BRAIN INJURY AND PSYCHIATRY Kelly Collins MD Physical Medicine and Rehabilitation Brain Injury Medicine Board Certified WHAT DOES A PM&R DOCTOR DO? See handout Physical Medicine and Rehabilitation physician or Physiatrist, NOT psychiatrist or physical therapist Our Outpatient focus (not comprehensive for PM&R): brain injury/concussion, stroke, brain tumor, SCI, amputees, MSK, EMG, joint and trigger point injections, spasticity management (incl. Botox) What we do not currently see: pediatrics, burn, chronic pain (not including spine) Looking to expand, but Neuro is main focus right now Inpatient: 20 bed unit PM&R Team: Kelly Collins, MD, Jeff Derr, MD, Ann Summar APRN CNP, Becky Kastanek APRN CNP BRAIN INJURY BASICS (WHAT I WISH EVERYONE KNEW) TRAUMATIC BRAIN INJURY Are brain injury and concussion interchangeable? Radiologic evidence of trauma (10% of the brain injury world) Basilar skull fractures can be our friends?!? Radiologic recovery often before functional recovery Anticipate full recovery vs plateau at 2-3 years, but may be sooner Anoxia is a type of brain injury doesn t really have its own category CONCUSSION POST CONCUSSIVE SYMPTOMS 90% of brain injury world Often missed common incorrect diagnoses are bipolar disorder, anxiety, depression, fatigue, migraines, headaches, chronic pain Concussions do not require impact to the head (ie. Rotational forces leading to axonal injury) See handouts Most patients with concussions (80-90%) fully recover (compensate for deficits) in 4 weeks Patients with post concussive syndrome (10-20%): symptoms lasting longer than 4 weeks Persistent post concussive syndrome means symptoms still present after 3 months 1
RISK FACTORS FOR WORSE OUTCOME AFTER CONCUSSION VISION AND CONCUSSION Hx of previous concussion with prolonged recovery Family hx of previous concussion with prolonged recovery (genetics) Hx of anxiety, depression, migraines (other psychiatric diagnoses) (Developmental vision issues, poor social support, increased stress with cognitive dysfunction) Life is not like the movies! If you had problems before your concussion, they are not expected to get better afterwards 80% of the brain either assists with vision or uses visual information to function Visual tracts are long (from eyes to occiput and brainstem) and at high risk for injury Occipital lobe is often injured (falling backwards, coup-counter-coup) Autonomic dysfunction affects vision stuck in fight or flight (or lack of parasympathetic input) causing loss of ambient vision EYE DOCTORS ARE NOT ALL THE SAME COMMON VISUAL EFFICIENCY FINDINGS ON EXAM Ophthalmologists Neuro-ophthalmologists Optometrists Neuro-developmental Optometrists Glasses: tint, prism, more than one pair Syntonics light therapy not FDA approved. Very effective for more difficult cases (more to come on this ) OUTCOMES FOR PATIENTS ANOSOGNOSIA An inability or refusal to recognize a defect or disorder that is clinically evident Medial inferior frontal lobe damage Big challenge and why many of my patients get missed initially 2
INDICATIONS FOR SYNTONICS LIGHT THERAPY (ALTERNATIVE MEDICINE NOT FDA APPROVED) FIRST TEST Anxiety PTSD Traumatic Brain Injury Omni Vision in Monticello. Bright Eyes in Otsego. Vision Cents in Little Falls. Costs under $300 for four months of treatment and testing. Lion s Clubs have been open to helping with payment Most Neuro-developmental Optometrists know about this Side effects, non-responders MOST RECENT TEST COMMON PSYCHIATRIC DISORDERS IN TBI Acquired attention deficit most resolve Anxiety Depression PTSD Also: grief, adjustment disorder, pain syndrome, emotional dysregulation, frontal lobe syndromes MEDICATION PEARLS TREATMENT PEARLS Start low and go slow! No benzodiazepines (Ambien) No medical cannabis - at least not THC No EtOH Higher risk for side effects than non-brain injured patients Treat these three symptoms first: Sleep Headache/pain Depression Common initial medications: TCAs, gabapentin, Lyrica, mirtazapine, acetaminophen, NSAIDs, trazodone, triptans, SSRIs, melatonin, *Wellbutrin Common secondary meds Buspar, neurostimulants, Sonata, SNRIs *Wellbutrin increases energy, increases cognitive functioning, improve sexual functioning, reduces depression 3
THERAPIES FOR BRAIN INJURY OTHERS ON THE TREATMENT TEAM Physical therapy Vestibular eval and training/balance (BPPV) Vision screen Cognitive screen Speech and Language Pathology (aka Speech therapy) Identifies and educates on symptoms and symptom management Teaches cognitive strategies Teaches life skill strategies Occupational therapy (usually the longest) Visual efficiency testing and treatment Sensory dysfunction eval and treatment Therapeutic listening (vestibular and cognitive strategies) Usually begins after seen by Neurodevelopmental Optometrist Social worker (Gwen Feddema LSW) Counselor (Dr. Karen Freed s groups, Chris Gilyard LMFT, others) Psychiatry Neurology (headache) Family members WHEN TO CONSULT US MISSED BRAIN INJURY SURVIVORS Inpatient: consider consulting us if there is concern of possible TBI/concussion Consider a follow up appointment with us after discharge (Inpatient Rehab Referrals) Outpatient current strategy is to start with PCP. If patient has severe symptoms or does not improve within 4 weeks, then consider referral. refer to therapy(ies). Be careful not to overwhelm patient Abuse survivors battered women and children Political Trauma survivors refugees Veterans Elderly person who falls or has heart surgery Student athlete (compensate well) Early intervention is key PEOPLE DO RECOVER FROM TBI AND CONCUSSION OTHER TIDBITS If you don t ask, they don t tell Preventative measures: helmets, no ladders, keep floors clear, substance abuse, etc. Different levels of recovery usually they plateau the new normal 4
Brainsafemn.com Central MN collaborative Research Impact Testing at high schools Standards of Care/templates Community outreach www.braininjurymn.org Walk for Thought St. Cloud, Twin Cities, Duluth each year Patient, family and provider educational resources Call Wendy Hoffman 612-378-2742 with questions (her number is on the website) QUESTIONS VS. DISCUSS MORE ABOUT VISION VS. OTHER 5