Social Practice. Traumatic Brain Injury and Therapy Report

Case Study

PT, a 24-year-old, unmarried Caucasian male, on leave from his OIF posting in Iraq, was apparently normal till he met with an ATV accident recently and now has presented with difficulties of mobility, memory deficits, speech impairment, difficulty in concentration, cognitive impairment, and pain of his right shoulder and a blurred vision. He can be described as a pleasant person with good insight into his cognitive deficits and the able handling of his mobile phone conveyed the picture of a positive thinking individual whose mental status was apparently steady and willing to undertake more for quick recovery, the right kind of patient.

His coping strategies appeared to be good. The war had not given him any injuries though he had faced 5 mortar blasts. Though the speech was a problem, PT narrated the history of the accident himself and what followed after from what his family told him. While on block leave from duty in Iraq, he had gone riding on an ATV and was later found hurt and unconscious by the police who took him to the hospital. Hospitalization at Loma Linda VA lasted 3 months though he believed that it was just a week ago where he was treated for TBI and the accompanying hemiplegia and other associated problems.

There was no memory of the accident. The last thing that he remembered was his ride. He was not wearing a helmet then. Then he was treated at Pavo Alto VA PTRP Program from where he reached Dr. Peppers of the PM and R Department of Polytrauma in January 2008. Dr.Peppers conducted the TBI Second Level Examination and referred him to the Polytrauma Social Work Assessment and Referral where I am a service provider.

He has his mother and a stepfather, a half brother, and 2 half-sisters. His father had passed away. His guide and mentor was his stepfather. PT says he receives social and moral support from his friends and family but refrained from naming anyone. There is no positive history of college education as he is vague about it. Currently, he has no job but wishes to do something when he is discharged from the army. His financial status appears to be steady now. He has been given an insurance amount of $50000 and has a total monthly income of $ 2520. PT does his own cooking and other activities himself.

History of alcohol or tobacco use is denied and PT recollected that he had abstained for more than a year. The nicotine patch is in situ. The history of using additional Trazadone tablets was volunteered. The automobile that he drives was obtained under a false name.

Carnival activities are his style of leisure.

Dr. Peppers’ Case records of TBI Second evaluation

Case records show no evidence of neurobehavioral symptoms as history before the accident. We can assume that he was a perfectly normal healthy person before the accident. Dr. Peppers of the WLA PM and RS Polytrauma Department saw PT after his discharge from the Palo Alto VA PTRP program. The history recorded said that PT had sustained a severe, non-penetrating head injury about some months back. There was associated unconsciousness then. The patient himself had given the history. Though having residual cognitive deficits and recovering left hemiplegia, he was ambulant at arrival at Dr. Peppers’s clinic. He was executing his daily functions fairly normally and was on medications for his residual problems: Trazadone, a nicotine patch, carboxymethyl cellulose ophthalmic solution, and Buspirone.

The medical record dated 17/1/08 showed that physical examinations were within normal limits for a pulse, BP, respiratory rate, general examination, respiratory system, and gastrointestinal system. Both thumbs exhibited a dislocation and relocation but the left thumb could not be extended. Neurological examination showed that he was cooperative, awake, and alert. The speech was fluent and appropriate. The Mini-Mental State Examination score was full implying that he had no obvious cognitive deficit. Cranial nerve examinations showed involvement of the III and VIII Nerves. The right eye did not accommodate and the left only slightly.

The tongue deviated to the left. The motor system showed normal power in the muscles of the limbs on the right side. The power of the muscles on the left was slightly affected in the upper limb including the deltoid, biceps, triceps, wrist extensors, wrist flexors, finger flexors, and interosseous muscle and the power in all were 4/5 with the movement against resistance present but without any clonus. All the other muscles from the hip downwards to the toes were normal. A trace of atrophy was observed in the left thenar eminence. The sensations of light touch and proprioception in the upper and lower limbs were normal.

The heel-toe walk was very slightly affected but he did not fall. The left upper limb muscles showed normal reflexes. The patellar reflex was very brisk on the left but normal on the right. The Babinski reflex was downgoing on the left. No clonus had been noticed. The tone in the left pectoralis major muscle was slightly increased especially in external rotation and in the left finger flexors and interossei.

Flaccidity was seen. The cerebellar functions were slightly disturbed on the left (finger nose test, rapid alternating movements, heel to shin). Romberg was normal. His gait was affected. There was left forefoot inversion, hip circumduction, mildly decreased hip flexion, no toe drag, left arm flaccid in internal rotation, and pronated and held below the beltline. Subluxation was not palpated in the left shoulder. Mild tenderness was elicited over the left biceps tendon and the acromioclavicular joint. Pearson’s test was positive and Speed’s test was negative.

Consultations had been arranged by Dr. Peppers with the neuropsychologist, occupational therapist, Ophthalmologist, physical therapist, and psychiatrist. The consultation was arranged for prosthetics also.

Psychosocial Assessment

This patient had pain in the left arm due to the increased tone of the pectoralis muscle, the occasional left humeral subluxation when walking, and because the arm is hanging without support. He probably had full-fledged hemiplegia earlier but was recovering. The same could be said for the cognitive deficits which did not recover as fast.

The tangential shift in the left eye is due to the involvement of the oculomotor nerve. Blurry vision and seeing double is because of the disturbance in accommodation caused again by the involvement of IIIrd Nerve (Oculomotor) along with hemiplegia which was due to involvement of the brain in TBI. The attempt towards the normal movements of the eye, when redirected during the examination, confirms that the nerve involved and the muscles are on a recovery path.

The loss of memory about the accident is indicative of post-traumatic amnesia which is a characteristic feature of Traumatic Brain Injury (Russell, 1932). This amnesia is seen as a period of disorientation and inability to form and recall new memories. Patients show a period of continuous improvement till they can finally recover to regain the ability to form and recall new memories. The duration of post-traumatic amnesia is used as an index for predicting the severity of TBI (Ellenburg, 1996).

A better term to describe the period is post-traumatic confusion as a state of attention and memory impairments is accompanied by a disturbance of consciousness, variation in psychomotor activity, and a ‘disrupted sleep-wake cycle’ (Sherer et al, 2008). The Confusion Assessment Protocol is a good instrument to assess the different manifestations of post-traumatic confusion in early recovery from moderate or severe TBI developed by Sherer et al (2008). The CAP measures 7 symptoms of “disorientation, cognitive impairment, fluctuation in symptom presentation, agitation, nighttime sleep disturbance, decreased daytime arousal and psychotic-type symptoms” (Sherer, 2008). A diagnosis of post-traumatic confusion can be made if 4 symptoms are present or 3 with one being disorientation.

Sleep disturbances are common following TBI, reported by 30-70% of patients (Oullet, 2007). PT has this problem and he has been prescribed Trazadone as a measure to help him sleep. 30% have insomnia syndrome characterized by frequent, pervasive

symptoms and affecting daily life. The problem could be that of falling asleep or maintaining sleep. Insomnia intensifies other TBI-related problems like cognitive deficits, pain, fatigue, or irritability. It also can be an obstacle in rehabilitation. An important part of TBI rehabilitation is preventing or treating insomnia (Oullet, 2007). The Diagnostic Interview for Insomnia obtains the description of the type of sleep problem.

The quality of life following a TBI is usually reduced. Cognitive, behavioral, and physical impairments could be accompanied by problems in the functional areas of work, interpersonal relationships, and leisure activities (Pagulayan, 2006). The health-related quality of life (HRQOL) depends on the patient’s view of his injury-related health status and his attitudes about the recovery of functioning. The HRQOL is an outcome that provides ample information about impairments and disabilities and an idea about the interventions for rehabilitation (Pagulayan, 2006). PT is a patient who is positive where HRQOL is concerned. He is cooperative and willing to comply, sometimes with a little persuasion. We can expect a favorable outcome for psychosocial interventions on his behalf. Present methods and measures do not focus on the functional domains of

social, emotional, cognitive, vocational, and physical nature for the psychosocial interventions for recovery of cognitive impairments. A method needs to be adopted to include these aspects in my work on PT. Records have identified other Axis I disorder. The Sickness Impact Profile is one measure that covers the numerous domains of functioning. PT has recognizable cognitive impairments which disturb his memory and sleep pattern, adjustment disorder, mixed anxiety and depressed mood which were diagnosed earlier at Pavo Alto VA and treatment is being continued still. All these come under Post Traumatic Stress disorder as the symptoms are persisting after a long duration of nearly a year.

Speech impairment and attention deficits are seen in PT. The neural networks subserving attention are found in the brainstem, frontal and parietal regions. Attention is considered to be a multifaceted cognitive process. Attention deficits are a major problem after TBI. To measure attention deficits accurately is a difficult task (Whyte et al, 2008).

The Moss Attention Rating Scale (MARS) is an observation rating scale of attention-related behaviors for assessment in patients with moderate to severe TBI especially for those undergoing rehabilitation. MARS is also recommended for speech-language pathologists, nurses, occupational therapists, and physical therapists. (Whyte et al, 2008).

PT had been advised to take half to one tablet of Trazadone 50 mg. at night when he had difficulty sleeping. 25 mg to 75 mg. is prescribed for insomnia. However, he had been using 2 or 3, tablets, probably because he did not have a favorable response with the small dosage. Usually, Trazadone is used for depression. Depression is caused by an imbalance of neurotransmitters like acetylcholine, serotonin, dopamine, and norepinephrine in the brain (Trazadone, WebMD). Trazadone acts upon the neurotransmitters by indirectly inhibiting the uptake of serotonin by the neurons in the brain and directly by increasing the action of serotonin. It can be used with other drugs for panic attacks. The normal dosage is 150mg per day. Suicidal attempts are possible with Trazadone.

The nicotine active patch 14 mg/24 hours was most probably used to encourage cessation of smoking. It could also have been to increase attentiveness in PT’s cognitive behavior. Nicotine has been found to increase attentional performance as measured by the Connors continuous performance test (CPT). Motor and memory function showed no difference (White, 1999) in his study on Alzheimer’s Disease (AD) patients. The explanation here is that loss of nicotinic acetylcholine receptors is associated with reduced cerebral perfusion in AD. Nicotinic receptor binding has been linked to cognitive performance. Transdermal nicotine has been found to increase whole-brain metabolism and improve event-related potentials in AD. The patch improved cognitive behavior in ADHD children and schizophrenia (White, 1999).

Carboxymethylcellulose eye drops are used as smoothening lubricant drops for PT’s eyes which are prone to drying due to inadequate closure of both eyes, the left more than the right..

Buspirone is being given for PT’s adjustment disorder, mixed anxiety, and depressed mood. PT desires to stop Buspirone as it does not seem to do him any good.

However, he has to necessarily continue it as he does have irritability and mood changes. Buspirone is being taken in doses of 10mg. or one tablet every morning and evening. PT must be told not to stop Buspirone as he needs it.

Recommendations

Further assessments need to be made to decide whether PT has PTSD by the definition in the Diagnostic and Statistical Manual IV and TR. The diagnosis can be made if PT has a combination of one re-experiencing symptom, 3 symptoms of increased avoidance, and 2 symptoms of increased arousal with significant impairment in one or more areas of work, home, relationships, and leisure activities and the symptoms last for 4 weeks or more. (Hughes, 2006). The Structured Clinical Interview could be used for making the diagnosis (Kindt et al, 2007). The main recommended therapies are cognitive behavioral therapy (CBT), cognitively based treatments of eye desensitization movements, and reprocessing which is also known as EDMR (Hughes, 2006).

PT may be given CBT as he has suggestive symptoms of post-traumatic amnesia, anxiety, and depression along with cognitive impairment and sleep disorders. The cognitive treatment should include ‘exposure to intrusive thoughts and images, especially hot spots’ and ‘the challenging of underlying and maintaining beliefs, assumptions and schemes’. (Hughes, 2006). The EMDR or eye movement desensitization and reprocessing therapy (Hughes, 2006) may be done remembering that PT has a recovering paralysis of the oculomotor nerve (part of the hemiplegia) which has caused a squint in resting position but eye movements are possible when redirected.

Bilateral stimulation of the brain is the aim here. (The oculomotor nerve provides the innervation for all the eye muscles except the superior oblique and lateral rectus). Reprocessing should be focused on desensitization to recurrent images and thoughts and installation of alternative cognitions (Hughes, 2006). Imaginal exposure combined with rescripting is a new technique for noticing the change in interpretation of the trauma. It is being instituted during CBT and after (Kindt et al, 2007). ‘Dysfunctional interpretations may best be corrected by inducing new perspectives on what happened during trauma by experiencing new views and new emotions’ (Kindt et al, 2007). Traumatic memories are thus desensitized.

References

Ellenberg JH, Levin HS, Saydjari C. (1996), “Posttraumatic amnesia as a predictor of outcome after severe closed head injury. Prospective assessment”. Arch Neurol 1996; 53:782-91.

Hughes, Jamie Hacker; (2006), “Psychology and cognitive processing in post-traumatic Disorders”, Psychiatry 5:7, History, Epidemiology and Treatment, Elsevier 2006.

Kindt, Merel et al, (2007), “Perceptual and conceptual processing as predictors of treatment outcome in PTSD”, Journal of Behavior Therapy and Experimental Psychiatry Vol.38 (2007) 491–506.

Oullet, Marie-Christie and Morin, Charles M.; (2007), “Efficacy of Cognitive-Behavioral Therapy for Insomnia Associated With Traumatic Brain Injury: A Single-Case Experimental Design”, Arch Phys Med Rehabil Vol 88, Pgs 1581-1592.

Pagulayan, Kathleen F.; Temkin, Nancy R.; Machamer, Joan and Dikmen, Sureyya S.; (2006), “A Longitudinal Study of Health-Related Quality of Life After Traumatic Brain Injury”, Arch Phys Med Rehabil Vol 87, Pgs 611-618.

Sherer, Mark; Yablon, Stuart A.; Nakase-Richardson, Risa and Nick, Todd G.; (2008), “Effect of Severity of Post-Traumatic Confusion and Its Constituent Symptoms on Outcome After Traumatic Brain Injury”, Arch Physical Medical Rehabilitation, Vol.89, Pgs 42-47.

White, Heidi K. and Levin, Edward D.; (1999), “Four-week nicotine skin patch treatment effects on cognitive performance in Alzheimer’s disease”, Psychopharmacology, Vol 143, Pgs 158-165.

Whyte, John et al, (2008), “The Moss Attention Rating Scale for Traumatic Brain Injury: Further Explorations of Reliability and Sensitivity to Change”, Arch Phys Med Rehabil Vol 89, Pgs 966-973.