realistic. When the individual displays a lower rate of an unwanted behavior, reinforcement is provided.

Individual Behavior Plans

Reinforcement systems may be combined to develop an individual behavior plan. Individual behavior plans are detailed plans that include strategies and interventions designed to address specific issues that are impeding an individual’s progress toward goals. The plan takes into account the individual’s strengths and weaknesses and individual learning style. Since precision and consistency of application is important for learning to occur and for new behavioral patterns to develop, scripts are incorporated into the plan. A script is a set of written instructions that direct individuals working with the person with brain injury on how to respond to certain behaviors or situations. A behavior plan addresses antecedents and consequences. It defines a way of responding that teaches, elicits, and reinforces adaptive behavior, minimizes reinforcement of maladaptive behavior, and ensures the safety of the individual. Prompts, cues, instructions, and gestures are used to elicit the desirable behavior that is subsequently reinforced. Verbal instructions, visual cues (pictures), physical guidance (hand-overhand), and modeling can be used to facilitate learning (Wood, 2001). Verbal mediation is another method used to elicit adaptive behavior. Verbal mediation is used when the precursors of maladaptive behavior become evident. Mediation is used to evoke thoughts (why am I feeling this way?) and problem solving (alternatives in dealing with the problem situation). In the area of non-violent crisis intervention, Caraulia and Steiger (1997) developed a verbal mediation strategy that is called CPI COPING. COPING stands for: recognition of lack of “control” which prompts the following sequence: “orient” the person to the facts, identify “patterns” of behavior, “investigate” alternatives to the behavior, “negotiate” using a behavioral or incentive plan, and “give” back empowerment. While its development was not geared specifically to individuals with TBI, several of the steps have been useful when practicing verbal mediation with individuals with TBI. When prompting or verbal mediation elicits adaptive behavior, the behavior is reinforced.

Specific reinforcers or rewards must be identified for the individual for whom the plan is being developed. Remember, we are all unique in our preferences and what one person may find reinforcing or rewarding may not be reinforcing for another. To identify preferences for reinforcers, can ask the individual, ask family or friends, or simply observe the individual. Primary reinforcers include, but are not limited to, praise, encouragement, and attention. Secondary reinforcers such as tokens or points may be earned and traded in for special outings, increased time in certain activities or with preferred individuals, or desired purchases. Rewards may be provided each time the desired behavior occurs or at scheduled times such as at the end of the day. Cognitive factors may influence the schedule of reinforcement (ResCare Premier, 2002). For example, memory problems may interfere with the effectiveness of a reward program that involves a lengthy delay; the individual may not recall what they did or didn’t do to obtain the reward. Alternatively, rewards given too frequently may result in the individual becoming satiated. The frequency of delivery of reinforcers must be identified in the behavior plan.

One type of secondary reinforcement system used within rehabilitation settings is the “token economy.” Ponsford (1995) recommends that a psychologist supervise this type of system. The individual may receive tokens as reward for desired behavior; they may then exchange the tokens for certain material rewards. A set of rules is established outlining the behaviors desired, the frequency with which the tokens may be earned, and how they can be exchanged. Tokens can be given immediately or at specified time intervals. A specified time interval is effective if you are teaching the individual to remain on task or to sustain learned behavioral changes. Difficulties with this system have been noted by Ponsford (1995) who points out that some individuals with TBI find the system demeaning. Therefore, she suggests that a point system be implemented instead. The points are earned, similar to tokens; praise and encouragement is provided at the time that points are awarded. The point system is very effective for both individuals with TBI and staff members as it increases both parties’ awareness of the expected behavior. The system promotes consistency and provides the opportunity for social reinforcement. Both token and point systems provide a visual cue so the individual can monitor his/her progress and successes throughout the day. Incentive programs such as point or token systems are used successfully to encourage participation in rehabilitation activities and development of adaptive behavior.

In addition to incentive programs, incidental and structured feedback may be incorporated into a behavior plan. Incidental feedback involves providing a prescribed response at the time that the alternative, adaptive behavior is observed. Structured feedback is a review with the individual of recent events or activities that have occurred. An individual may not have insight into what happened and why. Structured feedback provides an opportunity to get the facts and to analyze elements of the intervention plan that may not be working. The process can be a learning opportunity, an opportunity to develop preventive strategies for the future, and can be helpful in developing self monitoring skills. The review may occur at intervals throughout the day (at lunch, dinner, etc.). Each interval’s activities or events are reviewed.

Schlund and Pace (1999) conducted a study to examine the benefit of systematic feedback to reduce maladaptive behaviors in three individuals with TBI. Their study concluded that the implementation of this feedback resulted in a reduction of both the variability and frequency of maladaptive behavior.

Summary of guidelines for an individual behavior plan

The following are guidelines for implementing a successful behavior plan (Alderman, Davies, Jones, & McDonnel, 1999; Braunling-McMorrow, 1998; Ponsford, 1995; ResCare Premier, 2002; Wood, 2001).

  • The individual with TBI should be included in the development, design, and implementation of the behavior plan. If the individual has input into the plan, it increases motivation to participate.
  • The behavior targeted for change should be identified and clearly defined.
  • The alternative behavior to be reinforced must be identified and clearly defined.
  • Scripts and directions for teaching and eliciting the adaptive behavior should be included.
  • Types and timing of reinforcement should be defined. The plan should be as positive as possible. The focus of a behavior change plan should be on teaching and rewarding desired behavior. Rehabilitation is a difficult process. Encouragement and praise should be given liberally for all attempts to complete the desired behavior.
  • It is a misconception that punishment or loss of privileges is the most effective response to undesirable behaviors. Punishment should be used only after all other interventions have been attempted and exhausted and when the maladaptive behavior is extreme, putting the person or those in his/her environment at risk. If this type of intervention is necessary, all stakeholders (family, rehabilitation providers, funders, case managers, etc.) must be in agreement in regard to the strategy used. The strategy is then used in conjunction with incentives for positive behaviors.
  • The plan should be a tool for teaching. Some individuals may display ‘avoidance’ and ‘escape’ behaviors. When a demand is initiated, individuals with TBI may respond by acting out in order to escape the task. However, being proactive and teaching alternative behaviors can help the individual to cope with the task. For example, identify the skills needed to complete the avoided task, teach the skills to the individual in small, manageable steps, develop an advance agreement to complete the avoided task at a specified time thereby giving the individual the ability to prepare for the task, and follow task completion with a positive reinforcer to increase the likelihood that the desirable response will occur.
  • The plan should be carried out in all contexts. Behavior does not happen in a vacuum, it is influenced by environmental factors and therefore can be displayed in the home, in the community, in the rehabilitation setting, etc. Consistency in implementing the program is critical for its success. Any inconsistencies may cause confusion and may indirectly reinforce the undesirable behavior. All individuals implementing the plan should receive training in all aspects of the plan.
  • The plan should include opportunities for feedback.
  • The frequency in which the desired and undesired behavior occurs should be documented. This process serves two purposes. First, tracking behavioral frequency provides feedback for the individual regarding his/her progress. Second, by tracking behavioral patterns, the effectiveness of the individual behavior plan can be evaluated and revised as needed. It may be necessary to adjust expectations if the desired behavior is too easy or too difficult or to adjust the frequency or type of rewards.

Relaxation Training

Relaxation training is used to reduce one’s experience of anger and tension (Denmark & Gemeinhardt, 2002). It is thought that an individual cannot exhibit both relaxation and anger/tension responses at one given time. Therefore, the individual learns relaxation strategies that he/she can implement when feelings of anger/tension emerge in daily life. Some examples of these techniques are progressive muscle relaxation (focused relaxation of each muscle group in the body — feet, legs, torso, etc.), guided imagery (visualizing relaxing, peaceful, or encouraging experiences), biofeedback (monitoring the relaxation response by using electrodes which monitor and provide feedback about the activity of a muscle), breathing exercises, and forms of meditation (Denmark & Gemeinhardt, 2002). It is useful to incorporate role-play into relaxation sessions. The individual practices initiating relaxation techniques while thinking about potential real-life situations. There is very little literature that evaluates outcomes for the use of relaxation therapy techniques for individuals with TBI. This technique, however, has been used with success for individuals with learning disabilities and for children (Denmark & Gemeinhardt, 2002).

Social Skills Training

Social skills training programs are implemented with individuals who lack interpersonal skills and the ability to effectively communicate their desires in a problem situation or conflict (Denmark & Gemeinhardt, 2002). This type of program is geared toward individuals with problems in social interactions and includes focus on the development of social skills, assertiveness, and problem solving techniques. Social skills acquisition includes teaching the individual how to listen and understand others. Assertiveness teaches the individual to express him/herself constructively rather than in a confrontational manner. Problem-solving techniques allow the individual to develop conflict resolution skills. For individuals with TBI, this type of training can be especially useful as many individuals have difficulty expressing themselves, which often results in frustration and maladaptive responses. Denmark and Gemeinhardt (2002) suggest that role modeling the problem situations in a safe environment is the most beneficial. The role-playing allows the individual to learn appropriate responses or strategies at his/her own rate. It also provides opportunities for repetition and rehearsal of skills. The individual is able to internalize the behavior which helps to circumvent cognitive deficits such as planning, sequencing, and comprehension.

Anger Management

Novaco (1975) introduced one of the first multi-component approaches to anger management. He used a combination of behavioral, relaxation, and assertiveness training during three phases of treatment. The three phases included: 1) cognitive preparation, 2) skill acquisition, and 3) application of training. Medd and Tate (2000) conducted a study with persons with brain injury using a variation of Novaco’s principles. They modified the training by outlining anger syndromes and common difficulties relevant to TBI and developed handouts summarizing the sessions. The program encouraged the participants to increase their awareness of emotional, behavioral and cognitive changes that occur when they become angry. The participants practiced relaxation techniques, self talk methods, and time outs. Medd and Tate (2000) concluded that this type of intervention was beneficial to the individuals in their study. However, they also recognized that the individuals in their study had a relatively high level of cognitive ability with only minimal memory impairments noted. They questioned the effectiveness of this type of approach with individuals who had more severe cognitive impairments.

Another multicomponent anger management program was developed by Deffenbacher (1995) and was called ideal treatment package. This included assessing the individual’s anger and then working at developing self-monitoring, stimulus and response control, relaxation, cognitive restructuring, and interpersonal skills (Denmark & Gemeinhardt, 2002). A study has not been conducted to date regarding the application of this program with individuals with TBI.

Conclusion

In conclusion, several therapeutic approaches exist to assist individuals with brain injury to develop adaptive behaviors. At this time, there is not enough outcome data to dictate which therapy works best. The challenge for those who work with persons with brain injury is to find the intervention or combination of intervention strategies that works best for each individual. It is unlikely that one approach will ever be the ‘sole treatment’ for behavioral problems following brain injury. Unique individuals require unique and individualized treatment.

References

Albert Ellis Institute, & Abrams, M. (2004). Retrieved May 17, 2004, from Albert Ellis Institute Web site: http://www.rebt.org.

Alderman, N., Davies, J. A., Jones, C., & McDonnel, P. (1999). Reduction of severe behavior in acquired brain injury: Case studies illustrating clinical use of the OAS-MNR in the management of challenging behaviors. Brain Injury, 13(9), 669-704.

Alderman, N. (2003). Contemporary approaches to the management of irritability and aggression following traumatic brain injury. Neuropsychological Rehabilitation, 13(1/2), 211-240.

Bennet, T. L., & Raymond, M. J. (1997). Emotional consequences and psychotherapy for persons with traumatic brain-injury: Management of frustration and substance abuse. Journal of Head Trauma Rehabilitation, 13(6), 10-22.

Braunling-McMorrow, D., Niemann, G.W., & Savage, R. (Eds.). (1998). Training manual for the certified brain injury specialist (CBIS) (2nd ed.). Houston, TX: HDI Publishers.

Caraulia, A. P., & Steiger, L. K. (1997). Nonviolent crisis intervention: Learning to diffuse explosive behavior. WI: CPI Publishing.

Deffenbacher, J. L. (1995). Ideal treatment package for adults with anger disorders. In: H. Kassisnove (Ed.), Anger disorders: Definition, diagnosis, and treatment (151-172). Washington D.C.: Taylor & Francis.

Denmark, J., & Gemeinhardt, M. (2002). Anger and its management for survivors of acquired brain injury. Brain Injury, 16(2), 91-108.

Ellis, A., & Dryden, W. (1997). The practice of rational emotive behavior therapy (2nd ed.). New York: Springer.

Fluharty, G., & Glassman, N. (2001). Use of antecedent control to improve the outcome of rehabilitation for a client with frontal lobe injury and intolerance for auditory and tactile stimuli. Brain Injury, 15(11), 995-1002.

Kinney, A. (2001). Cognitive therapy and brain injury: Theoretical and clinical issues. Journal of Contemporary Psychotherapy, 31(2), 89-102.

Manchester, D. & Wood, R. L. (2001). Applying cognitive therapy in neuropsychological rehabilitation. In R. L. Wood & T. M. McMillan (Eds.), Neurobehavioral disability and social handicap following traumatic brain injury. Hove, England: Psychology Press.

Medd, J., & Tate, R. L. (2000). Evaluation of an anger management therapy programme following acquired brain injury: A preliminary study. Neuropsychological Rehabilitation, 10(2), 185-201.

Novaco, R. W. (1975). Anger Control. Lexington, KY: D.C. Health.

Pologe, B. (2001). About psychotherapy. Retrieved March, 2004, from http://www.aboutpsychotherapy.com.

Ponsford, J. (1995). Traumatic brain injury: Rehabilitation for everyday adaptive living. Hove, England: L. Erlbaum Associates.

Prigatano, G. P. (1986). Psychotherapy after brain injury. In G. P. Prigatano, D. J. Fordyce, H. K. Zeiner, J. R. Roeche, M. Pepping, & B .C. Woods (Eds.), Neuropsychological rehabilitation after brain injury. Baltimore: John Hopkins University Press.

ResCare Premier. (2002, June 19). Developing individual behavior plans [CO.Beh.401]. In Training, education, and mentoring system. St. Louis, MO: R. Estes (Ed.).

Schlund, M. W. & Pace, G. (1999). Relations between traumatic brain injury and environment: Feedback reduces maladaptive behavior exhibited by three persons with traumatic brain injury. Brain Injury, 13(11), 889-897.

White, S. M., Seckinger, S., Doyle, M., & Strauss, D. L. (1997). Compensatory strategies for people with traumatic brain injury. NeuroRehabilitation, 9, 205-212.

Wood, R. L. (2001). Neurobehavioral disorders: Their origin, nature and rehabilitation. Seminar provided at the meeting of the Ontario Brain Injury Association in conjuction with Brock University, St. Catharines, Ontario.

Wood, R. L., & Worthington, A. D. (2002). Neurobehavioral rehabilitation: a conceptual paradigm. In R. L. Wood & T. McMillan (Eds.), Neurobehavioral disability and social handicap following traumatic brain injury (107-132). Hove, England: Psychology Press.

Posted on BrainLine June 22, 2009.

via Interventions For Behavioral Problems After Brain Injury | BrainLine

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[Infographic] More in Common Than You Think

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[WEB PAGE] fMRI vs. SPECT Scan for the Brain: Know Your Options

By: Dr. Mark Allen PhD on February 3rd, 2020

If you’re struggling to recover after a brain injury, dealing with healthcare providers is often a frustrating process. Unless you have a clear, severe injury, they might be dismissive of your symptoms or just may not have enough treatment options to help you. Oftentimes, they’ll order an MRI or a CT scan.

But MRI and CT scans will only show structural damage. So, they’re helpful if you have a severe traumatic brain injury, but if you’ve had a mild traumatic brain injury (mTBI, aka concussion), they likely won’t show anything. If your structural MRI scan comes back as normal, many doctors won’t do much in the way of follow-up.

However, that doesn’t mean you’re out of options. If you’re here, you’ve probably heard of SPECT scans and functional MRI. These imaging tests can show dysfunction resulting from an mTBI.

But which one is right for you? In this post, we’ll explain:

  • What SPECT imaging and fMRIs actually are
  • What it’s like to get a SPECT scan or fMRI
  • What they can show, and what that means for your diagnosis.

Note: If you’re experiencing symptoms that won’t go away after a concussion, we can help. On average, our patients improve by 75% after treatment. To learn about diagnosis and treatment options, sign up for a free consultation.

All About Brain SPECT Scans

A cartoon graphic of a woman lying down in an fMRI machine.

What is a SPECT Scan?

SPECT stands for “single photon emission computed tomography.” That’s a mouthful, so here’s what it translates to:

Patients are injected with a radioactive isotope that emits gamma rays (electromagnetic radiation emitted by a decaying atom). As the isotope (also known as a radioactive tracer) travels through the patient’s bloodstream, it continues to emit radiation. (We know how that sounds, but it really is a safe level of radiation).

A special “gamma camera” is positioned above the patient and able to detect the gamma rays emitted by the isotope. A computer then triangulates in 3-dimensional space where the gamma rays are coming from.

In other words, it looks at multiple data points to figure out where the isotope was in your body when the radiation was emitted.

Over time, collecting multiple “images” can show physicians if blood flow in your body has been impacted by your condition.

Note: You may be more familiar with a PET scan (positron emission tomography). The imaging technique is very similar to SPECT scanning, since both use radioactive tracers to investigate blood flow. PET has greater resolution and fewer image artifacts, but it has other drawbacks.

What Can a SPECT Scan Show?

A SPECT scan for the brain shows an average over 10 - 15 min of scanning, but an fMRI can show each second of brain activity.

SPECT scans can be used to look at the heart, brain, and a few other things. In the brain, it can be used in evaluating conditions such as neurodegenerative diseases, stroke, seizures, tumors, and other brain trauma. In the heart, it’s most commonly used to view how well the heart is moving the blood that comes through it.

Because of the delay between when the isotope emits gamma rays and when the camera records them, combined with the inaccuracy of having to triangulate their position, SPECT images are an average over time rather than an instantaneous picture. In many cases, it can take 10-15 minutes to get that average image.

Because of that, it can identify certain conditions better than others. If you’ve had a concussion, brain SPECT imaging can confirm whether you have or have not sustained brain dysfunction after the injury. Unfortunately, it often can’t provide more detailed information about specific regions and how they were affected.

How Long Does a SPECT Scan Take?

The time you spend on a SPECT scan depends somewhat on where you’re getting the scan and why you’re getting the scan. They generally range from 1-2 hours (including the time needed for the injection).

The actual scan itself can take as few as 30 minutes.

How Much Does a SPECT Scan Cost?

SPECT scans are one of the more affordable ways to image the brain, but prices can fluctuate a lot based on location, the purpose of the scan, and what additional interpretation is involved.

According to MDsave, brain SPECT scans range from $1,300 to over $3,500.

Does a SPECT Scan Have Any Side Effects?

The main possible side effect of a SPECT scan is having an allergic reaction to the injected isotope. Some people can have bruising and soreness around the site of the injection as well.

If you’re nervous about the radiation, that’s understandable. As far as Western medicine is concerned, however, it’s perfectly harmless. Most people get more radiation from being on a plane at 30,000 feet in the air than they would from a SPECT brain scan.

All About Brain fMRI Scans

fMRI scan

What is an fMRI?

fMRI scans (functional nuclear magnetic resonance imaging) work through a combination of radio waves and magnets. Engineers have figured out how to magnetize soft tissues — such as the brain — very precisely. When you send radio waves through those magnetized tissues, the magnetic field changes the radio wave.

Sensors detect even minimal changes in the radio waves to form a 3D image of the scanned tissue. The only limits to how fine the imaging can become are human ingenuity and engineering skill.

In a structural MRI, that information is used to examine the physical integrity of the brain (or any other organ being imaged). It should show any physical brain damage you’ve sustained. A functional MRI is used to observe blood flow. Since increased cerebral blood flow is tied to increased brain activity, fMRI can show how the brain calls for resources during a given task.

If you’re trying to understand the difference between a structural MRI and a functional MRI, in terms of what it means for patients, this article will help.

What Can an fMRI Show?

A detailed fMRI scan

fMRIs can show detailed images of blood flow in internal organs. In brain imaging, this means doctors and researchers can see how the brain is managing its oxygen supply and whether the right regions respond in the right way when given a certain task.

For example, we found that patients who have post-concussion syndrome (the condition in which symptoms don’t go away after a concussion) will show tell-tale signs of hyperactivity and hypoactivity in the affected brain regions. Thanks to fMRI, we’re able to pinpoint for post-concussion patients which areas of the brain are dysfunctional and in what way.

To learn more about how we do that, you can read about functional neurocognitive imaging (fNCI), the specific type of fMRI we use.

How Long Does an fMRI Take?

Because fMRI is used more in the research setting than the clinical setting as yet, scan times can vary dramatically. The more you need to know, the longer the scan will take.

At Cognitive FX, an fNCI takes about 45 minutes. During that time, patients take six different cognitive tests while we image their brain to learn how it responds to that stimulation.

How Much Does fMRI Cost?

That depends on who you’re asking — researchers might pay hundreds of dollars per hour for access to one, but if you’re part of a clinical trial, it might be free. That said, if you’re looking to get a brain fMRI for diagnostic purposes, you’ll be charged for both the scan and whatever diagnostic analysis is performed.

At Cognitive FX, charges for an fNCI can run from $3,500 to $5,250, depending on several factors (such as whether you pay in full at the visit or via a payment plan, get the scan as part of a treatment package, etc.).

Does an fMRI Have Any Side Effects?

fMRI does not have any side effects per se, but there are situations in which you might not be able to use it. Some types of foreign metal objects in your body (such as surgical implants, braces, or even permanent eye-liner) may prohibit you from entering the MRI scanner. However, the imaging facility will provide you with full details before you commit to undergoing the scan.

If you have extreme anxiety or fear of enclosed spaces, that would also pose a challenge. fMRI is completed in an enclosed space and is very loud (you are given earplugs, headphones, and cushioning to make the noise more tolerable).

SPECT vs. fMRI: Which is Better?

fMRI vs SPECT scans

fMRI is a higher quality test than SPECT, for a few reasons. However, which functional neuroimaging test you need depends on your situation.

The spatial and temporal resolution of fMRI is significantly better: fMRI can see things down to a few millimeters, whereas SPECT resolution is on the centimeter scale. 

In other words, fMRI has at least 10x better spatial resolution.

When it comes to temporal (time) resolution, there’s no comparison. SPECT gives an image from 10-15 minutes of activity at a time. fMRI, on the other hand, can give a second-by-second picture of how your brain reacts to given stimuli.

While both methods can show if your brain has been affected by a concussion, fMRI can tell you which parts of your brain were affected (Thalamus? Basal ganglia? Prefrontal cortex?) and how (hyperactive or hypoactive). The latter information is far more useful: If we know which areas of the brain are affected, we can tailor treatment to target those regions. This insight into how your brain function has been impacted by injury is invaluable during treatment.

SPECT makes more sense than fMRI in the case of easier-to-see conditions such as stroke and seizure. Since a SPECT scan is typically cheaper than fMRI, there’s no reason not to use it when it will do the job. But for concussion diagnosis, fMRI provides much more robust, clinically useful data.

fMRI for Concussion Diagnosis

All that being said, it’s important to mention that neither fMRI nor SPECT can be used to diagnose a concussion unless the doctor reading the scans has the right information and tools available.

At Cognitive FX, we do a type of fMRI called fNCI, or functional neurocognitive imaging. It’s what allows us to pinpoint which brain regions were affected (as mentioned above).

fNCI uses the same technology of an fMRI, but the imaging process involves having patients perform standardized tasks while in the MRI machine. Over years of research, we built a database of healthy and unhealthy brains performing these tasks. We know which areas of the brain are supposed to be active during these tasks, and how much or little these areas should respond to each separate task.

When we give a patient an fNCI, we analyze the images of their brain to see which areas of their brain are not working optimally. This process allows for accurate diagnosis of injuries that hinder brain function (such as concussion, but sometimes other conditions like brain dysfunction from carbon monoxide poisoning.)

After the test, we meet with patients to discuss their results and how that will affect their treatment. Patients get an overall score and several pages breaking down how each brain region we scanned performed. Here’s an example that one of our patients agreed to share:

Exam 1: Matrix Reasoning Test Findings for Olivia

From Olivia’s story: “The fNCI showed that my thalamus was hypoactive and my basal ganglia was completely out to lunch. 3 standard deviations from normal basically means that there was no activation seen in that area on the fMRI. All the work was being routed around it — causing fatigue and stress on the rest of my brain. The inferior frontal gyrus was trending toward hyperactive (using too many resources for given tasks).”

Because fNCI is a kind of fMRI, the test is noninvasive and harmless. There is no radiation, however, the same restrictions around metal apply.

What You Can Do About Concussion Recovery

For many patients, concussion symptoms resolve after about two weeks. But for others, those symptoms just won’t seem to go away. If that describes your situation, you may have post-concussion syndrome. We’ve listed some of the symptoms in the chart below:

Post-Concussion Symptoms list

Your best bet is to seek treatment from a doctor or clinic that specializes in post-concussion treatment. If you’d like to know more about how we can help you, sign up for a free consultation.

Or, if you’d like to learn about choosing a clinic, here’s our post on the best concussion clinics in the U.S.

Active Recovery

In the meantime, there are things you can do to improve your chances at a good recovery. Do your best to fit these into every day:

  1. Plenty of rest (if you’re having difficulty, this post on post-concussion sleep may help).
  2. Light physical activity for 30 minutes per day (at whatever level you can tolerate without causing symptoms). Here’s our guide to exercising safely after a concussion.
  3. Cognitive activities like reading or logic puzzles, as tolerated.
  4. Work or school activities, as tolerated.

Conclusion

Knowing whether you need an fMRI or SPECT scan comes down to a matter of how much you need to know in order to receive effective treatment. If you’re suffering from post-concussion syndrome, a SPECT scan is better than nothing, but an fMRI is significantly more useful than a SPECT scan.

If you’ve been suffering from lingering symptoms after a concussion and haven’t found relief, you’re not imagining things: 10-20% of people who have had a concussion endure lingering symptoms that do not go away without treatment. We’ve written at length about some of the more common issues our patients face, such as headachesmemory problemsrelentless fatigue, and more.

To learn more about treatment options and what you can do next, sign up for a free consultation.  

via fMRI vs. SPECT Scan for the Brain: Know Your Options

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