Expert Advice for Managing Traumatic Brain Injury and Concussions

You. I'd like to welcome everybody to today's presentation on traumatic brain injury causes, consequences and interventions. I'm your host, Dr. Donnellyce Snipes. The PDF of the PowerPoint is available in the CEU class on traumatic brain injury at allce.com and more information can be found by asking my AI if you go to Dr. Snipes docsnipes.com clones I didn't even write my own web address right. Oh well. Objectives Today we're going to learn about causes of TBI and their consequences and interventions. We're going to touch on concussion and post concussion syndrome, chronic traumatic encephalopathy, stroke, anoxic brain injuries that happen when you're not getting enough oxygen, you stop breathing, toxic brain injuries and aneurysms. Clinicians those of us who are mental health clinicians, social workers, non prescribers, non medical people. It's important to recognize how many of the symptoms for these various traumatic brain injuries overlap with symptoms of mental health issues. And yes, TBI and disability adjustment and coping with the symptoms of TBI can cause anxiety, depression, grief, that sort of stuff. And we want to acknowledge and not miss potentially diagnosing an undiagnosed tbi. If somebody suddenly starts having particular symptoms, we cannot fix a tbi. A neurologist may be able to help, but a lot of times these tbis, they are what they are and we're hoping to create a situation in which the body and brain can heal themselves. We can help people reduce stress and stress related inflammation to promote neurogenesis and help them develop tools to live their most highest quality of life, even with symptoms that they may have temporarily or permanently. The brain is kind of like the motherboard, the ram and the storage on a computer. You've just got everything up here. In this case, when the brain is injured, it can short circuit the motherboard so things don't. Their communication doesn't go out at all. Or it can fry the ram, the short term memory or one or more hard drives, the long term memory. We do need to recognize that different parts of the brain are responsible for different things. We for example, as I'm always pointing to my forehead when I talk about executive functioning, this is where a lot of our executive functioning happens. So if you have a head injury that hits you from the back or hits you from the forward from the front and your brain bounces back and forth, it is going to potentially bruise the executive functioning areas and potentially cause some short term or long term deficits. While not a traumatic brain injury, many of us have experienced cognitive symptoms during periods of excess physical or emotional stress, like postpartum chemotherapy, grief. So we can kind of. If you haven't had a tbi, it's hard to understand what somebody's going through, but we can try to empathize to the best of our ability by thinking, you know, when my brain was just not working the way I wanted it to, how frustrating was that? In terms of traumatic brain injury symptoms, Thinking about as we go through these, how they impact each piece of your life. Physically, interpersonally, emotionally, cognitively, and even in your environment. People who have headaches, the light may make it worse, sound may make it worse. If they've got tinnitus, it in addition to the headache, then that can, you know, be compounding and can be exasperating and infuriating because the headache doesn't seem to go away. And when we have that kind of pain as well as frustration, it triggers the stress response. It puts us into fight orf flight, makes it harder to focus, Even if this part of our brain isn't injured and can contribute to cognitive symptoms and emotional disregulation. Blurred or double vision. We read. You read on your mobile device, you read on your computer, you watch television. When your vision is blurred or doubled, it is going to contribute to headaches, and it's going to contribute to difficulty with balance, which can make your environment something that needs to be addressed in order for you to be safe and avoid developing additional injuries. Tinnitus or ringing in the ears, and vestibular dysfunction. The bra, the body's ability to balance and know where it's at. Both of these things can occur as a result of traumatic brain injury. And if somebody has these, it can affect their ability to maintain their balance. It can contribute to dizziness and nausea. You know, all of these things can also contribute to headache and fatigue. Let's think about our symptoms of depression, fatigue, apathy. So we're starting to see how some of these symptoms may overlap. Sleep disturbances, insomnia can't get to sleep, or hypersomnia. Sleeping too much can be a symptom of traumatic brain injury, and it can also be a result or a consequence. When somebody has traumatic brain injury and they're dealing with these other symptoms over here, they may start developing what we commonly call depression and start sleeping more. So it's important to recognize, based on the proximity of the traumatic brain injury to what's going on. Obviously, right after a concussion, we want to be very conscious of somebody and, and their sleep. We don't Want them to develop a, a brain bleed. We don't want them to develop complications. A lot of times they say, yeah, you know, the person really shouldn't go to sleep for some number of hours. It's been a long time since I dealt with concussions, acute issues. But there's a period of time where they advise, you know, keeping an eye on the person, making sure they're still breathing. Prolonged symptoms can of traumatic brain injury can lead to chronic fatigue due to overactivation of the stress response or the autonomic nervous system. And that will not can that will affect your hormone and neurotransmitter balances your gonadal hormones, your thyroid hormones and your neurotransmitters. As that system, the autonomic nervous system starts to become dysregulated. As the person starts to develop what we call sympathetic dominance. Stress is their primary emotion. And the relaxation response, the vagus nerve and the parasympathetic nervous system just can't seem to get any traction. And then we start to see those hormones switch and we start to see glucocorticoid resistance where the receptors stop responding as effectively to cortisol. Now, you may have a lot of cortisol floating around in your system, but the receptors aren't being activated by it because they've become tolerant to it. So you can see these physical symptoms of traumatic brain injury in and of themselves can cause a lot of frustration. It can make it difficult to concentrate, it can make it difficult to want to engage with people. It can impact the person's self esteem and it can impact their, their relationships and patients with others. Emotional symptoms of traumatic brain injury and when I'm talking about these symptoms, these are symptoms that can result directly from the damage that's done to the brain. Again, they can also happen as a consequence of other symptoms to traumatic brain injury. Irritability and frustration. Well, if your stress response is on, if you're already in some level of fight orf flight, then you're already primed for irritability if you're in pain. Most people, when they're in pain, tend to be more irritable and have a lower frustration tolerance. It's human nature and helping people develop tools, which we'll talk about in a little while, to reduce this irritability and frustration, to reduce the activation of the stress response will also help reduce some of the inflammation and promote an environment that is supportive of neurogenesis or the brain sort of rebuilding itself. People can have mood swings if that autonomic nervous System starts to get dysregulated. Yeah, we're gonna have new mood swings. That is one of the underlying causes of emotional dysregulation. But on top of that, when people are stressed, they are, they may be trying to grin and bear it and get through it, and they're putting on a happy face. But it doesn't take much to cause them to feel free, frustrated or overwhelmed. So it seems like they're, they're more unpredictable or they have more of a hair trigger with their emotions, if you will. But it could just be that they're barely holding it together and they're trying to do their very best. But if you think of a pressure cooker, they're at max pressure and they can't take anymore. There's increased anxiety. Could be because of the areas of the brain that got damaged. Could be because they're not sure, am I going to recover or how much of my abilities am I going to recover, Is this going to get worse? Some traumatic brain brain injuries are progressive. Depression can happen as a result of the chronic pain and the sleep disturbance from the tinnitus and the headaches. That can cause people to start developing depressive symptoms. That can cause neurotransmitters to get out of balance. It can trigger. We've talked before about how when that ans autonomic nervous system gets disregulated, that we also see a much higher correlation with hypothyroid. We see a much more prevalent increase in sleep apnea, irrespective of a person's weight. People who've experienced trauma, and that includes traumatic brain injury, may be at higher risk for developing apnea, even if they didn't have it before then. We have grief, which you can imagine. If you have a traumatic brain injury, there may be grief from whatever caused it. If you got into a bad car accident, there may be anxiety and grief associated with that. If they tell you you've had a stroke and you're not going to regain a hundred percent function, there's going to be grief, guilt about not being able to do what you think you should be able to do. A lot of people when they have a traumatic medical incident, they suddenly lose a lot of the ability to do a lot of the things that they were relied on for. And there's a sense of guilt that, hey, I can't mow the lawn anymore, I can't drive anymore, I have to rely on other people, and I feel guilty about that again. The injury may trigger stress responses in every piece of life. Further Activating the stress response and impacting people's ability to regulate their emotions. You just, it just keep, the hits keep coming and the person can feel completely overwhelmed, exhausted, and, and just kind of at their very max cognitively. In traumatic brain injury, we very often see memory problems, slower process, slowed processing speed, executive functioning deficits. And remember, executive functioning is where we plan, we pay our attention, our concentration, our planning, our problem solving, our organizing. Those are probably your five executive functioning things. And if that front part of the brain is injured, then people can have executive functioning deficits. Feeling mentally foggy. Well, when your brain's inflamed because it's been injured, it's not going to be working as well. Let's just acknowledge that. In addition, if you're not getting adequate sleep, adenosine is not getting cleared out of your brain. So you're going to have brain fog. If you are sleeping a lot, but it's poor quality sleep, there's going to be brain fog. If you're taking certain medications, you may have brain fog. And again, just by virtue of the injury itself, you may have inflammation in your brain or of your brain that is going to just contribute to things not firing quite as well. And you may feel foggy. Developing tools to manage that is going to be important. Instead of developing dirty discomfort and getting angry about the fact that you're, you're foggy and feeling frustrated and helpless and anxious and all those other feelings, it's like, okay, you know, I'm kind of feeling foggy today. What do I need to do in order to compensate for that? Push notifications, writing things down, having reminders up as necessary? Hypervigilance is another cognitive symptom and it can be because of the injury itself, the part of the brain that gets injured. It can also be due to the person. Because of the injury, the stress response is already activated and the brain says, hey, I'm not a hundred percent, which means you're not 100%, which means we need to stay on alert. And so people with the traumatic brain injury may be startle easier and be more hyper vigilant because the underlying programming in our brain says if we're not 100%, then we're vulnerable. People can have negative perceptions and ruminations and intrusive thoughts. It can be really easy after a traumatic brain injury to start blaming oneself or blaming other people or having ruminations and intrusive thoughts about, well, what could I have done differently? What should I have done differently? What's going to happen now? And helping people these Are all things that counselors we deal with on, on the daily. Negative perceptions, hyper vigilance, ruminations. Those are all things we can help people identify and deal with. And something else I didn't put here and whether it should have been under physical or, or cognitive. Some people, when they have a brain injury, stroke, for example, they also may develop difficulty speaking you, articulating words. They know what they want to say, but they can't get them out or receiving information. They, they can talk, but when whatever they hear you say makes no sense to them or both of them. So you may have some levels of aphasia that you've got to deal with. Let's go through some of these issues that we're talking about. Concussion and post concussion syndrome. Most people at some point in their life have a bang to their head, have a head injury that may rank up there with a mild concussion. This can be a child that falls when they're learning how to walk or when they're out playing or they fall off the monkey bars. I remember one time my son fell when he was learning how to walk and he had this great big old goose egg on his forehead and, you know, I was terrified. Vehicle accidents, physical assaults, including child abuse and sports or playground injuries are also very common causes of head trauma. We do want to recognize a lot of times when we think about traumatic brain injury, we think about football, we think about car accidents, we don't think about. And, and I'm not going to belabor the point a lot today, but we do need to be cognizant. Children who are exposed to violence, physical violence, where they are being shaken, where they're being hit, whether, where they're hitting their head frequently can cause traumatic brain injury, whether it's a concussion or chronic traumatic traumatic encephalopathy, which we'll get to in a minute. In any event, think about your brain. You know, a lot of people think the brain is just really solid in there, and it's not. Your brain is floating around in fluid within your skull. So when you hit your head, it's not just, you know, hitting the brain, but the brain is going to bounce around and ricochet around in your brain, in your skull. And every time it hits the side of your skull, it kind of bruises it a little bit. And this can cause a variety of problems. When, just like when you hit your shin on something, I know I do that a lot. I'll hit my shin on, on something and I will get this big old knot on the front of my shin where it swells after, after that incident, the same thing is happening in your brain, but it's got nowhere to go because the skull is not flexible at all. And that's why my husband's aunt just recently unfortunately fell and she fell to such a great extent that she had a brain bleed and they had to take part of her skull off and they still haven't attached it back yet, which I don't know how all that works, but in order to release the pressure, a lot of times neurosurgeons have to go in and do that if the swelling's bad enough. It is important. And I was an athletic trainer for my entire high school career. And one of the things we always used to talk about was the players getting their bell rung. Oh, you got your bell rung, walk it off. When you get your bell rung, that is minimizing the damage to what's being done. People do not need to lose consciousness to have a concussion. Getting your bell rung is a concussion and we need to not minimize that. Interestingly, this is a new study that actually hasn't been officially published in a journal yet, but is a study from Columbia University links soccer Heading hitting the ball with your head to a decline in brain structure and function over a two year period compared to baseline. The high heading group people who hit the ball with their head 1500 times or more over two years. So these are like semi pro people, I guess, had measurable changes in brain microstructure similar to a mild tbi. Further analysis showed that the change in brain structure was at the gray matter white matter interface in the brain. And that played a causal role in the association of greater heading or with worsening cognitive performance. So not only did they have changes in the brain, it was correlated to a a decline in cognitive performance. They did a baseline test at the beginning of the two years and a test at the end of the two years. And people who were high headers had a decline in cognitive functioning, whereas people who were not high headers had an increase in cognitive functioning. Interesting, because a lot of times we think, well, you know, soccer that's so much safer than football, you know, maybe not. Concussions generally heal within a few weeks. The bi directional relationship between symptoms and stress can create a cycle that prolongs recovery. When we're stressed, we increase systemic inflammation. When we increase systemic inflammation, that includes the brain. So the brain that's trying to not to reduce its own inflammation and to try to heal is being bombarded by additional inflammatory cytokines. We need to help people reduce their stress. It's so important. Post concussion syndrome occurs when a concussion symptoms persist for weeks, months, or even years after the initial injury. Unfortunately, to the best of my knowledge, no known predictive factors exist for who's going to develop post concussion syndrome versus not, except maybe having multiple concussions. But this still isn't a one to one correlation. There are some people who've had multiple concussions and they heal back each time. They don't have any further problems. But then there are others who only have one concussion and they go on to develop post concussion syndrome. A lot of people who develop post concussion syndrome may start to get worried that they've got chronic traumatic encephalopathy, which we're going to talk about in a moment. But that is not. They're two different things. They are two different things, and one does not necessarily move on to the other. But if somebody does develop post concussion syndrome, our job as clinicians is to say, okay, we know that there are certain things we can do to help you reduce stress and enable your body to recover as quickly as possible. And let's figure out. And part of reducing that stress is figuring out some strategies to help you identify the symptoms that are keeping you from li living your highest quality of life. And let's figure out how to manage those in the best way possible. Chronic traumatic encephalopathy is a degenerative brain disease. And I have that bolded and italicized because it's important to recognize that people with cte, it's kind of like dementia or Alzheimer's in that it's not static. It, it, the brain is going to continue to degenerate over time. CTE is caused by repetitive head trauma. Athletes who have repetitive repetitive head trauma, boxers, football players especially, have developed cte. And soldiers who have been exposed to military blast injuries, especially repetitive blast injuries, are at much greater risk for developing cte. When there are repetitive head traumas, the brain, especially if the brain's not allowed to fully recover in between, then we start to see an accumulation of abnormal towel proteins, which, and, and widespread neurodegeneration. So we see the brain going, I can't quite, quite get healed and oh, you know, I'm injured again. And it never, each time, it never quite gets back to where it was before. And we start seeing this degeneration. But once we have that inflammation, once we have those tau proteins developing, then we start having degeneration kind of running off on its own. You don't need to continue having head trauma for the degeneration to continue. Symptoms that are unique to CTE include motor disturbances and tremors, muscle weakness, chronic depression, impulsivity. That's a big one that we see in a lot of people. And memory impairment that leads to dementia. Not that's like dementia, but it we see the neurodegeneration leading to the development of dementia. Symptoms for CTE begin years after the repetitive injuries have ceased and progressively worsen. Which is why I said there are a lot of people who develop post concussion syndrome who are worried that, oh my gosh, am I going to develop chronic traumatic encephalopathy? Well, we can't say yes or no. They can do a scan to look for particular changes in the brain. But it is important to recognize that even if you've got long standing, you know, it's lasted for months or years, post concussion syndrome, it doesn't necessarily mean it is going to progress to cte. The degenerative nature of CTE leads to a decline in functioning across multiple domains, just like we see in, in dementia and in Alzheimer's. Now it is interesting, I wanted to point out some of the athletes that we know that have been diagnosed posthumously with Chromat Chronic Traumatic Encephalopathy. And Aaron Hernandez, he was a football ball player for the Gators and he ended up going on to commit a homicide and then died by suicide. He had a lot of issues with anger management and impulsivity and mood swings. Frank Gifford was diagnosed posthumously and from what I understand, he had a lot of chronic debilitating depression. He wasn't as impulsive and it wasn't diagnosed or identified until after his death. Junior Seah was was diagnosed after he committed suicide. Bob Probert was diagnosed after he passed. And then interestingly enough, Sugar Ray Robinson, who is a boxer, was diagnosed with chronic traumatic encephalopathy. But Sugar Ray Leonard, who is still alive by the way, does not have it. And you know, he got hit in the head. So we can't say that everybody who has these repetitive injuries is going to. It's just not that clear cut. Things to look for though definitely are the wide mood swings and the impulsivity or a seemingly intractable major depression. Those are all huge warning signs that something's up, even if it's not cte. Something's up correlates with cte. Some things we can look back and go, these people are at higher risk if you started having multiple brain injuries before the age of 12. So people who are playing peewee football or unfortunately, child abuse victims, people who were shaken as babies or toddlers. The number of head injuries, particularly ones that resulted in knockouts, loss of consciousness also correlate to some degree. And another big one was the medical care and recovery time after a concussion. Getting your bell rung, you don't have to be knocked out after a concussion or knockout. It the American Academy of Neurology recommends refraining from contact drills for 30 days or more and then use a graduated return, starting with cardio exercises, aerobic activities, lifting weights before going back into a situation where you may hit your head again before where you may get another brain injury. But think about, you know, I'm thinking about the football players that I worked with in, in high school. I'm thinking about the football players that we see playing college ball, pro ball. They get their bell rung and they're back, generally back out pretty quickly. They're not out for 30 days. And so those people are at a higher, much higher risk of developing long term problems. Stroke, we talked about this in a previous class, so I'm just going to hit it real quick. Stroke occurs when blood to the brain is stopped due to blockages in the arteries or bleeding. My husband's aunt, she, when she fell, she caused a brain bleed and that brain bleed caused the pressure on her. Pressure on, on her brain. Strokes are linked to people having hypertension. It's also linked to blood pressure going up during alcohol detox. People, when you're detoxing from alcohol, it's no joke. Yes, alcohol is legal, but alcohol detox is one of the, one of the most dangerous detoxes out there because people's blood pressure can just spike in a heartbeat and it can be, it can cause a stroke. So it's always recommended to be medically supervised when withdrawing from chronic alcohol use. Atrial fiber fibrillation or afib. Clotting disorders, ather, atherosclerosis, which is developing plaques in your arteries, diabetes, smoking and genetics are all linked to an increased risk of stroke. Now some of these we can pay attention to. If you've got afib, they have medicines for that, they have treatments for that. Clotting disorders, there are medicines for that. Hypertension, there are medicines, but there are also strategies we can use to reduce our stress and lower or strengthen our, our parasympathetic nervous system to lower our blood pressure. Stopping smoking and controlling blood sugar are also huge things that we can educate people to help reduce their risk of stroke. Many times people may have more than one stroke and once you've had a stroke, you're apparently at risk for future strokes. We can help people recognize what their risk factors are and empower them. Use motivational interviewing to enhance their desire to take control and address the factors that they can. When people have a stroke, remember fast. There is sudden weakness or numbness, especially on one side. When one side of the face, face is the F, arms is the a. And that generally means that the person loses control or may lose control over functioning in one side of their body. And then speaking becomes difficult to understand when, when they're talking, it may be slurred or it may be nonsensical. Another thing that's not accounted for in fast, but it's important to recognize is, is people who are having a stroke may suddenly have vision problems, loss of balance or coordination, or an extremely intense headache. And these are all things. T stands for time to call 911. So face, arms, speech, and time to call 911. Recovery varies widely after a stroke, partly depending on how long the blockage last lasted, how much damage was done, whether there were had been other strokes, and the part of the brain that was impacted. Toxic brain injuries come from exposure to neurotoxic substances like heavy metals, chemicals, carbon monoxide, and, and other drugs that damage brain cells. Carbon monoxide. Get a carbon monoxide sensor for your house. It is a colorless, odorless gas. You need to be aware because it will cause brain damage, Occupational exposure, environmental contamination, and substance misuse. For example, huffing paint and then general poisoning can cause toxic brain injuries. You don't have to necessarily inhale something for it to get to your brain. You can ingest poisons, and it can get to your brain that way. And, and obviously any sort of exposure to these toxins. We want to try to help people figure out how they can minimize it. Physical symptoms of toxic brain injuries include headaches, dizziness, n, nausea, motor weakness, tremors, seizures, numbness, coordination problems, and sleep disturbances. So pretty much all the symptoms we already talked about symptoms can develop acutely. So obviously some of these symptoms start developing in you or somebody and, and they develop suddenly. We're going to say, okay, something's wrong here, what's going on? But like in the case of carbon monoxide poisoning or gradual ingestion of a toxin, it may develop more slowly. So paying attention if something's not quite right, even if it's not this sudden acute thing doesn't mean that there's not something wrong. Removal from exposure may lead to improvement, but sometimes some of the damage can be irreversible. I've worked with A lot of people who've huffed paint and some of that damage is irreversible. It just completely oversimplified. But we would say it basically liquefied a lot of their brain cells. And recognizing that some of that's not coming back is really important. An aneurysm is a weakened blood vessel that can rupture. Causes of aneurysms include hypertension, head trauma, genetic factors. Some people just are prone, genetically prone to have weak spots in their. In their blood vessels. Crush injuries to the chest. You have your abdominal aortic artery that is in your core. And if you have a crush injury that suddenly pushes that blood really forcefully out in, into the vessels, then it can create sort of like we have a balloon if you've ever had a water hose explode on you. And athero, atherosclerosis, like we talked about earlier, these are plaques in people who are stressed. When we have chronic stress, we develop more plaques in our arteries. People who are sedentary, people who smoke, drink, eat an inflammatory diet, or are sleep deprived. Sleep deprivation contributes to atherosclerosis, among a myriad of other things. If we can't convince people to do anything else, convince them to get good sleep. Physical symptoms of aneurysms. Sudden severe headache. I mean, it's just like crushing neck stiffness, light sensitivity, nausea, loss of consciousness, seizures, weakness or numbness, and speech difficulties. Now, some of these sound very similar to the symptoms of a migraine. So we don't want to ignore sudden symptoms, but we also want to recognize that somebody who has a migraine may need to figure out how to differentiate when do I need to go to the hospital. And there can be a level of anxiety about what's actually going on with them when they get a migraine if they're worried that they're having an aneurysm. Recovery from aneurysms depend on the bleed severity and the intervention speed. The faster the blood flow to the brain can be restored and the pressure can be removed, the better off we are. Anoxic brain injury occurs when the brain is deprived of oxygen due to cardiac arrest, arrest, respiratory failure, which opioid overdoses cause a bunch of anoxic brain injuries. Choking, drowning, suffocation, severe hypotension. That's low blood pressure, so the blood can't get to the brain. It's just pooling in your. Pooling in your feet, or surgical complications. There are times when the brain is just. It's not getting the blood and the oxygen it needs. Recovery depends on oxygen Deprivation duration and, and the damage extent. If somebody's deprived of oxygen for a minute or two, that has very different consequences than if they're deprived of oxygen for 10 minutes or 20 minutes. In terms of secondary effects that we can help people deal with chronic pain from headaches or neck problems or some other source can, and fatigue can reduce physical activity and lead to deconditioning. Deconditioning makes it harder to do just about anything and contributes to increased fatigue. We want to help people maintain their conditioning, whatever that looks like for them. I'm not saying they need to go to the gym. I'm just saying we need to make sure that they're continuing to maintain some level of physical mobility, if not fitness. Ans autonomic nervous system hyperactivation impairs sleep, worsening physical symptoms. We need to help people develop tools to downregulate their autonomic nervous system. Distress tolerance tools, guided imagery, meditation, yoga, whatever it is we can help them do that can help biofeedback. That can help them feel like they've got control and can downregulate that autonomic nervous system if they are struggling with chronic pain and then you're kind of fighting against that. To down regulate the autonomic nervous system and developing effective pain management tools is going to be essential, whether that's implementing a TENS unit or heat or ice or, you know, occasionally medication, whatever it is they need to do so they can actually get a decent night's sleep interpersonally. People with traumatic brain injuries, when they're feeling they've got a headache, their ears are ringing, they're feeling nauseous, they're tired, they're having difficulty thinking clearly. You can imagine that they may be more irritable and have mood swings that strain relationships. It's important for them to be able to assertively communicate to their loved ones, hey, I, this is what I'm struggling with right now. And, and I need a little space when you say something, give me a second to think about it because I'm not processing as quickly or I'm feeling kind of irritable today and it's nothing to do with you. I'm just, I'm cranky. That can go a long way to improving relationships. Fatigue and cognitive impairments may reduce the ability to nurture their relationships. In some cases, they may not even remember who people are or they may forget things. They were supposed to meet you for lunch and they totally forgot. It wasn't. They were being disrespectful. It just, it didn't stick that, that short term memory that RAM malfunctioned and just being tired can make it difficult to even want to go out and do things. So people can start to feel progressively more isolated. Communication difficulties. If the person's having difficulty speaking or understanding speech, or if they are slow in understanding, they, they're not as, as interactive, they're not as quick to put things together as they were before, that can hinder communication. And people may get frustrated because they feel like it's, you know, painstaking to talk to this person and the person can start to feel isolated. Remember on the videos we did some weeks ago on dementia, depression and lack of cognitive stimulation, lack of interaction, reduced oxytocin as a result, result of lack of interaction all can contribute to the development of cognitive decline. We don't want that. We want to help people figure out what they can do to prevent worsening, what they can do to manage the symptoms they have right now. Emotionally persistent symptoms, physical symptoms, cognitive symptoms contribute to anxiety, depression and emotional instability. It's exasperating, it can be frustrating. And again, if you're not getting enough sleep, you're going to tend to be more emotionally dysregulated. Feelings of grief over lost abilities and guilt about being a burden. Increased stress and autonomic nervous system activation, which again affect emotional regulation. Cognitively impaired concentration, impaired memory and executive functioning will impact work and school performance. If you, you know, maybe you were a CEO and you're still a CEO, but you have more difficulty planning things out, you have more difficulty connecting the dots on, okay, there's this problem. What's the solution? That can be exasperating because for a lot of people, that was a big part of their life and now they're having difficulty solving simple problems. It can feel just terrible. Hyper vigilance and ruminations increase due to stress and poor sleep will further impair cognitive function. We know when we don't get adequate sleep for whatever reason, we have more difficulty controlling our thoughts and we tend to be, have, have a stronger stress response during that time, which makes us also focus on the threats in the environment, not what's going well. So that can promote pessimism, that can promote stress, and again, it promotes systemic inflammation and autonomic nervous system disregulation. Environmentally sensitive sensitivity to light and noise limit participation in certain environments and may reduce social engagement. Balance issues increase the need for safety modifications and changes in living or working conditions may be necessary causing additional stress. What you did before the accident or before the stroke, you may not be able to do anymore. And that's a whole grief issue in and of itself. In addition to trying to figure out how to plan if I'm taking a cut in pay or, or whatever. So let's talk about management. Medical management. The doctors regular monitoring, symptom management and careful use of analgesics to prevent overuse. Rehabilitation therapies, again, generally not therapist counselors. Physical therapy to address balance issues and improve physical conditioning. We're not in a place to tell somebody how to work out or what to do, but physical therapy is important and we can encourage their participation. Vestibular therapy to reduce dizziness and improve balance, and vision therapy to manage visual disturbances. These are all going to be referrals made by the neurologist to other professionals. Sometimes, though, to the patient, it can feel like I'm going to 16 different doctors and I'm not making any progress. We can help them chart the baseline. We can help them identify small steps forward. We can help them understand why it's important that they continue to go to their vestibular therapist. For example, in terms of physical management, the primary deficits that people have are sleep disturbances, chronic pain, reduced energy and hormone imbalances. As clinicians, we can help people establish a consistent sleep routine and proper sleep hygiene. Most people have horrible sleep hygiene. They sleep with the TV on. They've got too much blue light, is too hot or too cold or too noisy. Their partner snores like a freight train. You. There are a lot of things that keep people from getting good quality sleep, and that's essential to the recovery process. We want to help people address fatigue with energy conservation techniques. What that means is chunk things, have them do a little bit of whatever it is. Instead of trying to go and do an hour of yard work, go out and do it for 15 minutes. If they can do it for 15 minutes and tomorrow they feel just fine, then the next time they do it, maybe do it for 20 minutes and keep increasing how long they're able to do it until they reach that point that, okay, that was a little too much, and then back down again. But as people redevelop their physical conditioning and their, their brain starts to heal and it can handle more, they're going to be able to do more and for longer. But we need to help people figure out what is it that you can do and how much is reasonable, and then what do you need to do to downregulate and give your brain and your body a rest. We want to encourage them to monitor their endocrine health, to Track insulin responses and, and their thyroid and gonadal hormone levels. If they have diabetes, then they can test their, they need to make sure that they're monitoring their blood sugar but also paying attention. Going to the doctor, getting a blood panel done for their thyroid and go nadal hormones at least once a year is ideal, especially in older people, just to make sure those aren't getting out of whack. Because as estrogen or testosterone get too low or too high, that impacts the availability of serotonin and dopamine and norepinephrine and the thyroid hormones. Everything plays together and if one starts going off kilter, it's going to take everything else off kilter. Pain management we want to help people learn how to use visual pain scales so they can effectively communicate their pain. And instead of going yeah, it's, it's, it's fine or it's not too bad, that doesn't tell me anything. So let's use a pain scale and have anchors on there for how bad the pain is. You can use colors, you can use faces, you can use percentages, whatever works for the person. So you know, zero is I have no pain. A hundred percent is I'm in excruciating pain and I can't do one more thing. And then we have a couple places in between. Occupational and physical therapists can also help with pain management. Guided relaxation Whether it's cued progressive muscular relaxation or guided imagery, self hypnosis There are a lot of different guided relaxation practices that people can engage in. Heat and cold therapy Some people prefer heat, some people prefer cold. Whatever feels better. Massage can help loosen up if it's muscular, if there's pain. Like sometimes if people have double vision, they'll have maintain a lot of tension in their neck and releasing that tension can be really helpful. And paying attention to ergonomics if they're sitting in this really funky position on the couch watching Netflix all day, that's going to exacerbate their pain. Making sure they're paying attention to how they're sitting, how they're sleeping to reduce any unnecessary pain. Nutritional support with a registered dietitian to help them identify ways they can incorporate in anti inflammatory foods into their diet. Not everybody's just going to switch over to a Mediterranean diet. I get it. However, there are certain easy swaps that might be able to be made to reduce inflammation, to reduce the sugar spikes and to increase the antioxidants. The color colors. So increasing fruits and vegetables that provide that antioxidant support will also help Reduce inflammation. We want to help them promote immune support. When you're stressed, whether it's because you're recovering from a brain injury or emotionally stressed, when you're stressed, your immune system is not as effective. We need to encourage people to pay special attention to their hand hygiene. That's one of the biggest things. And then pay attention to where they're going. If the flu is really high in their area, maybe back off from going to the gym every day or. Or going during a time when the gym is less busy so they're not as exposed to as much airborne stuff during this period where their body's really trying to focus as much energy as possible on healing that brain. If people have tinnitus, white noise machines or other devices can be really helpful. They have apps on the phone you can put in earbuds, and you can listen to particular noises that might help drown out or mask the ringing or buzzing that you have in your head. Some people prefer just to listen to podcasts or music, and that covers it up. But it can be really. It can almost feel like the silence is deafening. And I never realized I had tinnitus until I started doing some of this research a few months ago. And. And I realized, oh, it's not that the silence is deafening, it's that my ears are actually ringing. Well, go figure. But that can be really helpful because tinnitus is at best annoying and at worst infuriating because you just. It's there and it's loud and you can't make it stop interpersonally. But primary deficits include include loss of self esteem because of changes in what they're able to do, difficulty nurturing relationships, and communication challenges. Encourage the patient and their significant others to participate in support groups. It can be really helpful if they're participating in joint support groups as well as their own support groups where they can talk about their experience if their loved one had a stroke or if their loved one had an aneurysm. They can talk openly with other people that have gone through the same thing, and they can provide support. But the family or the significant others aren't worried about, well, I don't want to say anything because I don't want John to feel guilty or I don't want John to feel bad. They can go in there and they can go, oh, my gosh, this is miserable. And other people can go, yeah, you know, been there, it gets better. But that can be really helpful to encourage the mental health in both the patient and their significant others. But when they're Both the patient and significant others are less stressed. It's going to reduce conflict at home, it's going to reduce conflict in relationships, and it's potentially at best going to improve support. Peer mentoring can be really helpful for the person who has a traumatic brain injury and is living, learning how to live with the symptoms that they may have, whether it's balance issues or hyper vigilance or whatever. Walking that walk, if you will, with somebody who's already moved forward in their recovery and can say, yeah, I remember those days where some days were just awful. It felt like we were starting over again. Can be really helpful. It can be really encouraging to see, all right, I feel defeated today. But my peer mentor, look how far they've come. And with time I can get there. Family counseling, of course, and enhanced communication, assertiveness, not mind reading. If the patient is assuming that people know what they need, they're going to be disappointed. If the family is assuming that they know what the patient needs, they're going to be sorely disappointed. There needs to be communication. What is it that you need and want me to do to help you? Or let me tell you what is it? What it is that I need and want from you? Provide alternate communication methods. If the person is having difficulties with speech or is having, well, is having difficulty communicating verbally, writing things down can be really helpful. Sometimes you got to go to pictures. Depending on what degree their, their speech and language centers were disrupted, gesture training can be really important, especially like for people who are having difficulty thinking is clearly and processing is clearly. When they're in a conversation with somebody and they start feeling like they're getting lost, they're getting behind, they can raise their hand or make some other gesture which lets the speaker know, hey, I hear you. I want to know what you have to say, but you need to give me, give me a second to get caught up because my brain's kind of behind. That's okay. And that way the person doesn't have to feel like they're getting left behind. That also allowing them to do that and get caught up reduces cognitive load, which will reduce fatigue and it will reduce blood sugar spikes. It will do a lot and then pace management. Helping significant others or people who are interacting with the patient recognize that they may need to slow the pace and help them figure out how to do that in a way that is comfortable for both parties. Family education and experiential role playing can be helpful. The person with a traumatic brain injury may forget discussions that people have had. You know, I told you this, this morning. Oh, I forgot. And sometimes significant others can think well, you're forgetting intentionally. No, no, I'm not forgetting intentionally. It's just the way it is. It didn't, it didn't stick. So helping people remember times when they forgot something unintentionally helping people remember times when they did something that was misunderstood and, and then cognitive slowing again. When I was taking Spanish, I could read Spanish really well and I could understand Spanish if, if it was spoken slowly and clearly. But when I started spending time around native Spanish speakers, I was just clueless. I was just kind of sitting there dumb as doornail. And it can be helpful to draw those parallels for people. Think about how frustrated you felt when you couldn't keep up with the conversation. I felt the same way in math class, but that's a different video. Promote social interaction. People need to use it or lose it, and it's important that they continue to develop those connections and interact with others or they're going to have cognitive decline. Any interaction they do, any cognitive stimulation is going to help build and maintain those neural connections. Emphasize non verbals. If the person has a hard time speaking or understanding. Emphasizing your non verbals. Like, you know, I see that you're feeling very sad right now, and it may feel a little forced at first, but it can help communicate. And really focusing on their non verbals can be helpful too. I see that you're really frustrated that you can't communicate to me what you want to say. So let's figure out how to do this together. I went through that with a patient that had aphasia a few weeks ago. And then collaborative problem solving. The person with the traumatic brain injury generally doesn't want you to fix it for them. That makes them feel disempowered. That makes them feel helpless. Work with them to figure out what is the problem and let's figure out the best way to solve it in terms of emotions. Emotional dysregulation, dirty discomfort, depression, grief, and anxiety. We want to educate people about traumatic brain injury, the autonomic nervous system, and how when the autonomic nervous system is the, the sympathetic nervous system is on, it is more likely for people to dysregulate. And when people dysregulate, it means they have this flood of stress hormones and a flood of energy. So it takes them longer to get back to baseline than somebody who just had a little dribble of stress hormones and, you know, a little bit of blood sugar released. Dirty discomfort is when you have multiple feelings. You're you're angry and then you feel guilty about being angry. Then you're anxious that people are going to reject you and because you're angry and you start developing all these overlapping emotions. Learning how to embrace clean discomfort and developing a distress tolerance toolbox skills that work for that person to help them tolerate physical, interpersonal, emotional and cognitive distress. Use biofeedback to help them strengthen their vagal tone, which strengthens that parasympathetic or that rest and digest part of the autonomic nervous system so they feel personally empowered to better manage their dysregulation. In terms of cognitive deficits, we see hypervigilance, negative perceptions, ruminations, intrusive thoughts, difficulty concentrating and problem solving challenges. First and foremost for the hypervigilance we want to help them create safety so they know intellectually and physically that they're safe. Using grounding exercises can be really helpful where they're sitting in an environment and they say this is where I'm at, I'm safe. These are, you know, this, this is what's going on. And so they're oriented to the present time and place. Address negative perceptions. You can reduce emotional reasoning by helping people unhook I'm having the feeling that this is the worst thing in the world or I'm having the thought that I will never get better. Okay, you're having a feeling, you're having a thought. It's right here. What are we going to do with it? Help them develop hardiness, commitment to what's important in their rich and meaningful life and using their energy being empowered to use their energy to work toward that rich and meaningful life. Help them restructure their cognitions and live in the and I have tinnitus or I have chronic headaches and I can still do a lot of things to move toward my rich and meaningful life. Address cognitive distortions with fitcat facts in this context at this time, looking for exceptions to all or nothing thinking and finding alternate explanations for things that the person personalizes. Were they angry at you? What are three other reasons they may have been snitty today besides they were angry with you? Ruminations and intrusive thoughts. We can help them develop thought stopping activities. Develop a worry time box. When they have that intrusive thought, write it down and put it in a box and at a particular time each day they allow themselves 30 minutes, for example, to look at the stuff in the worry time box. But until then they're they're setting it aside and improve sleep. That will reduce ruminations additionally Cognitive rehab therapy focuses on gradual buildup to improve attention, memory and executive functioning and reduce cognitive fatigue. Like after you break your arm. You don't have the same strength and endurance in your arm once that cat cast comes off. Same thing's kind of true for your brain after a brain injury. So people need to strengthen those cognitive muscles, if you will. You can address attention and memory with puzzles from word finds depending on the person's capacity at that point all the way up to something like Sudoku. Solitaire is another card game acting if they want to learn lines to act in a one man play or something wrote memory quotes or prayers. Some people like doing that and that helps them. Even cooking. I've done I've made recipes before and I'll have the recipe open on my mobile device in the kitchen and the device will time out and it's really frustrating if I have to go back every two seconds and try to figure out what was it that I needed to add now. So developing those cognitive memory skills Remembering okay, I need a teaspoon of salt and a tablespoon of baking powder and blah blah blah. If I can remember chunks of information that strengthens the memory. Planning There's a game that I'm just absolutely addicted to called Bubble Breaker where you've got a plan to try to eliminate all of the bubbles anyway isn't sort of like Candy Crush but not exactly Checkers Picture slides. Oh I hate those things. Some people love them. Where you've got a picture and it's divided into nine different pieces and there's one piece missing and you've got to move the p picture pieces puzzle pieces around to make the picture Drives me bonkers. Gardening Scrabble Those also involve planning and organizing. If you're doing puzzles organizing for example the yellow pieces and the edge pieces that can be helpful. Playing gin rummy Organizing your cards to to figure out how you're going your strategy Fantasy football if you're into that kind of thing. Who's going to be on my team and what is it going to look like? Or what I call armchair coaching. Going back over watching for example University of Tennessee's basketball games and figuring out what their strategies are and then saying okay, you're going to go up against UT in a basketball game so tell me what your strategies are going to be and that can help people organize their thoughts. Mindfulness of strengths and mitigation of vulnerabilities is important. I encourage people TBI or NOT to do morning and evening mindfulness activities in the morning. They Focus on, you know, okay, who am I, where am I, when am I, and what is important in my rich and meaningful life? And how am I going to use my energy to move toward that today in the evening, who did I see today? What were the three best things that happened? What did I accomplish, and what can I learn or do better tomorrow? If anything, that involves all that memory and processing and organizing so the mindfulness actually strengthens cognate cognition. And then EMDR can be really helpful for integrating that traumatic event environmentally. And I know we're running over on time, and I apologize. You can go take your quiz if you need to. Informational notes with pictures. You may add pictures to phone contacts in the mobile device. So when you know, Mike comes up, there's a picture and the person, it triggers in that person's mind who Mike is. You can put names on pictures in albums, digital albums, or regular photo albums so the people can connect the name to the picture. Have notes on the refrigerator, for example, with their address, their doctor's name, and any other emergency numbers that they may need because they're not going to remember it, especially in an emergency. Wall calendars with pictures of who you're meeting and why. Whiteboards that have schedules on them for the day or for the week. Push notifications for appointments and medications. Those kind of go without saying. But also for things like paying bills and maybe even taking the dog on a walk. Or for their four or five walks throughout the day. Have a basket for their keys, their phone, their wallet, and their glasses. Generally, I say the bedside table because a lot of people want to keep their glasses with them till they go to sleep. But those are the four things people generally run around the house looking for before they go to work. So reducing stress means just getting into the habit of putting all of those things in that basket at the end of the day. Have extra reading glasses around the house so they can read and accommodate any visual challenges they're having. Address noise. Too much noise, Too little noise. They need background noise, whatever it is. Encourage them to use blue light blockers and screen magnification if needed. And if balance is an issue, make sure the person is addressing trip and fall hazards. We certainly don't need them breaking a hip on top of everything else. Tbis can be caused by a variety of things. Many of them go undiagnosed or minimized. Oh, you just got your bell rung. Effective interventions reduce stress to allow the brain to heal and gradually build up its cognitive capacity. Once again. Some TBIs fully recover. Others may have last lasting symptoms. We need to educate patients and their significant others about traumatic brain injury, what to look for, and strategies to manage any symptoms that they're having. Ultimately, we want to help empower people to use their energy to move toward their rich and meaningful life. I am so sorry. I know I ran terribly older. Oh, Holder. Over with that. Do you have questions? I'm going to try to. I see Adriana was. Had my back and was doing a lot of responding in here and I appreciate that a lot. NATO. I'm sorry to hear about that. That is devastating. And that's an interesting strategy you've developed. NATO. Having a box fan next to your ha. Next to your head on full blast. I find if I don't have television or something radio going in the background, mine bothers me a lot more. I actually do what I tell people not to and I sleep with the television on, or at least I fall asleep with the television on and then it times out at some point in the night. But that helps me because if I turn everything off and it's silent and the silence in my. In my ears is absolutely deafening. So that's a great solution that you found to deal with that. I haven't researched the spiritual side of tinnitus, but I will definitely look into that. It. If there's an absence of evidence in a clear CT or MRI and the s. The psychiatrist diagnosis suggests something other than tbi, how should therapy proceed? Any cautions? I would certainly just focus on the person's symptoms and helping them live their rich and meaningful life with those symptoms, as well as do as much as they can to reduce stress so their autonomic nervous system can re regulate so you can reduce any unnecessary systemic inflammation that may be contributing to the symptoms. That's really. That's what I would do. If they had a tbi or even if they didn't have a tbi, if you see a worsening of symptoms, then definitely encouraging them to get a second opinion would be what I would do because that would be an unexpected outcome. I'm glad you found this supportive. Adam, glad you were here. You are quite welcome, Lori. Let's see. Back at you, jax. Okay, I think I've gone through most of the comments and questions. I really appreciate y' all sticking with me. I know some people had to leave because they've got clients and it was only supposed to be an hour. So I appreciate anybody who was here, even if you had to leave to get on with your real life. And I will see you next week if you're in one of those areas that got the once in a lifetime snow. Enjoy it while it lasts.