Diagnosing Mild Head Injury in Traumatic SCI. Kathleen Castillo, MA, CCC-SLP Kazuko Shem, MD

Transcription

1 Diagnosing Mild Head Injury in Traumatic SCI Kathleen Castillo, MA, CCC-SLP Kazuko Shem, MD

2 Disclosures This continuing education activity is managed and accredited by Professional Education Services Group. Neither PESG nor any accrediting organization supports or endorses any product or service mentioned in this actvitiy. PESG Staff and the Program Planning Committee have no financial interest to disclose. Commercial Support was not received for this activity.

3 Disclosures Kathleen Castillo, MA, CCC-SLP Has no financial interest to disclose. Kazuko Shem, MD Has no financial interest to disclose.

4 Learning Objectives At the conclusion of this activity, the participant will be able to: 1. Participants will be able to determine the need for cognitive testing in the SCI population. 2. Participants will be able to establish proper treatment plan and goals for treatment. 3. Participants will be able to identify therapy ideas and activities to help facilitate cognitive recovery in individuals with dual diagnosis.

5 Obtaining CME/CE Credit If you would like to receive continuing education credit for this activity, please visit:

6 SCI Incidence / Prevalence Approximately 273,000 people with SCI in the US 12,000 new SCI cases each year Statistics are from the 2012 SCI Model Systems National Database

7 SCI Epidemiology Average age = 28.7 (1979) Average age = 42.6 (2012) 80% males

8 SCI Etiology Motor vehicle accidents (36.5%) Falls (increasing) GSW (gun shot wounds) Sports related injuries (decreasing )

9 Psychosocial consequences Decreased quality of life Difficulty with community reintegration SCI Employment 57% employed at the time of injury After 1 year ~ 12% returned to work After 20 years ~ 35% returned to work

10 Traumatic Brain Injury Incidence million individuals with TBI will present to the emergency room each year 80% will be released 275,000 hospitalizations

11 TBI Incidence Currently 10,600 persons followed today Average age = 40 75% male

12 TBI Etiology Motor vehicle accidents (53%) Falls (23%) Violence (13%)

13 TBI Employment 62% employed at time of injury 28% employed 1 year after injury

14 What does the research say?

15 TBI in SCI The mechanism of injuries involved in SCI an abrupt impact at a high velocity (Sommer 2004). Any mechanical injury severe enough to cause spinal cord damage is also likely to cause insult to the brain Contusion Diffuse axonal injury Concussion

16 TBI in SCI Many patients with SCI who sustain concussion or mild TBI may go undiagnosed and untreated, because most individuals with SCI without TBI may also have mood changes or other symptoms of head injury Headaches Dizziness Irritability Fatigue Sleep dysfunction Sommer 2004, Tolonen2007, Saunders 2012, Wijesuriya 2012

17 TBI in SCI Relatively high incidence of concomitant TBI of about 50-75% in individuals with traumatic SCI. mild TBI being the most common TBI severity Individuals with TBI have poor executive function, difficulties with attention, memory, information processing, communication, perception, and new skill acquisition; factors that may interfere with rehabilitation for SCI.

18 Toronto Rehabilitation Institute (2008) Prospective study N=10 TBI diagnosed with MRI PTA LOC Neuropsychological studies (Wechsler) Bradbury CL et al.

19 Toronto Rehabilitation Institute (2008) Poor on neuropsychological testing Higher cost to rehab $169,638 TBI and SCI vs $130,773 in SCI only LOS days vs days FIM scores not reflective

20 Shepherd Center (2008) Prospective study N=198 60% of the SCI had TBI TBI diagnosed based on GCS, PTA, imaging TBI associated with MVA, falls C1-C4 LOI Complete injury 34% mild FIM cognitive scores associated with severity of TBI Macciocchi S, et al

21 SCVMC Study Results 11 individuals with C4 to T11 injuries 10 of 11 subjects were male Age range: 20 years old to 56 years old 4 MVA 3 Bicycle accidents 2 Mechanical falls 2 Sports injuries

22 Results Limited sample size 4/11 subjects were unable to complete the full RBANS Total Scale percentile scores obtained ranged from 10 to 45

23 Percentile score Figure 1: RBANS subtest and total scores Immediate memory Visuospatial/ Consructional Language Attention Delayed memory Total

24

25 R B A N S Repeatable Battery for the Assessment of Neuropsychological Status Norms: 20 years 89 years (male/female) White African American Hispanic

26 Subtests List Learning Story Memory Figure Copy Line Orientation Picture Naming Semantic Fluency Digit Span Coding List Recall List Recognition Story Recall Figure Recall

27 List of 10 words List Learning A word is read every 1.5 seconds Subjects repeat as many words as are recalled after the entire list is read 4 trials

28 Story Memory (Contextual) Short story is read Subjects repeat details verbatim 2 trials

29 Figure Copy

30 Line Orientation

31 Picture Naming 10 pictures 20 seconds to respond per item Vary in degree of familiarity Or NOT

32 Semantic Fluency Fruit and Vegetable naming In 60 seconds

33 Digit Span Digit strings are read (1 digit per second) then immediately repeated Strings range from 2 to 9 numbers If the first string is failed, a second is presented; discontinue after two failures in a set

34 Coding

35 Recall Subtests List List recognition Story Figure

36

37

38

39

40

41 Conclusions The RBANS proved to be a workable mechanism for testing certain cognitive tasks in patients with SCI who were suspected of having TBI. Cognitive deficits especially in the Language and Attention subscales. Memory, both immediate and delayed, appeared somewhat less impaired. These deficits have serious implications for patients' ability to complete the learning necessary to adapt to life with SCI.

42 Limitations Three RBANS Subtests require written responses RBANS norms do not go below age 20 Pain, medications, psychological state may limit performance

43 Implications Comparable age and gender population vs. national statistics Functional implications of cognitive-linguistic deficits indicated by low RBANS scores (e.g. poor carry-over of weight shift and ICP schedules)

44