So, thanks all for joining us today. I hope I can give you a lot of information about brain injury, brain injury rehab, kind of what I do as a brain injury trained physiatrist. Is that me echoing? Okay, that's better. All right. And yes, I think we said that I'll kind of monitor the chat as well. So go ahead and throw questions in there. I don't have my picture box open to see if anyone raises their hand. So it'll be just easier to throw any questions in the chat and I can grab those as well. So as Amy said, I'm at Ohio State University or the Ohio State University if anybody knows all the drama behind the the. And I am an associate professor, I'm also the residency program director. I'm also the medical director of the brain injury program and the medical director of the Ohio regional model systems. And we'll talk a little bit about the model systems during our talk as well today. And I have nothing to disclose. I have no financial disclosures at all. So some of my objectives, you know, I'm really going to go through a big overview of TBI. I'm going to try to bring everything I do, my entire specialty into the next 60 minutes. So we might be going a little bit fast and there might be some things that I'm not expanding upon. So if you have questions or anything, please let me know. So my objectives are going to be really talking about the epidemiology, what some of the newer data we have as well, pathophysiology, grading of a TBI, some of the behavioral assessments we do, some of the medical complications we work on, and some of the outcomes that the model systems has been working on as well. So really, you know, from an epidemiology standpoint, this is all taken from the CDC. And you know, the data that they have is really based on TBI related hospitalizations and deaths. So this data was from 2019. And you know, they were saying, in a year, there's around two, you know, almost 223,000 TBI related hospitalizations, and around 70,000 of the deaths, and that was in 2021. So that means like, people are having, there's 190 TBI related deaths per day across the country. And that doesn't include the TBIs that are treated in the emergency department and go home. And that means the mild brain injury patients, the concussion patients that come into the ED. And then, as you've probably all heard, there are also patients that get a concussion, either on the field at play, or, you know, at home after a fall, and they never go to the doctor, they don't go to the emergency room. So there are, you know, TBI is a very big kind of morbidity in our country, but, you know, we just can't get all the data because we have people, it ranges from severity from mild, you know, concussion, mild, all the way to severe. So we won't be able to get perfect data. But the biggest thing that I kind of wanted to hone in on is some of the, you know, the biggest populations. So there are, it's kind of a bimodal distribution. So people 75 and older, that's where they're getting a lot of falls. And they account for about 32% of those hospitalizations I was talking about and 28% of the deaths. And then, you know, when we talk about, you know, male to female, males are two times likely, more likely to be hospitalized, and we're thinking that's because potentially more high risk activities. And then, you know, and they're three times more likely to die from a TBI than females. And so, you know, this data is actually in the CDC from 2010, because they were talking about, you know, two point, how many ED visits are there from TBI, ranging from mild all the way to severe. So they don't have more updated data since then. They have been collecting it, but they haven't published it yet. Their reports are really publishing more hospitalizations and deaths and looking more at the different classifications from mild, moderate to severe. So you know, and then the sports concussions are a whole different ballgame. You know, we have 1.6 to 3.8 million sports concussions each year. And then pediatrics is also another one. So in 2012, they estimated, you know, 300, almost 329,000, a little over that, children. This is 19 and younger were treated in the EDs for sports or recreation related injuries that included a concussion or a TBI. So you know, this is data from 2001 to 2012 in ED visits. So you know, it is a, it's a huge part of our, you know, system. So you know, I did mention one, so I was going to open this up if anybody wants to put it in the chat, but what are some of the other leading causes of TBI that you can think of in the country? You can either put it in the chat or you can yell it out, it's up to you. MVA is what I'm seeing in the chat. And that is one, yes. Any others? Firearms. Good job, yeah. And blast related for the military. And then there's one more. Sports are on there. Yep. But not as high. Physical assault. Good job. So the falls are one of the, is the highest cause and actually motor vehicle and fire armor, the next two. And actually in 2017, 15 to 17 firearm related causes actually surpassed motor vehicle traffic crashes. So, and then from the assault is intimate partner violence is actually the highest part of the assaults as well. And then black injury is the leading cause for TBI in active duty military in the, in the war zones. And then in from 2000 to 2021. And so as you guys know, that was during our conflict, you know, 450,000 US service members were diagnosed with a TBI. And so with that, when we think about falls, the biggest, like I said, bimodal on the falls, you have the children zero to 14, and then the TBI is 65, 75 and older. And then the firearm related is actually firearm related suicide attempts. So that's your past motor vehicle crashes. And then for motor vehicle traffic crashes, you know, it was on all age groups from that standpoint. And it was the second leading cause up until 2015 and then firearm tech kind of surpassed it. So, you know, 18% of all TBI related emergency department visits involve children, 30%, 32% of all TBI related hospitalizations were in adults, age 75 and older. And like I said, males were more often. So what groups are most affected by TBI, and this is kind of going into some of the healthcare disparities. So if anyone wants to throw those in the chat, homeless, correct, military, we get persons of color, athletes, older adults, and any other ones, Hispanic, yep, that's part of the racial and ethnic minorities and the persons of color. And then a couple and someone had talked about partner violence for kind of the leading causes. So yep, intimate partner violence. So older adults is of course, one of the biggest ones, but there's actually data with people with lower incomes, those without health insurance have less access to TBI care. So when we start looking at that, that's kind of some of the socioeconomic status of people in rural areas more likely to die because of being able to get to a hospital for care. So they have delayed access to care and then people who experience homelessness. And then you have the one that some people did not mention was people in correctional facilities or detention facilities. We see that a lot here at Ohio State because we are the state hospital and we work with the prison system. So we actually have an entire prisoner unit and I see quite a few patients that have come in as a result of TBIs as well. So when we start talking about healthcare disparities, we also want to talk about socioeconomic impact. So the lifetime economic costs of a traumatic brain injury, including direct and indirect medical costs was estimated to be around $76.5 billion and that's in 2010. They don't have updated data since then. So that's 13 years ago. And so if we can only imagine, with inflation and all of that, that's a lot more. So a lot of the work that's being done nationally is trying to get more funding for brain injury survivors and the associations to be able to support those survivors. And then the CDC estimated around 5.3 million Americans and that's about 2% of the population currently have long-term or lifelong need for help or performing ADLs as a result of a TBI. So a lot of what we've been doing, and it's a lot of state-specific, is really trying to get waiver programs and other things to be able to get people assistance at home or getting transitional rehab programs or educating skilled nursing facilities on how to manage patients with TBI. So we'll kind of take a change from epidemiology over to pathophysiology. And so from pathophysiology, there's four different things that can happen. We call them primary, secondary, tertiary, and quaternary injury. And quaternary was really added more recently. Really, it's primary and secondary. And then we'll kind of, I won't really talk about tertiary because that's usually some other things going on. But with a primary injury, that's the time of the trauma. So that's that acceleration, deceleration force we see, the penetrating head injuries like gunshot wounds, lacerations, contusions, skull fractures, intracranial hemorrhages. So that's kind of when you think of a primary etiology. So where do you guys think, this is, of course, the representation of the brain from the side. Where do you think the most common causes or locations for the brain injury to hit are? And you can put that in the chat as well. Temporal lobe, frontal lobe. And some people are talking about occipital lobe. OK, great. So the answer is actually the orbital frontal lobe and the anterior temporal lobe. Can anybody tell me why those two particular locations are going to be the most? Epidural hematoma, good thought, but not necessarily. Anyone else have an idea why those two are the most common locations? Like whiplash. So that's your acceleration, deceleration, least amount of cushioning. So good job. Whoever said the least amount of cushioning. So if you notice, that part of the brain is actually encapsulated by the skull. It's the first part to impact the skull. And then it's also the base of the skull. And the base of the skull has a lot of ridges on it. And so you're going to see a lot more impact there. Yes, your coup, contrecoup injuries could hit frontal occipital. But this is a little bit more cushioned back here. You have the cerebellum that's taking a lot of that kind of basilar skull area. So really the orbital frontal and anterior temporal. And a lot of the injuries are acceleration, deceleration. So really the brain's moving forward and then going backwards. So you're really going to see more orbital frontal, inferior frontal, and anterior temporal lobe. Good job, guys. And yes, where the most impact comes. And so when we start thinking about areas of the brain, and this is really what I started thinking about when I have someone in front of me, is what do all these areas of the brain control? And you really want to be, you know, neuroanatomy and neurology were my favorite subjects. But I went into PM&R because I really wanted to be someone that focused on function. I didn't want to just be the diagnostician. So at this point, when I have someone that comes in with a brain injury, I'm like, okay, well, you know, here's what they look like on imaging. They have contusions here. They're bruising here and things like that. Here's what they look like in person. And unlike stroke, where you can actually play the lesion game with brain injury, you kind of have to look at the whole grouping of it because we see a lot of shearing injuries, acceleration, deceleration forces, and that type of thing. So really knowing kind of what parts of the brain control what is kind of what I do when I'm seeing someone with a brain injury and trying to describe just, you know, just determine what medications and other things I'm going to do. And this, again, is the central part of the brain. And so really looking at, and I'm putting these up here just to help you guys to remind you, those that have been away from their neuroanatomy courses, you know, what each of these areas of the brain does. And I know you'll have these slides as a reference too, to be able to kind of quick reference those. And so the next part is a secondary injury though, when we start talking about the pathophysiology. And that's really on the cellular level. So it's looking at inflammation, you know, the cell receptors, the free radicals, some of the calcium and other ion mediated cell damage. This is where we're looking at this kind of secondary cascade. And this is what's really being focused on in the neuro ICU. But it helps us to find, to help with prognostication down the road, to see how much of a secondary injury actually happens. So really, you know, what I do when I start getting consults and I see consults for brain injury patients on the, in the acute ICUs as well, is I'm really trying to see, okay, what kind of effects do they have? Do they have their injury? I know that they have like an epidural or subarachnoid, but then I also want to see was an EVD placed because they had intracranial pressure elevation. Did they need to be intubated because of hypoxia? Did they have, you know, signs of cerebral edema? Did they have changes in blood flow? Like, did they have vertebral artery injuries or did they have, you know, other things that could alter blood flow? Did they, were they exsanguinating from places? So, you know, those are some of the things that I start looking at because not only does it help to look at what the image looks like, but it also helps to know what, what additional injuries happen. So that when I'm starting to think about, is this person going to have a good potential for recovery? Is it someone that I'll be able to bring into inpatient rehab? You know, what kinds of things do I need to do early on? But we also can help the ICU teams because we deal a lot with, you know, sympathetic storming. We deal with a lot with behaviors and agitation. So other things that could be, that we could treat to try to help prevent some of these secondary injuries from happening. And I did mention early, you know, about tertiary injury. Now, tertiary injury has been classified as the additional things, like broken bones, when it comes to like the blast related injuries, you know, if there's shrapnel or anything else that's coming into play, you know, those are kind of the tertiary injuries. It's kind of like the polytrauma of the injury. So how do we grade a TBI? Does anybody know what criteria we look at to grading a TBI? GCS, yep. The Rancho we'll talk about in a little bit, but that's more for prognostication and for recovery. Mental status, and that's part of the, and time of loss of consciousness with excellence. Brainstem affected, not so much. Mechanism of injury, that'll tell you about impact. So GCS and loss of consciousness are two of them. And then there's one more, and it may not be a term that you guys have heard yet. So we want to look at their best GCS within 24 hours. The SCAT is used for concussions, but good thoughts. Way to bring that up. But the best GCS within 24 hours. So there's a debate whether it's the initial GCS or the worst GCS, and quite honestly, it would be the worst GCS. And then you want to know the length of coma. So that's your loss of consciousness or length of coma. And then you want your duration of PTA. And the person that said OLOG, that's correct. You want to see, you know, if the OLOG is one of the scales we use to see if they're in post-traumatic amnesia and the duration of it. So that's how we kind of talk about when we grade a TBI between mild, moderate, and severe. And I'll give you guys a little table and a little bit about that. So then we look at the different disorders of consciousness. So when I said length of coma, there's coma, but then there's unresponsive wakefulness, and then there's minimally conscious state. And so in our disorders of consciousness programs, this is really what we're trying to differentiate. So can anyone tell me what criteria it is for coma? No eye and opening, good job. And that's our primary one, sleep-wake cycle. Yep, there's no sleep-wake cycle. Good job. So eyes are closed, no sleep-wake cycle, and no purposeful motor activity. So great job. And then what about unresponsive wakefulness syndrome? And if you guys haven't heard this term, cause it's the new term for vegetative state. Anybody know the criteria for that? Okay. So not eye tracking and not chain stokes, but it does have to do with the eyes. The eyes are finally open. So spontaneous eye opening, no evidence though of reproducible or purposeful behaviors to stimuli. And then there's a persistence, is if more than one month and permanent, if they're in an anoxic brain injury, it's more than three months. And if it's traumatic, it's 12 months. So the new term for vegetative state is now unresponsive wakefulness syndrome. So they do have spontaneous eye opening, but they don't have anything else. So they're really to come from coma to UWS, it's eye opening. And then the minimally conscious state, that's where you have a set of criteria, but you have to have one clearly discernible behavioral sign. So in that, the biggest thing with minimally conscious is that they're consistently inconsistent. So one day they could follow a command, the next day they don't. Sometimes they have a verbalization, sometimes they don't. A lot of families will say, oh, they squeezed my hand, but that could be a reflex response and not necessarily to command. But really it's that responses to environmental stimuli. They have a sleep-wake cycle that you can discern. And the biggest thing is consistently inconsistent. Just because they followed a command one time doesn't mean that they have emerged. So how do we recover that consciousness? So we look at plasticity. So this is one of our big things that we talk about and how do we get plasticity? So some is spontaneous, just from natural recovery. A thumb is from training and experience. And that's where you do consent of a lot of the environmental things. That's where you're doing therapies. That's where you're doing neuro-reeducation. And then you have some of the thalamocortical plasticity. And we'll talk a little bit about that at the end with some of the newer things going on in TBI rehab. So when we started talking about PTA or post-traumatic amnesia, like I said, I would talk a little bit more about that. And the person that talked about the O-log is correct. So this is the time from the injury to the time where new memories are being made. So they may be talking to you and everything, but then they can't remember what they ate for breakfast or they can't remember why they're in the hospital or they can't remember that the family members visited the day before. And so even though they're awake and alert, they seem like they're making memories, but then they have no recollection of those. They're still in post-traumatic amnesia. So we used to use the GOAT or the Galveston Orientation Amnesia Test to really determine when someone was out of post-traumatic amnesia. But we noticed that there wasn't the greatest inter-ratal reliability with that. So the orientation log or the O-log that someone mentioned, that is what we use. And that's what we're looking at. It has the best inter-ratal reliability for determining when someone's out of PTA. So I put the criteria in there. So for the GOAT is 75 or higher, two consecutive days, and the O-log is 25 or higher, two consecutive days. And the COAT is what we use on the pediatric side. It's just the GOAT that has been adjusted for pediatrics. So like I said, post-traumatic amnesia is that time from, you know, loss of consciousness, their brain injury, their loss of consciousness or coma and waking up in their post-traumatic amnesia. It's now called a post-traumatic confusional state as well. That's kind of the new terminology for it as well. And then they have variable recent memory. And this is because when people kind of are emerging from amnesia to the variable memory, they're still in that state of confusion. So they still could have not perfect memory. So that's why when we started thinking, going back to that grading of the TBI, we have our mild, moderate, and severe. So it depends on the length of loss of consciousness, your GCS, and then your post-traumatic amnesia. So this is a nice scale that kind of helps you delineate between mild, moderate, and severe. And then a lot of people will interchange concussion with mild TBI. And they can be interchanged technically, but not from a recovery standpoint. So the ACRM, or the American Congress of Rehab Medicine, went in and they kind of gave us a definition of mild TBI and concussion. And again, like I said, loss of consciousness less than 30 minutes, GCS after 30 minutes of 13 to 15, and then PTA of less than 24 hours. But this is also like acceleration, deceleration. There's a blunt force trauma, or the head is striking something. But this one is a little bit different in the fact that it doesn't have to have full loss of consciousness. It could be even any loss of memory or alteration of memories of mental state. So that's where kind of concussion and the mild TBI take a little bit of a difference. And then we grade those concussions. And so CANTU in Colorado, our traditional grading systems, this is what, you know, it's back from the 90s, but these are what we have and we still use to this date for kind of grading concussions. So we really want to look at loss of consciousness, PTA, and then your GCS. But in the concussion, we don't necessarily need GCS as much when we're grading it between a mild, moderate and severe concussion. So this is kind of the bread and butter of what I wanted to chat about. And it's really kind of a lot of the consequences of TBI. What do we do? So neurologically, there's a ton of consequences. You know, we have our autonomic instability, we have sensory motor issues, movement disorders, visual deficits, sleep disturbances. And so these are all things that we're looking at, you know, while they're in inpatient rehab, while they're in the hospital, you know, so we're really managing a lot of storming, especially for our disorders of consciousness patients. Seizures are another one that we are watching for. So even though we prevent seizures in the first week or try to, but if they had seizures early on and you see changes, you know, there's concerns for those movement disorders can start coming out like spasticity or tremors or apaxic movement disorders. So really a lot of those are things that we're working on. And headaches is, so headaches is primarily for my milder TBIs and not necessarily more for my moderate and severe. And does anybody know why that is? And then I'll answer the one question that's been put in the chat too. So in the mild TBIs, you're gonna have, nope, not due to increased ICP, but in mild, because mild TBI, you shouldn't have increased ICP, but really where are a lot of the nerve endings and things that are in the meninges and typically mild TBI is what's gonna be having more meningeal irritation, not necessarily moderate and severe, which hits more of the cortex. And so someone had put in the chat, I'm asking about can post-traumatic amnesia occur from emotional trauma too, or just physical? So those are two different types of things. So when you're talking about post-traumatic amnesia, you're talking about the PTSD related post-traumatic amnesia, that could be from emotional trauma for sure. But the physical trauma of post-traumatic amnesia, when you think about that after TBI, that's time that they'll never get back. There won't even be a way for them to recall that. Where the emotional amnesia from an event or an emotionally scarring event, they could potentially start recalling some of that because they were able to make a memory during that, but then their brain made them amnestic to that. So a lot of what we're talking about in the post-traumatic amnesia in TBI is truly the physical trauma. The emotional trauma or the emotional things, especially in our intimate partner violence, those are a little bit different in the fact that those can be things that are recalled, but the period of post-traumatic amnesia after TBI cannot be recalled. So, and then cognitive consequences. And so a lot of what I deal with is memory and attention are the kind of the top two. And then some of the other ones are abstract reasoning and insight. And then I was just joking around with another attending. I said, I have no pill for insight. And if I did, I'd have a million dollars. But the trouble is, is like people, when they have a brain injury, it's one of those that I call the unseen trauma. Because if they don't have polytrauma, they don't have physical impairments. And they feel, they look fine. They look fine in a mirror and everything. They feel that they can go out and do everything. And so they don't have the insight as to some of their cognitive deficits and how it could affect them from work, from driving, from relationships. So those are some of the things that we do a lot of work on, but there's not really medications to use for it. I use a lot of different neurostimulant medications as well. Things like, and Mantine and Riddle and I bolded here because those are the top two that we use. And the rest of these that are on the list, we do use, but we use them in specific instances. So I just wanted to put them up there. I could do a whole another hour long talk on every single medication, which I do have, and what they're all used for. And I am terribly sorry for my spelling error, but that's memantine with an E at the end. And I missed the E for that one. So behavioral consequences is another kind of bread and butter. So a lot of people ask, you do a lot of psychiatry. And I said, well, it's not really necessarily psychiatry because if they have a psychiatric disorder before their TBI, I usually consult psychiatry to come in and help because then we're dealing with a whole new brain than what they had before. So there might be changes in meds and things that need to be done. But really what I do from a, I do use a lot of psychiatric medications though because I am managing behaviors and aggression and restlessness, but those are all due to an organic cause of the TBI. And the way those need to be treated are a lot different than a true psychiatric disorder. So I do have a lot of behavioral consequences. And then I put down at the bottom, hallucinations, usually it's a side effect of the medications, but I have had some patients that had an emerged psychosis as a result of their TBI. But those are usually some of my patients that have potential ideas or inklings for psychosis even before the TBI. So the Agitated Behavior Scale that was created here at Ohio State eons ago, and that's something that's used across the country for assessing people when they're agitated. And so I usually use the scale throughout the day to see how my medications are doing and how patients are doing in general. If they are getting numbers of like 29, 35 or even above 35 consistently, I definitely know I need to get medications on board to treat and to calm these behaviors down. Otherwise your nurses and therapists are gonna hate you. So with the ABS though, this is how to grade it. It's on a scale of one to four and there are a total of 14 questions. And so with the 14 questions, it's basically these are all the different behaviors that you could see. And so what I do with the ABS on a daily basis is when the residents report to me whether ABS was 29, I ask them in what areas, so that way because that helps me understand which medications to use because different medicines like someone that's like pulling at lines and tubes and wandering, I treat a little bit differently than somebody that's actually got a short attention span or somebody that's actually violent. So there's different medicines used for different things. So that's why on the ABS, you wanna see, and it is a very subjective. So if you have nurses that are brand new, to them a four present to an extreme degree might be different than one of my nurses that's been there for 30 years, who's used to this behavior and to them it's like, yeah, it's no big deal. So really that's why we try to do is we do the ABS for multiple times during the day so we can see if there's a consistency and multiple different raters for it. So that way we can see, is it just because there's one staff that's just not used to these, they're newer staff, or is it because it's truly a behavior we need to treat? So these are the medications we commonly use. The most common to use and has the most data behind it is beta blockers. And then after that is the anticonvulsants. But you'll see a lot in the ICU, the acute care hospitals, benzodiazepines and typical antipsychotics such as Haudel being used. And I put in bold there, do not use Haudel. And the reason why is because it can actually slow cognitive recovery and actually completely alter cognitive recovery or recovery from a brain injury. So we try to stick with more of the atypical antipsychotics in the acute care if they absolutely need something. There's also data on imantadine to help with behaviors, not only from a neuro-stim standpoint, but also a behavioral standpoint. Some of that literature came out through the model systems data as well. And then we use a lot of the antidepressants, especially for like a perseverative behaviors, restless behaviors and things like that. So really, these are the meds we use, but the reasoning for them is different. So the one thing I would have to say is, when you're on rotations or anything like that, or eventually if you decide to go to PM&R residency, every single consult note will always say, do not use HODL, so don't use it. Have that in your back pocket. So someone had mentioned earlier the Rancho Los Amigos scale, and this is actually a scale that we use more for tracking recovery, not necessarily for grading of the TBI. And so this really helps us to kind of hone in our treatment interventions and the levels are based on behavioral observations. So it's a 10 point scale. When I was a resident, it was only a seven point scale. So now it's gone up to a 10 point scale. It was seven and then went to eight and now it's at 10. And I'll kind of go through each of the different phases, but really what you need to know is like, one, two and three on the Rancho scale is the disorders of consciousness. Coma, unresponsive, wakeful, and then minimally conscious. Your four is right when they're starting to emerge and they're in that post-traumatic confusional state, so they're confused and agitated. And then your five, six and seven. So your five and six, they're in that post-traumatic confusional state. They could still be in post-traumatic amnesia, but they're not agitated, but they still could be inappropriate. And then they move to being more appropriate. And then their seven is really, they're doing those automatic tasks, like robot-like tasks, but they're not, you know, interacting and independent with that. And then that's when the eight, nine, and 10 come into play. So this is where they're more purposeful, more appropriate with especially social and emotionally. And then they move on to being modified and independent. So this scale really helps us determine, and it helps me talk to families about where patients are in their recovery process. And so some of these behavioral assessment methods, especially in disorders of consciousness, we use a lot more scales. And the one that we use the most is the coma recovery scale revised that has the most data behind it. It has the best sensitivity and specificity to talk about when patients are emerging through the stages from UWS to MCS, minus MCS plus, and then into emergence. So the CRSR is the first scale that we are using for patients in our disorders of consciousness. If they're already at a range of four and beyond, we don't use the CRSR at all. I put these other scales up there because you will see them in literature. You will see them on different things out there. So, but this is kind of a nice little graph about each of those scales that I just mentioned. And then IRR is Interrater Reliability. TRR is Test and Retest Reliability. Then you have your Construct Validity, you have your Internal Consistency, then your Sensitivity Specificity, and then you have what it's used for, Diagnosis, DX, Prognosis, PX, and Treatment of TX. So if you kind of look at the CRSR, it has plus signs in the most areas. So it actually has the best use for it, Interrater Reliability, as well as from Diagnostic, Prognostic, and Treatment Planning. So that's why we use the CRSR, or that's the Coma Recovery Scale Revised. And they're creating, they have created one from a pediatric standpoint. And so it's currently in the studying phase to see how it's gonna be. But each of these are different scales that we use. And I'll give you guys a link to where you can find all these scales at the end. And then Social Consequences of TBI. Now, this is huge. This is where I spend a lot of my outpatient time. There is a much higher suicide risk, lots of relationship difficulties. I can't tell you the number of my patients that have gotten divorced, lost relationships with spouses, friends, children, the economic strain of being unemployed because they cannot return to gainful employment sometimes. Substance abuse is, this is a huge thing. We have something called the TBI network here in Ohio, actually at Ohio State, and it really focuses on patients with brain injury, traumatic acquired or any kind of brain injury and substance use disorder. And that is definitely something that we see a lot of because if we, you know, we went back and you saw the behavioral and cognitive changes and some of the medications they use like Ritalin or opiates, you know, they are potentially having abuse potential to them. So we do see that we do see people with, you know, heightened anxiety, they lose their relationships, they turn to alcohol and other drugs. So we do see that quite a bit. Someone may ask in the chat about medical marijuana and how that is in here. And medical marijuana, at least in the state of Ohio, and I can talk about state of Ohio, it is an approved use for TBI. And I counsel my patients that they can use it in TBI, but they have to also recognize that the THC can cause cognitive slowing. So I will recommend it to my patients if they, you know, have other things that they need to use it for spasticity, you know, anxiety, other things, but with the education that if they go and seek a medical marijuana card, that they really have to think about the cognitive changes that could happen with it. Isolation and legal issues are another one. Family and caregiver burden is huge. So we take a lot of time to educate our families. We have, we have psychologists on our unit that will work with families. We have social workers working with the families because these patients need 24-hour supervision. And I mean, you know, that person's already lost their job because they've had a brain injury and now their caregiver, their loved one has to take time off from work because they're, they need 24-hour supervision. I mean, financially, it's a huge strain and a burden. So a lot of, you know, and there's not a lot of resources especially when it comes to home healthcare and waiver programs and things. So, and the patient usually has poor insight. They don't really understand why they have these issues. So doing a lot of family education and then doing a lot of community reintegration. So how to help them maintain social relationships, how to help sustain gainful employment. But society is sometimes unaware because they look fine. So, you know, medical complications, this is where we spend a lot of time in inpatient rehab. There's a lot of them. It pretty much affects our entire body system. So I call the brain, the computer hard drive for the body, and it controls every single system in our body. And so these are just kind of some examples of the medical complications. Again, it could probably go into an entire two to three hour talk on all the different medical complications after brain injury and what we have to do with it. But from a neurological, endocrine, vision, musculoskeletal, pulmonary, cardiovascular, gastrointestinal, gastrointestinal, urinary, and insegumentary, so skin related, there are consequences to TBI pretty much head to toe. So, you know, those are things to think about. And this is the reason why a lot of patients in brain injury need that close medical supervision. And then I'm going to kind of talk a little bit more about rehab, you know, and as physiatrists, what our role is, you know, in our last, you know, 10 to 15 minutes before I open up to questions, I really want to talk about, you know, what I do in brain injury rehab. And from the outpatient side, you know, really a lot of behavior management, symptom management, headaches, sleep, vision, things like that. And then spasticity management. So I do a lot of procedures. I am also a trained acupuncturist. And then you do trigger point injections, joint injections. So there's still a lot of procedures I can do in brain injury. So, because I tell everybody, I'm like, I love to stick needles and things and that, but I'm not an interventional spine specialist. So, but I do all of these procedures in clinics as well. I do some of them on the inpatient unit too. Equipment, you know, there's a lot of DME that could be involved depending on the level of injury. And of course, therapy prescriptions. And then disorders of consciousness is a whole different part of brain injury rehab that I do. You know, so this is where, you know, I'm actually functioning as a detective. I'm actually trying to figure out why this person is still in a disorder of consciousness. Is there a reversible cost? And there was literature that came out in 2013 from the ACRM or American Congress of Rehab Medicine that said, you know, 40% of patients that are labeled in a disorder of consciousness actually have a reversible cost. And so what I do in our DOC program and, you know, when I see DOC patients is really try to play detective, you know, are there medications that are holding them back? Do they need neurostimulants? Do they need modification of any confounding variables? Like, you know, do they have hydrocephalus? Are they having seizures? Are there infections? Are there any neuroendocrine abnormalities? So I'm really doing kind of a full workup to try to figure it out. But then I'm also using things like medications and then some of the newer technology out there like transcranial direct current stim to try to see if I can really help promote that arousal. Reviewing imaging and all of that stuff as well. So disorders of consciousness is a whole field of brain injury medicine that's different than traditional rehab. And then on the inpatient side, like I said, you know, from the inpatient side, I'm really doing a lot of those, you know, medical management things, of course, behavioral management from the acute care, and then also doing a lot of family education. But I'm also working on a lot of prognostication. So I'm also talking to families and I'm always getting the question, you know, is my loved one going to get better? Am I going to be able to do this? So really, this was a nice graph that was put out by the VA. And they kind of talked about, you know, the severity of the TBI, so mild, moderate and severe. Then they talked about length of PTA or post-traumatic amnesia. And then if they had integrated memory problems, and then, you know, the time of injury, if there's any retrograde amnesia, but then, you know, timing post-injury. So if you see mild TBI, very brief post-traumatic amnesia, they'll get back to pre-injury functioning pretty quickly, usually within three months, but if it's even faster than that, they might still have some mild things, but usually they're 100% back to where they need to be within three months. But the moderate and the severe TBIs, these are the ones that are going to take the longest. Moderate, of course, up to, you know, 12 months and beyond. And if they even will obtain, you know, their previous level of functioning, or even like 50% of it, and moderate can get closer, but still have significant troubles. So the, you know, there's a lot that's out there that says the first six months is where the patients with brain injury heal the fastest. And as you can tell with the trajectory of the curve, that's 100% true. The next six months, they'll still make progress, but it's a little bit slower than what they had before. And so some of the poor predictors of prognosis and outcome, you know, is their GCS score, what their CT scans look like, their age, and then some of the neurological things. So light reflexes, doll's eyes, if you do cold caloric testing, and some of that is more from when you're thinking about brain death testing, or, you know, DOC testing, motor responses, their SSEPs. So SSEPs are somatosensory evocative potentials. We don't do those anymore. They do them on the pediatric side, but not on the adult side. And then their post-traumatic amnesia. So really the main things that I'm looking at, because I'm not necessarily doing all of these things, is your GCS, your CT scan, and your post-traumatic amnesia. And then five-year outcomes of persons with the TBI. You know, this is where, this came from the TBI model systems data, and this is for people 16 years of age and older. So 22% died, and then, but up to 26% improved. 22% stayed the same. So really this is kind of where we as a physiatrist are really, you know, key. You know, how can we prevent them from becoming worse? Are there ways that we can do that? How do we prevent, how do we maintain, and then how do we help improve? So, you know, we really kind of come into play quite a bit when it comes to those areas. And then other predictors of outcome. You know, when we looked at the TBI model systems, national data sets, they actually did a study. They looked at, you know, they took 566 patients prospective, multi-centered, and they looked at where do people go? And it said more than half of those don't go to specialized neurorehab facilities or inpatient rehab facilities. A lot of them are going to skilled nursing facilities and or, you know, you know, they're not getting the care that they need. So really it's that early specialized treatment that we really want to get for these patients. And so predicting post-acute care disposition, severity of the brain injury, overall injury, and some of their social biological status. So, but as a TBI physiatrist, you know, what do I do? You know, there was a retrospective review and they looked at IPR admission and this was at one rehab facility and 148 patients from four different centers. Three centers did not have a physiatrist in the acute care, so it didn't do consults and one trauma center did. The programs that had a physiatrist in acute care actually had better functional outcomes on discharge. So really starting their recovery process early, getting our physiatrist involved early. And that's been one of the big pushes, you know, because everyone's like, well, why are you being consulted in the ICU? They're still intubated and sedated. I'm like, yeah, but we have data that says if we can get in early and we can manage some of these things like storming and agitation, that'll help decrease ICPs, that'll help decrease secondary injury, we can have a better prognosis. And then, you know, what do we do? Like I said, we're managing sleep, starting neurostimulants, you know, and then those patients that we did some of that stuff on, they had a higher FIM. So FIM is the functional independence measures. You guys will hear that a lot over the time that you're learning about rehab. But, you know, they had a higher FIM on entrance to inpatient rehab and then therefore they had a higher FIM when they left rehab. So so that's the one, the program that had the physiatrist, that had the physiatrist started these interventions before inpatient rehab. So some cool things, you know, there are some new frontiers in neurostim. And this is some of the things that I, you know, have been getting very involved with recently. And we do a little bit on our inpatient unit is using transcranial direct current stem. And with the direct current stem, it's basically putting a stimulator electrode on the head, a different depending on what we're trying to affect and then having a reference electrode either on the forehead or the arm and doing, you know, 20 minute sessions a day. TDCS has been seen gamers use it to help improve their gaming. People are using it. We actually did a fun trial with residents. They were taking their self-assessment exam or their their in training exam. And we're like, oh, well, let's throw a TDCS on them for the morning. And those that did the TDCS that morning felt like they were more awake and learned how more stamina to take the four hour exam. So I thought that was pretty cool. And then with TDCS that we use, of course, for PBI, we're using it for a host of different things, DOC for sure, to try to help with neurostimulation. And then we also use it in depression, anxiety. We can also use it in aphasia and motor recovery as well. TMS or transcranial magnetic stim, that's still getting that's more in the stroke literature right now. We don't have a ton in the brain and traumatic brain injury literature yet, but we're starting to get more information about it in TBI. But a lot of the information right now for TMS is in the stroke literature and we're seeing some good effects with it to help with motor recovery after stroke. Deep brain stimulation, there are some case reports out there about using DBS in disorders of consciousness patients to help with neurostimulation, to help emerge them to the next level of consciousness. They're really focusing on the thalami, the bilateral thalami, to really help to see if that improves arousal and alertness. But we use DBS all the time for our patients with movement disorders. So if they develop a movement disorder as a result of the TBI, whether it's like Parkinsonian-like movement disorders with tremors and bradykinesia and things, or whether it's actual dystonia and things too, that we can use DBS for. So we do use DBS quite a bit in TBI, not necessarily for arousal and neurostim. And there's thoughts to do for DOC, but really use it more for the movement disorders that can be a result. And then we do a lot of technology-based interventions. And these are already things that are going on and they're pretty robust. Assistive technology, there's lots of different microswitches, there's different communication devices that we can use, iPads, the different apps and stuff that we're using, especially for doing visual scanning and have attention and stuff. So some of those things that we talk about with using some of the games we play, like they have those brain game apps, those don't have any data behind it, but some of the other apps like Fruit Ninja, we were using that in our inpatient rehab unit, or like the bubble pop game or, you know, so that people can scan and look at colors and they're really trying to hand-eye coordination and stuff and reaction time. So, and then computer presented stimulation. So we're doing a lot of that from like brain computer interfaces and things. And then there's virtual reality, use a lot of virtual reality and gaming is huge. We have, you know, you'll see a lot of inpatient rehab units. They have a Wii that they're doing like Wii Fit and things and bowling. And then we have the Connect and we're doing using VR to do a lot of different things, especially from a pain management standpoint too. So someone had a question, is there any role or work done in the use of psychedelics in TBI recovery? Yes, actually. So that's a really good question. While we're talking about new frontiers, I was actually just at the International Brain Injury Conference on this past March, and there's a group out of Belgium that's doing some work on using magic mushrooms and looking at ketamine for recovery from disorders of consciousness. So, and they've had some pretty, they've only, I mean, these are all ends of like three or four. They don't have a lot, have large end because first they have to get people to, you know, be willing to use psychedelics and ketamine, but we are seeing some data out there coming through. It's all not in the U.S., but it's coming out of Europe and Belgium. So a good question, but yes, there are some roles coming out about that because they're also wondering if some of the people in disorders of consciousness are actually in a catatonic state and they're not necessarily in a DOC because of their brain injury. It could be they developed a catatonia afterwards. And I did, you know, I had one patient who had emerged, went home, rancho five, everything, then started declining and then started staring and his, you know, we brought him back in and his mom said, well, when they gave him Versed for replacing his PEG tube, he woke up and started talking. And I was like, okay, well that could mean they're catatonic. So we started, we did an Ativan trial, man, if I would not tell you this kid was up and walking and talking. So it's actually really cool. And then there was some, there's some reports on using sleep medication, gulpidem or Ambien to see if that would help with improvement in, in, you know, alertness and things after DOC. And there are some case reports in that as well. So good question. So in summary, like I said, the brain is a computer hard drive to the body. Every organ system can be affected. What's the role of a physiatrist, you know, at that time, medical management, neurostim, behavioral management and prognostication. So and I put some useful links up here on these. So the COMBI is featured scale, the TBI model systems, knowledge transit, knowledge translation center has a lot of brain injury fact sheets, the trauma brain injury concussion in the CDC, as well as the NIH are the next two links, have a lot of important information. And then there's a TBI important links that has information about different things like domestic partner violence, traffic, incidences and things like that. So there is one more. Okay, yeah, it's interesting. Yep. Using there's some interesting results of ketamine and PTSD. So yeah, that's very true. So if anyone else has any questions, you know, you're either can open that up to you guys, yelling out your questions or putting them in the chat. And I'm happy to answer them in the last couple of minutes. And are there certain OMM modalities you prefer to use? Yep, so good question on that. I use a lot, so I'm actually trained in craniosacral therapy. And so craniosacral, I use a lot with my patients with headaches especially, but I also use it for some of the attention and concentration issues too. I do a lot for my polytrauma patients, especially the ones that were motor vehicle accidents, I'll do a lot of pelvic and sacral work as well, but really looking at craniosacral as kind of my primary for some of the headaches and other things that I see from TBI, but craniosacral, and I would say, like some of my pelvic realignments are my main stay of OMT. Any other questions? Well, you're welcome. You're welcome. I hope I could give you an overview of TBI and what I do and give you some information, but there's so much more out there. So I'm glad and thanks guys. Oh, go Bucks. And then, oh, one question came up about, what are your thoughts about stem cell therapy? So right now, there is some research being done in some locations on stem cell therapy, but the data out there is not showing much, if any improvement at all. So especially with TBI, because it's such a diffuse injury, there's not really a way to really focus those stem cells. Unlike in spinal cord injury, where you're like, okay, this is the area of the cord that's been hurt. Let's try to focus the stem cells here. We don't really see that from a TBI standpoint, but good question. And then, and then, yes, you can stick around and ask me a question. I think that's one person that asked that. And then at what point in time is the physiatrist consulted regarding a TBI patient in the OR or after the acute management part and things? So typically TBI physiatrists, we are consulted when they're in the ICU setting. So after they get out of the ER and they're in the ICU, usually about 48 to 72 hours after they've been admitted into the ICU and they've been a little bit stabilized is when I usually get consulted. Sometimes I get consulted later when they're transferred out of the ICU to the regular floor. But for the most part, we're getting, at least here at our trauma center, we're getting consulted in the ICU. Okay, and it looks like one other person has a question of role of AI in diagnosis and therapy for TBI. So yes, there's actually a lot going on with AI. And trying to see how we can use that for more of the recovery and the rehab standpoint, not necessarily as much in the diagnostic prognostication, because a lot of these algorithms that we have, they aren't for everybody. So there's a lot of differences between the patients. So no two patients, even if your head imaging looks the same, one could be walking and talking, the other one could be in a DOC. So AI doesn't really, won't really help as much with that because they do more of that algorithmic thing when it comes to prognostication, but definitely we can use them a lot in our rehab and recovery. And then one last question, someone with a relative. Okay, how are some ways you navigate family education, cultural? Okay, that's a really good question. So navigate family education and cultures in families that may not appreciate the severity of a TBI, dealing with a patient who may not be as compliant with treatment due to diminished insights. So it's a very good question because we, I pretty much deal with this all the time. There's lots of cultural differences between survivors and their families of TBI. And so, coming from a culture that really tries to sweep a lot of things under the rug, especially psychiatric and behavioral issues, there are a lot of those stigma and we do have to navigate them. Part of that is learning the culture. So what I've really had to learn over the last 15 years of practice is really learning different cultural things. Like I've learned about a lot about Somali culture because we're one of the largest Somali refugee locations in the country here in Columbus, Ohio. And I really took the time to learn about that culture because even though religiously they may have the same religion as Muslim or Christian or whatever, but their culture is very different. And it's the same thing, like I'm Indian, but I'm from a different part of India than others. And there's a very different culture in every state in India. So really the number one thing I tell, I recommend is learn the culture, take a second to listen. What I do is, cause there's even different cultures within the US, it doesn't necessarily have to be somebody that's from a different racial or ethnic background. It could be just even within the US, rural culture versus urban city culture. So I really take a step back and I wanna listen and figure out what it is. What is the carrot? What is the issue? And when you start like really listening and a lot of it is they just don't have the education or they don't wanna hear, wanna know, they don't want to hear how bad it is because a lot of the times people don't want to acknowledge that and that's okay. But really sitting down and thinking about, okay, well, if they don't wanna acknowledge this, but how about we give them examples or try to ask them to be like, okay, well, you did this, is that something you would have normally done or is that something they would have normally done? Or is there a reason why they're having trouble with relationships? Like it's kind of like really sitting down and taking that time. So good question, it's a lot of navigation, it's a lot, it's difficult and sometimes you can't get through it all. But for the most part, nine times out of 10, if you just really listen to what is the issue and then reframe things based on their thinking has really helped me. Okay, well, I know it's five after, so I'll let you guys go. And I think the one person that wanted to stay and ask another question, I'm happy to answer that. Sure, so thanks so much for a great presentation. Thanks everybody for sticking around. I will see you all tomorrow. We have our last presentation for the week on spinal cord injury with Dr. Garstang. The slides from today are uploaded on the Google Classroom site, so you can get them there if you would like to. The PDF of the slides with the links and everything. So they are available for you and I will see you all tomorrow. Thanks for joining us today.

brain injury

physiatrist

medical professional

prevalence

functional outcomes

neurological consequences

cognitive consequences

behavioral consequences

medical management

technology-based interventions