Tbi functional assesment tool

Such measures include Neurobehavioural Function Inventory and specific neuropsychological tests like Rey Complex Figure for visuoconstruction and memory, Controlled Oral Word Association for verbal fluency, Symbol Digit Modalities verbal for sustained attention and Grooved Pegboard for fine motor dexterity.

The problems with outcome measures include poor operational definitions, lack of sensitivity or low ceiling effects, inability to evaluate patients who cannot report, lack of integration of morbidity and mortality categories, and limited domains of functioning assessed. Therefore, patient self-report of previous head trauma is often used in both clinical practice and research as a screening method to identify TBI.

However, the most common practice of asking one or two questions to identify a history of previous TBI has been found to be inadequate in that all but the most severe or recent injuries are missed Corrigan and Bogner, b. The problem of recall is most apparent in adults attempting to report TBI that occurred in childhood. Even when carefully cued, adults with TBI events occurring before age 4 were unable to report prior injuries 25 percent of the time even when hospitalization was involved McKinlay et al.

In general, most previously unreported childhood TBI is not recollected, although having been older at the time of injury and having experienced a more severe injury were found to increase the likelihood of remembering prior injury McKinlay and Horwood, Failure to recognize the etiology of symptoms precludes appropriate treatment or symptom management Yi and Dams-O'Connor, While the literature provides evidence that self-report might be helpful for the initial screening of TBI and its symptoms, the evaluation is greatly enhanced by structured interviews using validated instruments.

Furthermore, self-report does not replace the need for a clinical evaluation for TBI and comprehensive neuropsychiatric testing Corrigan and Bogner, a. Given the complexities in diagnosing TBI, especially mTBI, and the time that might have elapsed since the original injury, a diagnostician needs to be trained on and familiar with the standard diagnostic tools discussed earlier in the chapter used in making a determination of brain injury and its severity.

Currently the VA requires one of four medical specialists to diagnose TBI: a neurologist, neurosurgeon, physiatrist, or psychiatrist. The physician making the diagnosis should be familiar with the signs and symptoms of TBI, abnormal structural imaging, and abnormal physical findings on exams such as neurologic exams.

Additionally, the diagnostician should be aware of common psychological comorbidities that often present with TBI and should be prepared to refer the patient for additional evaluation. For example, in cases where the neurologic exam is normal in an individual with mTBI, a physician specializing in concussions might need to work with a psychologist as part of a team approach to ensure a comprehensive evaluation and diagnosis.

Additional specialties might need to be available, as part of a team, and the physician should not hesitate to call on those team members who might assist in making the diagnosis.

Thus, making a diagnosis of brain injury might include. Clinical psychology and clinical neuropsychology, for example, are disciplines where specialized training in assessment of TBI consequences is common and documentable Podell et al.

Even if the sole determination is not made by a professional of one of these specialties, it is difficult to see how adequate information about cognitive consequences of TBI could be collected without a formal assessment. Given today's increased awareness of TBI, more medical specialties now include training in TBI within their curriculum and have continued updates concerning the current state of the science. Thus, the VA should allow health care professionals, including non-physicians, with additional training and experience in brain injury, to make TBI diagnoses.

The committee believes that it is the training and experience, not necessarily the medical specialty that renders a health care specialist capable of an accurate diagnosis. The committee recommends that the Department of Veterans Affairs allow health care professionals who have specific traumatic brain injury TBI training and experience, in addition to the current required specialists, to make a TBI diagnosis.

Furthermore, the committee recommends pertinent and ongoing clinical training that is up to date with the state of current knowledge regarding TBI. The committee notes, however, that specific and ongoing clinical training does not automatically guarantee knowledge and skill acquisition.

Thus, the VA should consider implementing a mechanism to prove the success of educational initiatives through demonstration of competency in assessing and diagnosing TBI.

In addition to the complexity of diagnosing TBI as described above, common co-occurring conditions including PTSD, depression, pain, and sleep disturbance may also complicate the diagnosis. TBI has been associated with behavioral health problems such as persistent pain, depression, sleep, anxiety, aggression, and impulse control and overlaps with the symptoms of PTSD Collins et al. PTSD and other mental disorders are often diagnosed concurrent with or following a brain injury.

PTSD and TBI share some key neuropsychologic and functional neuroanatomic characteristics, and both are associated with cognitive impairment and sleep disruption Tanev et al. Dissociative symptoms are often observed in PTSD, and there is evidence that TBI can result in dissociative-like symptoms, such as emotional numbing, derealization, reduced awareness of surroundings, depersonalization, and amnesia Bryant et al. Further complicating the issue of comorbidity is that TBI, PTSD, and depression are also associated with chronic pain, which similarly overlaps with those conditions Bryant et al.

Farmer and colleagues used Military Health System electronic health record data to characterize common symptoms associated with an mTBI diagnosis in the Military Health System. The symptoms included headache, sleep dysfunction, dizziness, and balance disorders. Additionally, the report reinforced earlier findings that individuals with an mTBI diagnosis are also frequently diagnosed with behavioral health conditions such as depression and PTSD.

Farmer et al. The most common behavioral health diagnoses were adjustment disorder 16 percent and anxiety disorder 14 percent , followed by a diagnosis of depression. Hoge et al. A study by Hoge et al. However, after the researchers adjusted for PTSD and depression, they found that mTBI was no longer significantly associated with those physical health outcomes or symptoms, except for headache.

Furthermore, the study found that PTSD and depression are important mediators of the relationship between mTBI and physical health problems Hoge et al.

A recent study of veterans without TBI who had returned from Iraq and Afghanistan reported prevalence rates of 23 percent for PTSD, 17 percent to 21 percent for depression, and 7 to 15 percent for alcohol-related problems.

The rates were much higher among veterans with TBI, with 89 percent having a comorbid psychiatric diagnosis, including 44 to 54 percent who had a diagnosis of PTSD and 70 percent who had pain diagnoses Armistead-Jehle et al.

TBI may result in co-occurring mental and physical symptoms, mental health symptoms may exacerbate pain and other post-concussive symptoms, and symptoms may occur coincident to one another. Pain, the use of medications, alcohol or drug use or intoxication, or PTSD, which can be present either in isolation or in addition to a brain injury, can confound or complicate the diagnosis Hoge et al. Damage to the brain after trauma is referred to as traumatic brain injury.

TBI may be blunt, non-penetrating, penetrating, or due to blast. The resulting neuropathology consists of a primary injury that is a direct consequence of the traumatic insult and a secondary injury that results from a cascade of molecular and cellular events triggered by the primary injury and that leads to cell death, axonal injury, and inflammation. According to CDC, mTBI often referred to as a concussion manifests initially as a brief change in mental status or unconsciousness, whereas severe TBI results in an extended period of unconsciousness or amnesia.

TBI severity is typically defined at the time of initial injury; the GCS has been the gold standard of neurologic assessment of trauma patients since its development by Teasdale and Jennett in Other TBI severity-classification systems grade single indicators, such as loss of consciousness and duration of posttraumatic amnesia.

The predictive value of those measures has been demonstrated, but each may be influenced by factors unrelated to, or only indirectly related to, the severity of the TBI e. Ultimately, the severity of the injury defined initially does not necessarily predict the trajectory or natural history of TBI, as individuals diagnosed with mTBI can experience ongoing impairment. In the absence of clear biomarkers, self-report based on a validated screening method is currently considered the gold standard for obtaining a comprehensive lifetime history of exposure to TBI.

Reliance on medical records is often insufficient because many injuries are not treated, including, occasionally, even more severe injuries. Screening instruments vary in the extent to which their psychometrics have been established, with single-item screens tending to be the least reliable and least likely to capture all TBIs.

The current method of TBI diagnosis after initial injury relies on the report of certain symptoms at the time of injury from the person who was injured or from a witness.

However, not all individuals who have sustained a TBI are identified at the time of the initial injury as, in the case of complex polytrauma, for example, other injuries might appear to be more severe and the head injury is not assessed, or, in the case of mTBI, the individual might not present for medical care. Furthermore, there are no current tests to help make, and perhaps document, the diagnosis more than 24 hours after injury, although new tests have been approved by FDA for use early after injury.

Thus, when considering the diagnosis of TBI in the clinical setting, it is important to understand the role that patient and family self-report have in providing evidence of injury. While prospective evaluation is often able to document an initial injury, prior injuries are typically undocumented or elicited via informal methods.

Furthermore, TBI is often confused with a variety of other conditions including aging, depression, and emotional problems such as PTSD. Even when medical records are available, a large percentage of prior injuries often do not receive recognition or medical attention. TBI has been associated with such behavioral outcomes as depression, anxiety, aggression, and impulse control and overlaps with the symptoms of PTSD.

Thus, a TBI evaluation might be incomplete unless the diagnostician is familiar with the symptoms of PTSD and other common comorbidities. PTSD and other psychiatric conditions are often diagnosed concurrent with or following a brain injury.

PTSD and TBI share some pathophysiological characteristics and both are associated with cognitive impairment and sleep disruption. It is important to recognize that mental health symptoms might have causes other than TBI. These causes include pain, the use of medications, alcohol or drugs use or intoxication, or PTSD, all of which can be present either in isolation or in addition to a brain injury and, as noted, confound or complicate the diagnosis.

Given the complexities in diagnosing TBI and the time that might have elapsed since the original injury, a diagnostician needs to have experience with TBI and be trained and familiar with the state of the science in order to accurately make a determination of brain injury and its severity. In addition, there is ongoing research and new theoretical views on the trajectory of recovery after TBI, so new developments are likely forthcoming that would help providers who have training and experience with TBI to accurately diagnose TBI.

There are many specialties and subspecialties involved in making the diagnosis of a brain injury, particularly if the diagnosis occurs months to years following the injury. Universities and medical schools offer special training in brain injury to train physicians and other health care professionals with an interest in the field to assist in the diagnosis, treatment, and rehabilitation of individuals diagnosed with brain injury. Thus, the VA should consider allowing other health care professionals with experience and pertinent ongoing training in brain injury to make TBI diagnoses.

The committee believes that it is the training and experience and not necessarily the specialty that renders a health care professional capable of an accurate diagnosis. The authors note that it is unclear the relative roles biophysiology, anthropomology, and sociocultural constructs play in these differences.

Clinicians use the DSM to diagnose disorders affecting mood, personality, identity, cognition, etc. The DSM has been updated several times since it was first released in , and it is published by the American Psychiatric Association.

Subdural hematoma is an accumulation of blood above the brain but below the dura, which appears as a crescentic or concave opacity overlying the brain on CT. Epidural hematoma is a traumatic accumulation of blood between the inner table of the skull and the stripped-off dural membrane. Intra parenchymal hemorrhage is one form of intracerebral bleeding in which there is bleeding within brain parenchyma. Turn recording back on.

National Center for Biotechnology Information , U. Search term. Mechanism of Injury There are various mechanisms that can bring about a traumatic brain injury, which can result in physiologic or structural brain damage.

Blast-Induced TBI Blast-induced traumatic brain injury bTBI has become a common type of military head injury, although non-blast mechanisms are still common in the military and civilian population e. Neuropathology TBI neuropathology consists of a primary injury that is a direct consequence of the traumatic insult and a secondary injury that results from a cascade of molecular and cellular events triggered by the primary injury and which leads to cell death, axonal injury, and inflammation McKee and Daneshvar, ; Taylor and Gercel-Taylor, Recovery Trajectories of TBI In this section, the committee presents a conceptual model for understanding recovery trajectories of TBI and then describes subject-level factors that might influence TBI recovery.

Age While the median age of incident TBI is relatively young, especially in cases due to trauma occurring during active duty, it is highly variable. Sex There is strong evidence that sex plays an important role in various aspects of TBI, from pathophysiology to clinical care. Type of Injury The types of TBI have been investigated, and significant differences in medical complications have been reported.

Comorbidities Medical conditions associated with TBI are often diagnosed concurrent with or following the brain injury Farmer et al. Genetic Predisposition In the era of promoting precision medicine for the treatment of specific disease and disorders in individuals, genetic predisposition plays an important role in TBI outcomes.

Access to Care and Disparities in Outcomes, Treatment, and Follow-Up While it is apparent that age, sex, race, and other factors are associated with differences in TBI incidence, presentation, and severity, studies investigating the follow-up of TBI are critical to determining if and what factors might affect long-term outcomes. Screening A number of screening instruments have been developed to detect potential cases of TBI.

The MACE 2 form consists of four sections see Appendix G : Concussion screening: includes a description of the injury event event as described by the service member or a witness, observable signs, type of event, and whether there was a blow or jolt to the head and screening questions about loss of consciousness, alteration of consciousness, and posttraumatic amnesia.

Also included in the concussion screening are a checklist of symptoms and specific questions regarding medical history related to concussion, headache, migraine, depression, anxiety, and other behavioral health concerns. Cognitive exam: assigns scores for orientation, immediate memory, concentration, and delayed recall.

The scores are totaled out of 30 possible points and reported at the end of the MACE 2 form. Neurologic exam: tests for speech fluency and word finding, grip strength and pronator drift an indicator of muscle weakness and compensation , balance and gait, normal or abnormal pupil response to light, and eye tracking.

The evaluator is instructed to consider deferring this test if the patient is overly symptomatic or a trained provider is unavailable. Clinical Criteria and Case Definitions Clinical criteria provide guidance to clinicians on the specific signs, symptoms, or test results that indicate the presence of an illness, and they guide the classification of patients into diagnostic categories.

Department of Veterans Affairs and Department of Defense mTBI diagnostic criteria range from observations relating to one or more of the common four factors neuroimaging, loss of consciousness, posttraumatic amnesia, and the Glascow Coma Scale score to the use of symptom checklists or some combination of these. TBI is defined in the DSM-5 as an impact to the head or other mechanisms of rapid movement or displacement of the brain within the skull, with one or more of the following: loss of consciousness,.

Neuroimaging Neuroimaging plays an essential role in identifying patients with a brain intracranial injury, both acute injuries and, in some cases, injuries with persistent symptoms.

CT Imaging NCCT is the most common imaging technology used to assess TBI because it readily detects trauma-related fractures, hemorrhage, intracranial injury, extra-axial fluid collection, brain tissue swelling, and radio-opaque foreign bodies e. Advanced Imaging Techniques Diagnosing brain injury for all levels of TBI severity is a particularly active area of research.

Limitations of Current Approaches in the Clinical Diagnosis of Mild Traumatic Brain Injury The current methods of mTBI diagnosis rely on a report of certain symptoms at the time of injury from the person who was injured or from a witness.

Health Care Professionals Trained to Diagnose Traumatic Brain Injury Given the complexities in diagnosing TBI, especially mTBI, and the time that might have elapsed since the original injury, a diagnostician needs to be trained on and familiar with the standard diagnostic tools discussed earlier in the chapter used in making a determination of brain injury and its severity.

Thus, making a diagnosis of brain injury might include A detailed neurologic exam including a headache specialist, a vision specialist, and a balance specialist to assess vestibular dysfunction ,. Cognitive evaluation by a psychologist with formal training in the assessment of TBI-related cognitive and executive functioning deficits, and. Evaluations by physical, occupational, and speech therapists to clarify the extent of the TBI and the deficits that might present, including exertional symptoms.

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Epigenetics of lifestyle. Sharjah U. Epigenetics of stress; pp. Neck strength: A protective factor reducing risk for concussion in high school sports. Journal of Primary Prevention.

Find a Doctor Find a Location. Refer a Patient. Have a Question About Click for Content Navigation. AbilityLab menu. Last Updated June 14, Link to Instrument Instrument Details. Acronym FAM. Non-Specific Patient Population. Brain Injury. The FAM consists of 12 items. Tasks are rated on a 7 point ordinal scale that ranges from total assistance or complete dependence to complete independence.

Scores are generally rated at admission and discharge. The Functional Assessment Measure. Wright is not the scale author for the FAM. Check flow chart for specific items, but may need food to assess swallow, car, reading materials, writing materials, etc.

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