Substance Abuse and TBI

BR A IN INJURY professional vol. 10 issue 2

The official publication of the North American Brain Injury Society

Substance Abuse and TBI Traumatic Brain Injury and Substance Abuse Individuals with Comorbid Traumatic Brain Injury and Substance Related Disorders: A Clinical and Programmatic Perspective within a Community re-entry Setting Rehabilitation Case Management for Individuals with Comorbid TBI and Substance Related Disorders within a Community re-entry Program Alcohol Use After Brain Injury: To Drink or not to Drink – That is the Question The Substance Use and Brain Injury Bridging Project: How to Catch a Hot Potato BRAIN INJURY PROFESSIONAL

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contents

BRAIN INJURY professional vol. 10 issue 2

The official publication of the North American Brain Injury Society

north american brain injury society

30 legal spotlight

chairman Mariusz Ziejewski, PhD VICE CHAIR Debra Braunling-McMorrow, PhD Immediate Past Chair Ronald C. Savage, EdD treasurer Bruce H. Stern, Esq. family Liaison Skye MacQueen executive director/administration Margaret J. Roberts executive director/operations J. Charles Haynes, JD marketing manager Megan Bell graphic designer Nikolai Alexeev administrative assistant Benjamin Morgan administrative assistant Bonnie Haynes

33 literature review

brain injury professional

departments 4 editor in chief’s message 6 guest editor’s message

34 bip expert interview 36 non-profit news 38 legislative roundup

features 8 Traumatic Brain Injury and Substance Abuse

By John D. Corrigan, PhD and Jennifer Bogner, PhD 12 Individuals with Comorbid Traumatic Brain Injury and Substance

Related Disorders: A Clinical and Programmatic Perspective within a Community re-entry Setting

by Dustin J. Gordon, PhD, Loretto A. Brickfield, PhD, and Erick D. Dranoff 16 Rehabilitation Case Management for Individuals with Comorbid TBI and

Substance Related Disorders within a Community re-entry Program

By Dawn M. King, Loretto A. Brickfield, PhD, and Dustin J. Gordon, PhD 20 Alcohol Use After Brain Injury: To Drink or not to Drink – That is the

Question

by Nathan D. Zasler, MD 26 The Substance Use and Brain Injury Bridging Project:

How to Catch a Hot Potato

by Carolyn Lemsky, PhD, C.Psych.

publisher J. Charles Haynes, JD Editor in Chief Ronald C. Savage, EdD Editor, Legal Issues Frank Toral, Esq. Editor, Legislative Issues Susan L. Vaughn Editor, Literature Review Debra Braunling-McMorrow, PhD Editor, Technology Tina Trudel, PhD founding editor Donald G. Stein, PhD design and layout Nikolai Alexeev advertising sales Megan Bell

EDITORIAL ADVISORY BOARD Michael Collins, PhD Walter Harrell, PhD Chas Haynes, JD Cindy Ivanhoe, MD Ronald Savage, EdD Elisabeth Sherwin, PhD Donald Stein, PhD Sherrod Taylor, Esq. Tina Trudel, PhD Robert Voogt, PhD Mariusz Ziejewski, PhD

editorial inquiries Managing Editor Brain Injury Professional PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Website: www.nabis.org Email: contact@nabis.org

advertising inquiries Megan Bell Brain Injury Professional HDI Publishers PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Email: mbell@hdipub.com

national office

North American Brain Injury Society PO Box 1804 Alexandria, VA 22313 Tel 703.960.6500 Fax 703.960.6603 Website: www.nabis.org Brain Injury Professional is a quarterly publication published jointly by the North American Brain Injury Society and HDI Publishers. © 2013 NABIS/HDI Publishers. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without the written permission from the publisher. For reprint requests, please contact, Managing Editor, Brain Injury Professional, PO Box 131401, Houston, TX 77219-1400, Tel 713.526.6900, Fax 713.526.7787, e-mail mbell@hdipub.com

BRAIN INJURY PROFESSIONAL

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editor in chief’s message “Alcohol and substance use & abuse – are we just adding fuel to the fire?”

Ronald Savage, EdD This issue of Brain Injury Professional addresses a very complex problem faced by thousands of individuals after sustaining brain injuries and their families – substance use and abuse, including alcohol, marijuana, and drugs. Dr. Greenwald, BIP Guest Editor, notes than even given what we currently know about the significant interplay between TBI and substance abuse, the question still remains, what is “safe” use after TBI or are we just adding “fuel to the fire”.

Legendary in the field of TBI and substance abuse issues, Dr. John D. Corrigan, in our expert interview, cites the better recognition and understanding

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of this problem by professionals, as well as the development of various treatment programs since the 1980’s, but cautions us about how much we still do not know.

Dr. Corrigan states “There is a pressing need for comparative effectiveness studies of proven substance use disorder treatments when applied to persons with TBI… I believe the developing field of neuromodulation may present unique opportunities for restoring a person’s ability to self-control behavior––we have not even conceptualized all the opportunities in this arena.”

Drs. Gordon, Brickfield, and Mr. Dranoff write about the array of deficits associated with TBI, including cognitive impairments of attention, memory, and executive functions and behavioral impairments of depression, higher levels of anxiety, psychosocial dysfunction, and lower levels of self-esteem. These cognitive and behavioral deficits can then contribute to the increased use of alcohol and substances that further negatively impact a person’s life after TBI. Furthermore, they note, these problems can also be exacerbated by a person’s prior history of alcohol and substance abuse before the TBI. As Dr. Nathan D. Zasler states in his article: “Given the neuropathology associated with TBI; specifically, primary injury due to focal cortical contusion (with greatest propensity for frontal and temporal parenchyma) and/or diffuse axonal injury, as well as, some degree of

secondary brain injury in many cases, it would seem unwise for anyone with a brain injury to consume alcohol on a chronic basis.”

Fortunately, new treatment models are emerging, including Dual Diagnosis Treatment (IDDT) which is based upon the work with individuals with mental health problems and substance abuse issues. In addition, innovative clinical programs do exist to support individuals with TBI and alcohol/substance abuse problems, such as the Substance Use and Brain Injury Bridging project (SUBI) in Ontario, Canada. Dr. Carolyn Lemsky provides an overview of this communitybased program that works collaboratively with other health care professionals and a large, academic medical center dedicated to addictions and mental illness. Drs. Bogner and Corrigan have also described a 4-quadrant model for “conceptualizing the opportunities for intervention based on severity of TBI, severity of the substance problem and the setting where the person is encountered”.

NABIS wants to thank Dr. Brian D. Greenwald, MD for serving as Guest Editor of this important issue of BIP. Dr. Greenwald’s leadership and experience in this area of TBI and related alcohol and substance use and abuse will help professionals better understand how to support individuals who face these problems every day.

Ronald Savage, EdD

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guest editors’ message

Brian D. Greenwald, MD As a clinician treating persons who have sustained traumatic brain injury (TBI), I regularly am faced with issues relating to substance use (e.g., alcohol, marijuana, prescription drugs, etc.) Questions regarding a return to small or moderate amounts of alcohol consumption or drug use subsequent to TBI are common of patients and their families. Given the significant interplay between traumatic brain injury and substance misuse disorders, the question of substance misuse treatment regularly arises. Clinicians must be ready to discuss the question of return to social substance use and be aware of the resources to treat patients with substance misuse disorders.

The complex nature of the cognitive, behavioral, emotional and social consequences of TBI can limit options for referrals and achieving success with traditional treatment paradigms. It has been recognized

for the last 30 years that a systematic way is needed to identify patients with substance misuse issues and to explicitly strategize the process for getting treatment.

This issue of Brain Injury Professional sheds light on what you need to know when presented with questions of casual substance use after TBI and discusses how to maximize successful treatment of substance related disorders. Readers will become familiar with: the history of some of the well known treatment programs; some of the core components of treatment; and consideration of the future needs to improve care for this complex problem.

I interviewed Dr. John Corrigan, a well recognized clinician and researcher regarding substance misuse and TBI for this special issue to understand his perspective on the history, current state and future of treatment in this area. Along with Dr. Jenny Bogner he also has an article that discusses risk factors for substance misuse before and after TBI as well as the effect on recovery from TBI. Dr. Dustin Gordon and his colleagues discuss clinical programming for individuals with substance related disorders in a TBI community re-entry setting. They review the challenges to abstinence in community re-entry and the components to create a successful treatment program.

Dawn King and colleagues provide their perspective on case management in general after TBI but specifically comment on the importance of case management in obtaining and maintaining successful substance misuse treatment. They review the unique challenges facing case managers and the tools that are at their disposal to assist in treatment.

Dr. Nathan Zasler tackles the complex topic of whether persons after TBI should

consume alcohol or not. He reviews the effect of alcohol on the brain, alcohol and seizure risk and alcohol consumption effect on medications. He discusses the questions about increased alcohol sensitivity after TBI, the impact of alcohol use on brain recovery, and the morbidity and mortality risks of alcohol use after traumatic brain injury.

Dr. Carolyn Lemsky discusses how the Substance Use and Brain Injury (SUBI) Bridging project. This stemmed from the need to increase the capacity of the health care system in Ontario to better manage a group of clients who were falling into the great divide that existed between community based brain injury and addiction services.

She reports how the Community Head Injury Resource Services of Toronto and the Centre for Addictions and Mental Health (CAMH) came together to “end the game of referral hot-potato that begins when a complex client is identified as having both a brain injury and problematic substance use”. Using an adapted version of the Ohio Valley Centre for Brain Injury Prevention and Rehabilitation manual, cross-training workshops were untaken and partnerships between brain injury providers and addictions providers were fostered. Dr. Lemsky provides an overview of the successes and challenges that presented when establishing their program, as well as of their future plans for expanding and studying it.

I want to thank the esteemed contributors to this edition of Brain Injury Professional. Their articles highlight the complexity, accomplishments and difficulties of treating this population. I also want to thank NABIS for supporting me in my selection of this important topic.

Brian D. Greenwald, MD

about the guest editor Dr. Greenwald is currently the Medical Director of Center for Head Injuries and the Associate Medical Director of JFK Johnson Rehabilitation Institute.

He is a Clinical Associate Professor in the Department of Physical Medicine and Rehabilitation at Robert Wood Johnson Medical School.

He completed his residency training in the Department of Physical Medicine and Rehabilitation at New Jersey Medical School. He was fellowship trained in brain injury rehabilitation at Virginia Commonwealth University. He is board certified in Physical Medicine and Rehabilitation. Prior to joining JFKJohnson Rehabilitation Institute Dr. Greenwald was the Medical Director of Brain Injury Rehabilitation at the Mount Sinai Hospital’s Rehabilitation Center in New York City and the Medical Director for the New York Traumatic 6

BRAIN INJURY PROFESSIONAL

Brain Injury Model Systems.

Dr. Greenwald has been serving on the Board of Trustees for the Brain Injury Association of New Jersey since 2002. In 2012 he was the given the Kristjan Ragnarsson Angle Award from the Sarah Jane Brain Foundation for leading research advancing the field of pediatric acquired brain injury. He was the recipient of the 2009 Physician of the Year Award at Mount Sinai Medical Center. He is recognized by his peers through the Castle Connolly surveys as one of the Top Doctors in the New York Metro Area. Dr. Greenwald has published multiple articles and book chapters in the areas of brain injury rehabilitation. Currently he is involved in several research studies to improve the care of brain injury survivors.

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Traumatic Brain Injury and Substance Abuse

By John D. Corrigan, PhD and Jennifer Bogner, PhD

The editor of this special issue of Brain Injury Professional invited us to provide an introductory article to provide context for understanding co-occurring traumatic brain injury (TBI) and substance abuse. We will briefly discuss risk factors, both before injury and for developing problems after, the effect on recovery and how much use is harmful. Treatment of such a large topic in so little space means choices are made and nuance will suffer.

The interested reader is referred to recent chapters by Miller and Werner in Textbook of Traumatic Brain Injury 2nd Edition (American Psychiatric Publishing)1 and Corrigan and Mysiw in Brain Injury Medicine 2nd Edition (Demos Medical Press)2.

A note on terminology. We use “substance abuse” in this article because of its familiarity in the brain injury rehabilitation field. However, in chemical dependency it is inexact to the point of extinction. With the advent of the DSM V (www.dsm5. org) it is more precise to speak of “substance misuse” when the consumption is potentially harmful (e.g., drinking more alcohol than recommended for your age and gender) but does not qualify as a substance use disorder. In the DSM V, the terms “abuse” and “dependence” have been combined into the single term “substance use disorder”. In this article we use the inexact term “substance abuse” to refer to either substance misuse or substance use disorder.

Risk factors before and after TBI* Many people who incur a TBI are having problems with their 8

BRAIN INJURY PROFESSIONAL

use of alcohol, are using illegal drugs or are misusing prescription drugs before their injury. These individuals are at the greatest risk for developing problems after their injury. Population-based studies have estimated that 23% of adolescents and adults receiving rehabilitation with a primary diagnosis of TBI were misusing alcohol during the time in their life when they incurred the injury that required rehabilitation. Twelve percent had used illegal drugs in the year preceding injury. Of course, there is a substantial overlap between those who misuse alcohol and those using illegal drugs.

Studies consistently find that younger age groups (16 to 40) and men are at greater risk of substance misuse; however, women and persons of any age can have these problems. Trauma, whether recent or remote, also predisposes people to substance misuse. Childhood abuse, intimate partner violence and exposure to military combat all place persons at greater risk. Recent work is also suggesting that, in addition to psychological trauma, a TBI earlier in life, even if mild, may predispose to the development of later substance abuse. After a TBI, individuals who have a history of misuse, psychological trauma or prior TBI will be at greater risk of subsequent substance misuse. Indeed, it is not uncommon for our patients to have all three risk factors.

Like all severe injuries, initially after medical care for a TBI there is often a “honeymoon” when consumption may cease or at least diminish. However, studies have found that for many,

eventually alcohol use resumes, getting progressively worse in the months to years after the injury. Unless something is preventing resumption, many return to ingesting their prior levels of alcohol or use of other drugs. Situations that limit resuming use include having to live in an institutional setting where alcohol and other drugs may be less available, or living under closer supervision of family members who help the individual consume less. Use may reduce or stop if the individual is provided information about the effects of alcohol and other drugs after TBI (Screening and Brief Intervention) or provided treatment if the person is diagnosed with a substance use disorder, provided treatment.

In addition to the large number of individuals who had a substance use disorder before their injury and return to that behavior after, some studies have indicated that as many as 10% of persons with moderate or severe TBI develop a substance use problem for the first time after their injury. There is minimal research on who these individuals are, but persisting pain and/or the development of anxiety or depression are likely risk factors.

Thus, taken together, a substantial proportion of individuals who have been hospitalized for TBI are at risk for developing a problem after their injury — either because they had problems with substance misuse before or because of the vulnerabilities created by the injury itself. We have previously recommended that all rehabilitation programs should have a systematic approach to identifying and addressing substance misuse. For Level I trauma centers, the American College of Surgeons expects routine screening and brief intervention.

Effect on recovery There are multiple reasons why alcohol and other drug use after TBI is not recommended. The substance abuse education series “User’s Manual for Faster, More Reliable Operation of a Brain after Injury”3 enumerates eight: 1. People who use alcohol or other drugs after they have a brain injury don’t recover as much 2. Brain injuries cause problems in balance, walking or talking that get worse when a person uses alcohol or other drugs.

3. People who have had a brain injury often say or do things without thinking first, a problem that is made worse by using alcohol and other drugs.

4. Brain injuries cause problems with thinking, like concentration or memory, and using alcohol or other drugs makes these problems worse.

5. After brain injury, alcohol and other drugs have a more powerful effect.

6. People who have had a brain injury are more likely to have times that they feel low or depressed and drinking alcohol and getting high on other drugs makes this worse.

7. After a brain injury, drinking alcohol or using other drugs can cause a seizure.

8. People who drink alcohol or use other drugs after a brain injury are more likely to have another brain injury.

While this article is too brief to discuss all of these reasons, it is worthwhile to take a moment to discuss why substance misuse would limit recovery. There is mounting evidence about the adverse effects of alcohol and other drug use after TBI. Several studies have observed an association between use and such un-

wanted outcomes as unemployment, becoming isolated, criminal activity and lower life satisfaction. While these studies have observed associations, the causal links or underlying processes have not been fully explained.

There are also studies suggesting an “additive effect” on brain structure and function for substance misuse and TBI. One example is the study by Ian Baguley and colleagues from Australia who examined event-related evoked potentials (an indication of how fast the brain detects new stimuli).4 Their study showed a clear additive effect of heavy social drinking and TBI requiring hospitalization. Those subjects who had either of these conditions were slower responding then people with neither; and those with both were slower still. Similar additive effects have been observed whether looking at other functional effects like cognitive abilities5 or structural indicators like brain atrophy.6 Still, like the mechanisms of addiction itself, exactly how substance misuse limits recovery requires further study. We suspect that the relationship occurs at multiple levels of social, psychological and biological function.

Misuse weakens or eradicates social supports (e.g., creating marital problems, losing family support, abandonment by nonusing friends) and sometime leads to outright environmental limitations (e.g., losing your drivers license, being fired, serving jail time, or being kicked out of your living situation). These kinds of consequences are not limited to the frankly addicted person but can arise from binging, even if not regular. After TBI, diminished behavioral control, even if subtle, may make negative consequences more likely.

Psychologically, the fingerprint of addiction is that other interests and goals lose importance in the face of acquiring and using substances. But even short of addiction, emotional distress and instability, as well as subtle impairment of cognitive function, can result from harmful use of substances. The additive effect of TBI may result from these vulnerabilities being more likely, either occurring to more people, or occurring more easily.

The biological relationship is the most speculative, but recent work in addictions has pointed to networks connecting the midbrain and prefrontal cortex, especially the dopaminergic circuits, as central to the development of addictive disorders. Parts of the frontal lobes and midbrain that comprise these same circuits are vulnerable to contusion and shearing as a result of TBI. Literally, we may process rewards and consequences differently after TBI or due to an addiction, or both.

How much alcohol or other drugs is it safe to consume after brain injury?

The answer to this question requires multiple considerations.

First, there are many reasons why it is not safe to consume illegal drugs, including their interactions with prescribed drugs or other medical conditions, the potential for being arrested, the proven greater vulnerability to injury or being victimized and last, but not least, the potential for additional brain damage from these uncontrolled substances.

While state laws are changing regarding the legality of marijuana, it is important to remember that it is still a toxic substance that has some of the same risks for re-injury as any other intoxicant. While the long-term effects are not fully understood, from our point-of-view empirical evidence is definitely indicating that cognitive impairment and emotional vulnerabilities can arise from chronic use.

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Alcohol – because it is a legal substance for adults – raises the most complex question of what is harmful. Our starting point is that certainly no one should consume more alcohol after TBI than would be considered safe for an adult who had not. Many people do not realize that for adult men it is recommended that no more than 14 alcoholic drinks should be consumed each week. For women, the recommended maximum is 7 drinks per week (www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking). So the question becomes, after TBI should an individual drink even these amounts? We suspect that especially during the early period of recovery – the first several years when the brain is attempting to spontaneously heal and otherwise accommodate the injury – alcohol can inhibit these natural processes. We are also concerned about what happens when the normal aging process interacts with earlier life brain changes from TBI and a lifetime of even moderate use.

Based on information known to date about how alcohol and TBI add together to change brain structure and function, we believe that there is no amount of alcohol that can be declared a safe level for regular consumption.

References *

1.

2.

3.

In lieu of citing individual references for research in this paper, readers are referred to the chapters by Miller & Werner 2011, and Corrigan & Mysiw 2012, mentioned above and included in the reference section.

Miller NS, Werner T. Alcohol and drug disorders. In: Silver JM, McAllister TW, Yudofsky SC, eds. Textbook of traumatic brain injury. Second Edition ed. Washington DC: American Psychiatric Press; 2011:461-482.

Corrigan JD, Mysiw WJ. Substance abuse among persons with TBI. In: Zasler ND, Katz DI, Zafonte RD, Arciniegas DB, Bullock MR, Kreutzer JS, eds. Brain injury medicine: Principles and practice. Second ed. New York: Demos Medical Publishing; 2012:1315-1328.

Ohio Valley Center for Brain Injury Prevention and Rehabilitation. User’s manual for faster

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4.

5.

6.

more reliable operation of a brain after injury. Columbus, OH: Ohio State University; 2004.

Baguley IJ, Felmingham KL, Lahz S, Gordan E, Lazzaro I, Schotte DE. Alcohol abuse and traumatic brain injury: Effect on event-related potentials. Archives of Physical Medicine and Rehabilitation. 1997;78(11):1246-1253.

Dikmen S, Machamer JE, Donovan DM, Winn HR, Temkin NR. Alcohol use before and after traumatic head injury. Annals of Emergency Medicine. 1995;26:167-176.

Bigler ED, Blatter DD, Johnson SC, et al. Traumatic brain injury, alcohol and quantitative neuroimag-ing: Preliminary findings. Brain Injury. 1996;10(3):197-206.

about the authors

John D. Corrigan, PhD, is a Professor in the Department of Physical Medicine and Rehabilitation at Ohio State University, and Director of the Ohio Valley Center for Brain Injury Prevention and Rehabilitation.

He is the Project Director for the Ohio Regional Traumatic Brain Injury Model System and chairs the Executive Committee of the TBI Model Systems Project Directors. He is Editor-in-Chief of the Journal of Head Trauma Rehabilitation. He has served on the Advisory Committee to the National Center on Injury Prevention and Control at the Centers for Disease Control and Prevention, and is a former member of the boards of directors of the Commission on Accreditation of Rehabilitation Facilities (CARF) and the Brain Injury Association of America. Dr. Corrigan has received many awards for his service and research in the field, including the Brain Injury Association of America’s William Fields Caveness Award and the 2007 Robert L. Moody Prize.

Jennifer Bogner, PhD, ABPP is the Vice-Chair of Research and Academic Affairs for the Department of Physical Medicine and Rehabilitation, Ohio State University. She has worked within the field of traumatic brain injury rehabilitation for over 20 years, is a board certified rehabilitation psychologist (ABPP) and Associate Professor in the Department of Physical Medicine and Rehabilitation at Ohio State University. Dr. Bogner has authored or co-authored over 45 publications in professional journals and one book chapter. She has presented nationally on topics related to brain injury and serves as the Associate Editor of the Journal of Head Trauma Rehabilitation. She is a Member-At-Large on the Board of Governors of the American Congress of Rehabilitation Medicine.

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Individuals with comorbid traumatic brain injury and substance related disorders: A clinical and programmatic perspective within a community re-entry setting

by Dustin J. Gordon, PhD, Loretto A. Brickfield, PhD, and Erick D. Dranoff

Traumatic brain injury (TBI) and its sequelae have received increasingly more public awareness, particularly with a greater sensitivity to injuries resulting from military service and from professional sports (Halbauer et al., 2009; Amen et al., 2011; Golub et al., 2013). A need for specialized services for persons with TBI and comorbid substance related disorders also has been highlighted within these contexts (Olson-Madden et al., 2010).

As individuals with TBI work toward reintegration into their communities, they face a magnitude of long lasting, multifaceted challenges that are not likely to be resolved easily. These challenges become substantially more pronounced with the presence of substance misuse (Smedema and Ebner, 2010; West, 2011).

Conversely, the challenges themselves often lead to maladaptive coping and substance related disorders.

Epidemiologic studies indicate a significant portion of the brain injury population has been diagnosed with an alcohol or substance related disorder at some time preceding or following injury (Parry-Jones et al., 2006). There is suggestion that preinjury substance misuse is a strong predictor of misuse subsequent to TBI (Horner et al., 2005). The relationship between TBI and substance related disorders, however, is full of complexities due to the contribution of many confounding variables, such as multiple TBIs, pre-existing or post-injury comborbid psychiatric disorders, risk taking behaviors, lower levels of subjective feeling of well being, reduced quality of life, and reduced access to mental health care options (West, 2011; Corrigan et al., 2012).

The patterns of substance misuse change over time following TBI. There is suggestion that substance misuse initially declines in acute care following TBI and increases over the first months and years subsequent to injury (Ponsford et al., 2007). While the exact relationship remains unclear, the need to reduce substance misuse following TBI is a compelling treatment objective for individuals with TBI and their families due to the deleterious neurological, psychiatric, and psychosocial effects of misusing substances (Ponsford et al., 2007; Olson-Madden, 2010).

Traditional substance misuse treatment methods often are based on a model of talk therapies, peer support, and self monitoring of behaviors and are not sensitive to the cognitive and behavioral deficits that result from brain injury (Corrigan et al., 1995). As a result, the individual’s potential for success is limited. Even physical limitations preclude many individuals from the ability to 12 BRAIN INJURY PROFESSIONAL

navigate traditional treatment forums (West, 2011). Traditional community interventions and supports often are well meaning, but bewildered by the cognitive and behavioral complexities that present in persons with traumatic brain injury.

An intricate and individualized approach to the assessment, treatment, and ongoing monitoring of individuals with comorbid TBI and substance related disorders, which is grounded in understanding both the neuropsychological effects of TBI on brain based behaviors and the dynamics of misuse and recovery, needs to be utilized. An individualized perspective allows therapists to capitalize on the person’s strengths and to assist in the remediation of ineffective coping strategies and maladaptive behaviors by tailoring and modifying existing treatment protocols to the specifications of the individual’s TBI neurobehavioral needs. Within the context of a community re-entry setting, the service must be integrated into a larger rehabilitative model within which communication and coordination of care are maximized. Community re-entry programs must be prepared to assist these persons in coping with these new challenges (Hensold et al., 2006).

Challenges to abstinence in community re-entry The interplay of neurologic, psychiatric, and behavioral sequelae of TBI is well documented (McAllister, 1997). The sudden and abrupt onset of the disability and premorbid lifestyle losses associated with TBI often result in significant affective changes and associated behaviors. Individuals with TBI experience compromises in interpersonal dynamics and relationships, resulting in a decline or loss of their support network including family and peer supports. Increased downtime and limited access to social, recreational, and employment opportunities and settings may result in interpersonal isolation and loneliness.

Higher levels of anxiety, depression, and psychosocial dysfunction and lower levels of self-esteem in persons with TBI are associated with nonproductive coping behaviors, such as avoidance, excessive worry, wishful thinking, self-blame, and misuse of drugs and alcohol (Curran et al., 2000; Jorge et al., 2005; Anson and Ponsford, 2006). Attempts to cope with the extreme and often permanent changes following TBI may lead to feelings of frustration and helplessness. Behavioral changes, such as irritability, poor frustration tolerance, and impulsivity, are common consequences of TBI and may contribute to poor decision-making

(Graham and Cardon, 2008). All of these psychological changes profoundly alter the individual’s experience of self in the world and necessitate a reassessment and restructuring of one’s self-concept.

As one contends with these new, complex, and undesirable circumstances, there is an increased likelihood of engaging in ineffective and potentially detrimental coping behaviors, even for those with essentially insignificant pre-accident histories. Thus, these psychological factors, including difficulties in psychosocial adjustment, and cognitive compromises, particularly in decisionmaking, may increase risk post-injury independent of the presence of pre-accident misuse.

Coping style prior to injury influences post injury coping and adjustment (Godfrey et al., 1996; Anson and Ponsford, 2006) and there is suggestion that coping style is more associated with premorbid personality, age, and social factors than the severity of TBI (Herrmann et al., 2000). Premorbid maladaptive personality characteristics, which may not have been manifest in persons preinjury as these attributes were at a subthreshold level, now are evident post-injury due to their interaction with the multifaceted consequences and psychosocial compromises of TBI (Gagnon et al., 2006). Thus, ineffective coping and maladaptive relating pre-injury may be as important a determinant for subsequent misuse as pre-injury misuse itself. Pre-injury personality and psychosocial attributes associated with at-risk behaviors, poor coping, and affective disturbance must be assessed and treated accordingly. Information gathering with an emphasis on preinjury psychological functioning from family, friends, and long term treating professionals thus is essential.

Presentations that resemble personality disorders are not uncommon in individuals with traumatic brain injury (Yeates et al., 2008). Personality change following brain injury can be described as “an alteration or discontinuity in personhood postinjury” (Yeates et al., p. 567). Such changes can have substantial psychosocial consequences and can contribute to ineffective and impulsive decision making behavior. Premorbid personality disorder traits and neurologically induced personality disordered attributes may coexist in individuals with TBI (Gagnon et al., 2006), further complicating the clinical picture and potentially increasing risk of subsequent misuse.

Cognitive compromises, such as impairment of attention, memory, and executive functions are common among individuals with traumatic brain injury. These acquired deficits can influence decision-making significantly, particularly within the context of poor coping and impaired psychosocial adjustment (Graham and Cardon, 2008). Cognitive deficits further may limit the resources individuals have available to them for adaptive coping strategies by compromising their ability to recall, select, and execute them based on the demands of the situation (Bryant et al., 2000).

For some individuals with TBI, substance use alone may create a significant risk for clinical complication and the need for intervention by further weakening an already vulnerable and affected neurologic system (Halbauer et al., 2009). For example, an injured brain is more vulnerable to seizure activity. There can be many negative interaction effects between prescribed medications and ingestion of substances, which can amplify risk.

Alcohol, in particular, a known central nervous system depressant, may intensify existent depressive disorders. Substance use may exacerbate existing impairment of cognition, mood regulation, and physical functions, such as gait disturbance and poor balance, which results in a more compromised altered state and creates additional risk for falls and secondary brain injuries.

The larger program Our community re-entry program offers a team approach to the development, coordination, implementation, and management of treatment protocols. It provides comprehensive assessment, treatment, and monitoring of individuals with comorbid TBI and substance related disorders. All individuals are screened upon admission to assess level of risk for substance misuse. Once atrisk individuals are identified, they are referred for additional assessment. Individualized treatment protocols then are developed and implemented based upon review of available records, clinical interview, and formalized assessment. Assessment and treatment of individuals are provided by a team of professionals, which includes the neuropsychologist and doctoral level neuropsychology externs.

Coordinated care is important Coordinated care and continuity of communication are essential components within the community re-entry setting. Individuals with TBI often have multiple treating physicians for a variety of medical conditions and undergo many treatments for emotional and physical pain. Overall, they are found to have a high prevalence of prescription medication use (Yasseen et al., 2008).

Coupled with physical and financial limitations, there is increased risk for misusing prescription medications. Continuous and diligent coordination of clinical care is imperative to facilitate wellness for persons with TBI as well as to monitor potential prescription medication misuse.

Case coordinators, as well as other administrative staff, serve pertinent roles in the coordination of ongoing clinical care.

Certainly, ensuring effective communication between multiple treating professionals can be challenging. While families and friends often serve as a means for continuity of communication and support when individuals are residing at home or are traveling outside of the rehabilitative program, case coordination ensures an efficient feedback loop between treating professionals, families and other support persons, funding entities, and the individuals with traumatic brain injury (Jaffee et al., 2009).

Each individual is assigned an internal case coordinator who is responsible for the continued monitoring of the individual’s overall clinical regimen. The case coordinator serves a critical role in the individual’s treatment from initial assessment throughout the entire rehabilitation process until eventual discharge by assuring continuous transition from the community re-entry setting to those community resources recommended by the treatment team (Sminkey, 2012). Efficient correspondence between each of the individual’s clinical therapists is critical toward maximizing compliance with programming (Jaffe et al., 2009). When treating individuals with TBI, a considerably greater amount of time on the part of the treating professionals often is required and case coordination will streamline this process. Individual psychotherapy treatment alone may not allow for effective handling of the case management needs and the task of coordinating care may interfere with the psychotherapy dynamic.

Clinical case coordinators work toward increasing treatment efficacy overall (Tahan and Sminkey, 2012). As stated above, for example, they can minimize prescription medication misuse by increasing communication between treating physicians.

They manage crisis situations and maximize efficacy of crisis interventions. They establish and maintain relationships with hospital treatment programs and outside community resources and are liaisons between clinical treatment support persons and funding entities. They assist residential staff in identifying and managing BRAIN INJURY PROFESSIONAL

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stress points and enhance reinforcement of strategy usage outside the confines of the clinical setting. All of these roles work toward ensuring continuity and efficacy of treatment.

Treatment considerations First and foremost, treatment focuses on the maintenance of abstinence and prevention of relapse. Individuals are assisted in the recognition of ineffective and maladaptive coping strategies and in the learning of adaptive coping behaviors. In the case of relapse, an individualized approach, taking into consideration the person’s cognitive abilities and deficits, coping resources, and nature of the relapse, is developed and implemented by the clinical team.

At this time, the person’s level of treatment may be increased so that a more intense monitoring of his/her use and at-risk behaviors may be conducted. If necessary, individuals are referred for acute inpatient services or substance abuse residential programming in a hospital setting.

Within the community re-entry setting, it is imperative to develop a strong and reliable relationship with a local hospital or medical center’s substance abuse inpatient program. Dual diagnosis programs, which are versed in treating persons who rely on prescription medications, are most appropriate for this population as many have extensive medication regimens. There are times when individuals are referred to these inpatient programs upon initial screening, with the goal of transferring back to our day or residential program with a behavioral treatment plan already prepared and ready for implementation.

Treatment objectives are focused on reducing substance seeking behavior, determining more effective methods of coping, and recognizing cues that may trigger future misuse or maladaptive behaviors. Context specific interventions tailored to the individual’s unique cognitive profile are utilized to foster the development and strengthening of internal and external coping strategies.

Specific abstinence oriented behavioral routines to maximize goal directed problem-solving and to promote generalization to novel situations are emphasized. Multiple structured opportunities to practice and to internalize self-regulation and self-monitoring skills in a collaborative environment also are an important element of treatment. Treatments may include a combination of individual and group psychotherapy sessions, family collateral sessions, psycho-education, ongoing monitoring protocols, and utilization of community resources when appropriate (i.e., Alcoholics Anonymous).

Behavioral contracting also serves as a useful tool for those who have previously relapsed or whose at-risk behaviors have escalated (Clark et al., 1999). For some, behavioral contracting may be more effective or efficient with residential placement, as compliance and oversight are maximized. One of the benefits of residential programming is its capacity to ensure continuity of communication and treatment interventions and allow for a more secure oversight by rehabilitative staff. Behavioral contracting provides a tangible, readily accessible tool to convey programmatic expectations and adaptive coping strategy reminders, while supporting self-regulatory and self-monitoring skills in high-risk situations. Behavioral contracting also is indicated for proper transitions to and from acute settings, such as a 28-day inpatient program. Contracts help to ensure a smooth transition of settings and continuity of and compliance with treatment protocol.

Advanced doctoral students provide direct treatment interventions under the supervision of licensed psychologists with specialties in neuropsychology. These students enter our program 14 BRAIN INJURY PROFESSIONAL

with prior training in psychotherapy treatment of comorbid populations and already have obtained training in neuropsychology at other training sites. It is imperative that the direct care staff has the appropriate knowledge and skills base, particularly within this complex and at times challenging population. Strong and ongoing university affiliations assist in maintaining the most current and efficacious treatment interventions and modalities, which are grounded in the scientific literature. Ongoing research studies with the assistance of accredited doctoral program faculty also are a central component of the overall program. In-services and additional didactics and training occur within this context.

Final thoughts Only an individualized and integrated rehabilitative approach to the treatment of individuals with comorbid TBI and substance related disorders appropriately considers the unique dynamic of the multifaceted consequences of traumatic brain injury. A highly coordinated and well-managed protocol, including case management, is needed within a community re-entry setting.

Ongoing communication between all involved parties, including therapists, prescribing physicians, families and other supporting entities, and funding agents, is required to maximize abstinence and overall treatment efficacy and outcome. Additional research investigating these principles specifically within the community re-entry rehabilitation program is required to objectify the intricacies of these unique and challenging dynamics.

References

Amen, D. G., Wu, J. C., Taylor, D., et al., Reversing brain damage in former NFL players: Implications for traumatic brain injury and substance abuse rehabilitation. Journal of Psychoactive Drugs. 43: 1-5, 2011.

Anson, K. and Ponsford, J., Coping and emotional adjustment following traumatic brain injury. Journal of Head Trauma Rehabilitation. 21: 248-259, 2006.

Bryant, R. A., Marosszeky, J. E., Crooks, J., et al., Coping style and post-traumatic stress disorder following severe traumatic brain injury. Brain Injury. 14: 175-180, 2000.

Clark, J., Leukefield, C.m and Godlaski, T. Case management and behavioral contracting. Journal of Substance Abuse Treatment. 17: 293-304, 1999.

Corrigan, J. D., Lamb-Hart, G. L., Rust, E., A program of intervention for substance abuse following traumatic brain injury. Brain Injury. 9: 221-226, 1995.

Corrigan, J. D., Bogner, J. and Holloman, C., Lifetime history of traumatic brain injury among persons with substance use disorders. Brain Injury. 26: 139-150, 2012.

Curran, C. A., Ponsford, J. L., and Crowe, S., Coping strategies and emotional outcome following traumatic brain injury: A comparison with orthopedic patients. Journal of Head Trauma Rehabilitation.

15: 1256-1274, 2000.

Gagnon, J., Bouchard, M-A., and Rainville, C., Differential diagnosis between borderline personality disorder and organic personality disorder following traumatic brain injury. Bulletin of the Menninger Clinic. 70: 1-28, 2006.

Godfrey, H. P., Knight, R. G., and Partridge, F. M., Emotional adjustment following traumatic brain injury: A stress-appraisal-coping formulation. Journal of Head Trauma Rehabilitation. 11: 29-40, 1996.

Golub, A., Vazan, P., Bennett, A. S., et al., Unmet need for treatment of substances use disorders and serious psychological distress among veterans: A nationwide analysis using the NSDUH. Military Medicine. 178: 107-114, 2013.

Graham, D. P. and Cardon, A. L., An update on substance use and treatment following traumatic brain injury. Annals of New York Academy of Sciences. 1141, 148-162, 2008.

Halbauer, J.D., Ashford, W.J., Zeitzer, J.M., et al. Neuropsychiatric diagnosis and management of chronic sequelae of war-related mild to moderate traumatic brain injury. Journal of Rehabilitation Research and Development. 46: 757-796, 2009.

Henshold, T., Guercio, J, et al., A personal intervention substance abuse treatment approach: Substance abuse treatment in a least restrictive residential model. Brain Injury. 20: 369-381, 2006.

Herrmann, M., Curio, N., Petz, T., et al., Coping with illness after brain diseases - a comparison between patients with malignant brain tumors, stroke, Parkinson’s disease and traumatic brain injury.

Disability and Rehabilitation. 22: 539-546, 2000.

Horner, M. D., Ferguson, P. L., Selassie, A. W., et al., Patterns of alcohol use 1 year after traumatic brain injury: A population-based, epidemiological study. Journal of International Neuropsychological Society. 11: 322-330, 2005.

Jaffee, M.S., Helmick, K.M., Girard, D.G., et al. Acute clinical care and care coordination for traumatic brain injury within Department of Defense. Journal of Rehabilaition Research and Development, 46: 662-663, 2009.

Jorge, R. E., Starkstein, S. E., Arndt, S. et al., Alcohol misuse and mood disorders following traumatic brain injury. Archives of General Psychiatry 62: 742-749, 2005.

McAllister, T., Evaluation of brain injury related behavioral disturbances in community mental health

center. Community Mental Health Journal. 33: 341-358, 1997.

Olson-Madden, J. H., Brenner, L., Harwood, J. E. F., et al., Traumatic brain injury and psychiatric diagnoses in veterans seeking outpatient substance abuse treatment. Journal of Head Truama Rehabilitation. 25: 470-479, 2010.

Parry-Jones, B. L., Vaughan, F. L., and Cox, W. M., Traumatic brain injury and substance misuse: A systematic review of prevalence and outcomes research (1994-2004). Neuropsychological Rehabilitation. 16: 537-560, 2006.

Ponsford, J., Whelan-Goodinson, R., and Bahar-Fuchs, A., Alcohol and drug use following traumatic brain injury: A prospective study. Brain Injury. 21: 1385-1392, (2007).

Smedema, S. M. and Ebener, D., Substance abuse and psychosocial adaptation to physical disability: analysis of the literature and future directions. Disability and Rehabilitation. 32: 13111319, 2010.

Sminkey, P., Beyond the care episode: Patient-centered case management along the continuum. Journal of Professional Care Management. 17:186, 2012 Tahan, H. and Sminkey, P. Motivational interviewing: Building rapport with clients to encourage desirable behavioral and lifestyle changes. Journal of Professional Case Management, 17: 164-165, 2012.

West, S. L., Substance use among persons with traumatic brain injury: A review. Neurorehabilitation. 29, 1-8, 2011.

Yasseen, B, Colantonio, A., and Ratcliff, G. Prescription mediation use in persons many years following traumatic brain injury.

Brain Injury. 22: 752-757, 2008.

Yeates, G. N., Gracey, F. and Collicutt McGrath, J., A biopsychosocial deconstruction of “personality change” following acquired brain injury. Neuropsychological Rehabilitation. 18: 566-589, 2008.

About the Authors

Dustin Gordon earned a bachelor’s degree in psychology with focus in cognitive science from the University of Rochester in 1991 and earned a Ph.D. in clinical psychology from Fairleigh Dickinson University in 1996. Dr. Gordon completed a neuropsychology internship at Cornell University Medical College and a NIH neuropsychology postdoctoral fellowship at Johns Hopkins School of Medicine in 1998. He has an independent neuropsychology practice specializing in traumatic brain injury and is the Director of Neuropsychological and Clinical Services at Rehabilitation Specialists, where he also serves as a primary clinical neuropsychology supervisor for APA accredited Ph.D. programs in clinical psychology.

Loretto Brickfield, Ph.D. is a clinical psychologist at Rehabilitation Specialists where she has overseen community based rehabilitation for individuals with traumatic and acquired brain injuries since 2008. Dr. Brickfield earned her doctorate in clinical psychology from Adelphi University. Dr. Brickfield completed an internship at the New York Veterans Administration Medical Center in Manhattan and a fellowship in Neuropsychology and Rehabilitation Psychology at the International Center for the Disabled. Dr. Brickfield has twenty years of experience in providing neuropsychological treatments to adults with psychological difficulties due to traumatic brain injuries, strokes and other neurological issues. She has a psychology practice in Roseland, NJ. Dr. Brickfield is a member of the New Jersey Board of Psychological Examiners since 2005 where she currently serves as Vice Chairperson.

Erik Dranoff is an advanced doctoral student in the Ph.D. Program in clinical psychology at Fairleigh Dickinson University. He completed an externship in comborbid TBI and substance related disorders at Rehabilitation Specialists from 2009-2011. He currently in completing his predoctoral internship at Woodhull Medical Center in Brooklyn, New York.

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Rehabilitation case management for individuals with comorbid TBI and substance related disorders within a community re-entry program

By Dawn M. King, Loretto A. Brickfield, PhD, and Dustin J. Gordon, PhD

The demand for clinical care management of individuals with traumatic brain injury (TBI) has increased exponentially over recent time, as more persons of moderate to severe brain traumas and their families have sought out specialized brain injury treatment services. Initially conceived as a simple cost containment measure, case management has evolved into a well-coordinated, systematic, comprehensive approach involving quality, costeffective, compassionate, and creative care (Owen and Commons, 2012). Clinicians and researchers now recognize that case management is vital to the operation of a multidisciplinary treatment model, which has been found to be most efficacious in addressing the long-term physical, psychological, cognitive and psychosocial consequences of TBI (Jaffe et al., 2009). Case managers today almost universally are involved in organizing and coordinating rehabilitative services and resources to maximize an individual’s functional recovery subsequent to a traumatic brain injury. Specifically, they serve as a driving force of the collaborative team of care providers and utilize a wide range of clinical and administrative interventions to assist individuals with TBI through the rehabilitation process.

Individuals with comorbid TBI and substance related disorders present with a myriad of neurologic, psychiatric, cognitive, and psychosocial difficulties, which easily can derail the rehabilitation progress if not properly identified and managed. Case management services are integrated into the larger rehabilitative program and play an integral role in the assessment of substance misuse risk and the maintenance of abstinence (U.S. Department of Health and Human Services, 2010). The case manager ensures continuous transitions in the community re-entry setting and assists in the planning, implementation, and monitoring of the treatment program to ensure its success (Sminkey, 16 BRAIN INJURY PROFESSIONAL

2012). Case management mobilizes an efficient feedback loop that includes individuals with TBI, treating professionals, families and other support persons, and funding entities (Jaffee, et al., 2009). At the same time, it provides a nexus to available treatment venues and community resources to support a substance free lifestyle and to manage risk for substance misuse.

Rehabilitation case managers working with individuals with TBI frequently are clinical social workers or other mental health professionals with education and training in psychology and clinical management. They must have a strong foundation of knowledge about brain injury, substance misuse behaviors, and recovery. Many case managers practicing within this population now have obtained certifications from the Academy of Certified Brain Injury Specialists (ACBIS).

Role of Case Manager

Case management is defined as “a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes” (CMSA, 2009). In typical TBI community reentry programs, the case manager assumes many roles. First and foremost, they ensure clear and timely communication for all the stakeholders in an individual’s brain injury treatment.

Stakeholders in this process include physicians, clinical therapists, family members, funding entities, social service organizations, employers, and the individuals with TBI. Effective case management of individuals with comorbid TBI and substance related disorders identifies and advocates for specialized treatment models that accommodate each individual’s neurobehav-

ioral and cognitive presentations (Jaffee, 2009). Case managers educate their clients and their families about TBI sequelae and substance misuse, involve them in the formulation of treatment goals, provide individuals with a voice within their place of care, and work to invest them in the therapeutic process. Comprehensive case management involves an individualized and collaborative approach that works toward maximizing improvement of quality of life for individuals with TBI and for their families (Heinemann et al., 2004; Tahan and Sminkey, 2012).

Individual focused management is considered to be more effective than injury focused management, as it fosters continuity of delivered care (Sminkey, 2012). All of this works to establish a relationship of trust, compassion, and personalized attention for successful re-entry into the community.

Ongoing adjustments to existing case management models may be required in order to meet the complex needs of persons with TBI and substance related disorders (Bogner et al., 1997).

As such, standards of practice for case management must incorporate an understanding of the unique dynamics involved with persons with comorbid TBI and substance misuse. Rehabilitation case management professionals must consider the person’s history in its entirety, including past and present neuropsychological functioning, pre-injury medical and psychiatric histories, and history of substance use and treatment. They often need to track a large team of medical professionals and consider physical barriers and changes in physical functioning, such as impaired balance and gait disturbance, as obstacles when planning treatment interventions. Case managers may provide concrete external structural support services, such as appointment reminders, simple written instructions, and transportation arrangements, to compensate for real time barriers that impact compliance with treatment recommendations. This type of case management is labor intensive and is meant to facilitate a positive change within the individual’s environment (Tahan and Sminkey, 2012).

Today’s case managers must understand TBI care options and efficacious practices, the nuances of co-occurring substance related disorders and other comorbid psychiatric presentations, the individual’s racial and cultural background, and the varying attitudes toward disability and illness and how they influence healthcare decisions. They simultaneously must navigate today’s ever-changing healthcare system with regards to insurance, compensation, resource allocation, and documentation requirements. Complicating matters further, many individuals with TBI may not be their own legal guardian, which adds complexities to both privacy concerns and compliance with HIPAA regulations. Case managers maintain and monitor inter-agency relationships, program improvements, and changes in regulatory requirements. They work to identify opportunities to expand limited social, employment and recreational endeavors.

Perhaps most critical to maintaining treatment momentum is regular face-to-face contact between the case manager and the individual with TBI. Understanding and meeting the changing treatment needs and fostering motivation to successfully achieve identified treatment objectives are essential.

An effective case manager ensures that the treatment team is documenting progress and working toward interim and longterm goals (Owen and Commons, 2012). The case manager keeps the treatment team well informed of pertinent client in-

formation so clinical decisions incorporate accurate information about the individual’s most current status. If an individual does not achieve expected treatment outcomes or relapses, the case manager quickly must identify interfering challenges and assist in developing a transition plan to utilize more intensive treatment resources. Referral to inpatient dual diagnosis units, management of psychiatric crises, establishment of behavioral contracts, and monitoring clients upon return to residential settings once abstinence has been re-established are all critical functions in case management.

Challenges facing the case manger

Family members often are overwhelmed by the multifaceted consequences of TBI (Kreutzer et al., 2010). In many cases, the family’s ability to function as a support structure has been damaged irreparably, leaving the person with little emotional support and few personal relationships and resources on which to rely. Families may react to individuals with TBI and substance misuse with anger or helplessness and further may be burdened by the individual’s need for increased supervision and monitoring of behavior (Kreutzer et al., 2010). The case manager must recognize these family stressors and offer a safety net and bridge for the individual with TBI to access the community with supervision.

Within the rehabilitative program, case managers must advocate and coordinate with funding sources and physicians to assist in obtaining current pharmacological interventions. They may need to coordinate multiple medical appointments, attend medical consultations to educate physicians about pertinent substance misuse histories, and monitor the individual’s access to pain medications if this has been identified as a particular risk area for misuse. With consent, the case manager must educate and communicate an accurate and full clinical picture to all professionals involved in treatment, including the prescribing physicians. Medications, including those to address pain and mood disturbance, may be prescribed without consideration of substance misuse potential if physicians are not privy to such information.

Compromising deficits in self-regulation, self-monitoring, impulse control, and problem-solving, which are not uncommon in persons with TBI, creates additional challenges toward achieving and maintaining abstinence (Graham and Cardon, 2008). At the community re-entry level of TBI rehabilitation, individuals with substance misuse histories may demonstrate higher levels of treatment non-compliance and may leave therapy against medical advice. Case managers face tremendous challenges at all levels of care, including discharge planning, as they must develop a plan that understands the likely long-term and persistent challenges in maintaining a substance free lifestyle.

Case Manager Tools

The case manager maintains a compendium of resources, which includes knowledge of traditional, complementary, and alternative care treatment modalities. They devise care plans which address treatment interfering psychosocial obstacles, improve structured support both in the program setting and in the community to decrease treatment destructive behaviors, reinforce adaptive coping skills, and strengthen treatment compliance.

They can facilitate the integration of outside supportive treatBRAIN INJURY PROFESSIONAL

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ments. For example, with guidance from treating physicians, case managers may implement services such as acupuncture, guided imagery, and dietary therapy into a care plan to complement an existing therapeutic intervention protocol. Case managers should possess knowledge of the latest assistive technology such as iPads, iPhones, Dynavox devices, and WalkAide ambulatory attachments to assist individuals to gain access to existent recovery support resources such as Alcoholics Anonymous and Narcotics Anonymous, as well as to positive recreational and social opportunities that promote a healthy lifestyle that maximizes abstinence.

TBI community re-entry programs, which incorporate an abstinence support model, have staff persons that directly treat individuals with TBI and substance misuse disorders by using individual and group psychotherapy, psychoeducation, family interventions, and cognitive remediation. It is critical that the case manager considers these avenues of support to assist the individual in maintaining abstinence and to educate the family on how to reinforce and to generalize recently acquired abstinence strategies. Behavioral contracts, with external monitoring contingencies agreed upon by the case manager, clinical therapists, and individual with TBI, often are utilized to maximize treatment compliance (Clark et al., 1999).

Case managers may develop and implement facility managed monitoring protocols, which reassure families that their loved ones are safe and helps restore familial ties by alleviating potentially burdensome supervisory responsibilities. Training in adaptive coping skills, stress and anger management skills, relaxation exercises, problem-solving and restructuring strategies, and social skills are instrumental in addressing the executive and psychosocial deficits common after injury and must be built into programming. Providing modifications in written materials, ensuring multiple opportunities to practice behavioral self-monitoring strategies, and assisting in the identification and understanding of triggers are essential components of a comprehensive treatment plan. Utilizing feedback to maintain abstinence is critical and case mangers must address misperceptions to facilitate an individual’s internalization of this important information (US Department of Health and Human Services, 2010).

Final Thoughts/Summary

Effective case management for individuals with comorbid TBI and substance misuse presentations is a complex process of offering and implementing ongoing, on-site, individualized services, with continuous monitoring of progress and modification of the treatment plan as needed. They assist these individuals in obtaining a larger voice in the delivery of their care and provide more personalized attention to their needs. Ongoing engagement of the individual with TBI to enhance motivation for progress and to maximize treatment compliance is essential.

Within a community re-entry model, the case manager coordinates the expertise of professionals, agencies, suppliers, and family members to create an individualized care model to individuals with traumatic brain injury. They draw on traditional, complementary, and alternative treatment interventions, as well as community and recovery resources, to support the individual with TBI in a mission to maintain abstinence.

An active case management model with modifications to address the unique challenges of individuals with TBI and co-occurring substance misuse presentations is required to maximize 18 BRAIN INJURY PROFESSIONAL

success in abstinence maintenance, relapse prevention, adaptive coping, productivity, and overall increased feelings of well-being. The integral role of case management in community reentry programs reflects a growing realization of the importance of supportive services within a multidisciplinary rehabilitation setting.

References

Bogner, J. A., Corrigan, J. D., Spafford, D. E., and Lambg-Hart, G. L. Integrating substance abuse treatment and vocational rehabilitation following traumatic brain injury. Journal of Head Trauma Rehabilitation. 12: 57-71, 1997.

Case Management Society of America, (2009). (CMSA) Mission and Vision. Retrieved from http://www.cmsa.org/Home/CMSA/WhatisaCaseManager/tabid/224/Default.aspx Clark, J., Leukefield, C.m and Godlaski, T. Case management and behavioral contracting. Journal of Substance Abuse Treatment. 17: 293-304, 1999.

Graham, D. P. and Cardon, A. L., An update on substance use and treatment following traumatic brain injury. Annals of New York Academy of Sciences. 1141, 148-162, 2008.

Heinemann, A.W., Corrigan, J.D., and Moore, D. Case Management for Traumatic Brain Injury Survivors with Alcohol Problems. Journal of Rehabilitation Psychology, 49 (2), 56-166, 2004.

Jaffee, M. S., Helmick, K. M., Girard, D.G., et al. Acute clinical care and care coordination for traumatic brain injury within Department of Defense. Journal of Rehabilaition Research and Development, 46: 662-663, 2009.

Kreutzer, J. Marwitz, J, Godwin, E. et al. Practical approaches to effective family intervention after brain injury. Journal of Head Trauma Rehabilitation. 25:113-120, 2012.

Owen, M. and Commons, D. Refelctions of a worker’s compensation case manager. Journal of Professional Case Management, 16:188-190, 2012.

Sminkey, P. Beyond the care episode: Patient-centered case management along the continuum.

Journal of Professional Care Management, 17, 186, 2012.

Tahan, H. and Sminkey, P. Motivational interviewing: Building rapport with clients to encourage desirable behavioral and lifestyle changes. Journal of Professional Case Management, 17: 164-165, 2012.

United States Department of Health and Human Services, Center for Substance Abuse Treatment.

(2010). Treating Clients with Traumatic Brain Injury. [Data File]. Retrieved from http://kap.samhsa.gov/products/manuals/advisory/pdfs/Advisory_TBI.pdf

About the Authors

Dustin Gordon earned a bachelor’s degree in psychology with focus in cognitive science from the University of Rochester in 1991 and earned a Ph.D. in clinical psychology from Fairleigh Dickinson University in 1996.

Dr. Gordon completed a neuropsychology internship at Cornell University Medical College and a NIH neuropsychology postdoctoral fellowship at Johns Hopkins School of Medicine in 1998. He has an independent neuropsychology practice specializing in traumatic brain injury and is the Director of Neuropsychological and Clinical Services at Rehabilitation Specialists, where he also serves as a primary clinical neuropsychology supervisor for APA accredited Ph.D. programs in clinical psychology.

Dawn King earned a bachelors degree in psychology from Kutztown University in 1980 and a master’s degree in education in clinical counseling from William Paterson University in 2000. She has been employed in the fields of mental health and brain injury, working primarily as a case manager for private social service agencies, as well as working as a Certified Mental Health Screener. She joined the team at Rehabilitation Specialists in 2008 as a case coordinator for individuals with traumatic brain injury.

She received certification as a Brain Injury Specialist from the Academy of Certified Brain Injury Specialists in 2011. She facilitates the Northern New Jersey Brain Injury Support Group for Passaic and Bergen Counties (as part of the NJ Brain Injury Alliance).

Loretto Brickfield, Ph.D. is a clinical psychologist at Rehabilitation Specialists where she has overseen community based rehabilitation for individuals with traumatic and acquired brain injuries since 2008. Dr. Brickfield earned her doctorate in clinical psychology from Adelphi University. Dr. Brickfield completed an internship at the New York Veterans Administration Medical Center in Manhattan and a fellowship in Neuropsychology and Rehabilitation Psychology at the International Center for the Disabled. Dr. Brickfield has twenty years of experience in providing neuropsychological treatments to adults with psychological difficulties due to traumatic brain injuries, strokes and other neurological issues. She has a psychology practice in Roseland, NJ. Dr. Brickfield is a member of the New Jersey Board of Psychological Examiners since 2005 where she currently serves as Vice Chairperson.

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ALCOHOL USE AFTER BRAIN INJURY: To Drink or not to Drink – That is the Question

by Nathan D. Zasler, MD

There are numerous controversies regarding the use of alcohol by individuals following traumatic brain injury (TBI) that are often based on misinformation or incomplete current knowledge regarding the subject matter. These issues become problematic from the clinician’s point of view when patients and their family members ask about the “rules” regarding alcohol use following TBI. Some of the alcohol related issues that professionals must deal with include fears regarding risk of seizures, drug interactions with alcohol, as well as alcohol side-effects after TBI. The aforementioned are only some of the important issues that clinicians, patients and their caregivers should be aware of as related to alcohol use in general and particularly after TBI (Zasler, 1991).

As noted, many of the relevant issues regarding alcohol use after TBI are poorly understood by professionals dealing with this patient population; yet, there are reasonable resources and evidence based answers, some possibly surprising, to most of the common patient and family queries. For example, many clinicians advise their patients after TBI not to drink any alcohol and make it an absolute contraindication on medical grounds; yet, have no real rationale for doing so other than they heard that was the position to take. Another common stance is that alcohol should not be consumed by any patient after TBI because it can cause seizures.

Both these positions should be approached, as with any other issue on this topic, from a scientific standpoint and not one of “because that’s what I got taught in residency”.

Effects of alcohol on the brain

It is known that ethanol has multiple effects on CNS neurotransmitter systems, the strongest of which involves the gamma-aminobutyric acid (GABA) neurotransmitter system; the brain’s major inhibitory neurotransmitter system. Other neurotransmitters and neuropeptides that are affected by alcohol use include dopamine, serotonin, glutamate, endorphins (i.e. endogenous opiates) and acetylcholine. Alcohol ultimately disrupts the delicate balance between inhibitory and excitatory neurotransmitters (Mukherjee, Das, Vaidyanathan & Vaudevan, 2008).

GABA is a central nervous system depressant at low to medium doses, mainly through GABA agonist activity. At high doses, alcohol is a (N-methyl-D-aspartate (NMDA) antagonist (meaning 20 BRAIN INJURY PROFESSIONAL

it blocks the effects of glutamate) which is the main excitatory neurotransmitter in the CNS (Oscar-Berman & Marinkovic, 2003). Glutamate is important in memory but can also suppress activity of the cerebellum which is involved with motor control and balance, among other functions. With very excessive alcohol consumption, there can be suppression of brainstem activity (vital for life-sustaining functions such as breathing). Dopamine (DA) is involved in reward processes and is likely responsible for the rewarding aspects of alcohol consumption. Serotonin also appears to play a role in reward processes and therefore seems to be important in alcohol use and abuse. In addition, serotonin is involved with regulating mood states, impulse control and aggression (Valenzuela, 1997; Oscar-Berman & Marinkovic, 2003; Mukherjee, Das, Vaidyanathan & Vaudevan, 2008).

The impact of alcohol, as with substance abuse in general, also needs to be looked at from an age standpoint as in younger individuals, particularly adolescents, it has been shown to potentially disrupt normal brain development and may result in increased risk of neurocognitive damage due to its impact on systems subserving CNS plasticity. TBI, in and of itself, may predispose an individual to impulsive behavior. Adolescence produces a “double whammy” effect in that adolescents typically are at increased risk of impulsive behavior including experimentation with alcohol and other drugs.

Along with a number of other physiological alterations which occur in the adolescent brain changes also occur in brain regions that have been implicated in reinforcing the properties of alcohol. It has been speculated that damage during early stages of brain development due to alcohol use can cause long term and irreversible brain damage ((Jain, Balhara, 2010).

A number of factors have an impact on how alcohol affects the brain including the amount, frequency and duration of alcohol usage, genetic loading risk factors for alcoholism, gender, the individual’s age, and general health status (Oscar-Berman & Marinkovic, 2003). Neuropsychiatric and medical risk factors can further compound impairment associated with alcohol use including such disorders as malnutrition (i.e. thiamine deficiency), liver and cardiovascular disease, neurological conditions such as acquired brain injury, fetal alcohol syndrome and/or psychiatric disorders such as depression, PTSD, anxiety disorders and schizo-

phrenia. Recent research suggests that females are more vulnerable than males to the neurotoxic/neuroinflammatory effects of alcohol, thus supporting the view that women are more susceptible than men to the medical consequences of alcohol abuse (AlfonsoLoeches, Pascual, Guerri, 2013).

In individuals with no history of significant brain injury, it does not take much of a blood alcohol level to create impairment and performance. For example, at a blood level of 0.02-0.03, there is typically slight euphoria and loss of shyiness and the person may feel somewhat relaxed and a little lightheaded. By the time one reaches a blood alcohol level of 0.04-0.06 (still below the typical illegal blood alcohol level of .08), 1/10 to see further lowering of inhibitions, euphoria, onset of reasoning and memory impairment, as well as some early disinhibition and emotional intensification.

Once a level of 0.8 is reached, then impairments of balance, speech, vision reaction time hearing, self-control, and judgment become more pronounced with individuals generally feeling that they can function better than they can in reality. By the time the blood alcohol level reaches 0.1-0.125, there is increased euphoria with significant impairment of motor coordination, speech is slurred, balance judgment vision reaction time and hearing will all be further impaired. With levels above 0.25 there is severe impairment of mental and sensorimotor functions and that 0.3 and above they’re typically is some impairment of consciousness starting with stupor and leading to possible, and even death due to respiratory arrest with levels above 0.4. When used with other “depressants”, alcohol can be fatal at much lower concentrations. Persons after TBI may experience more profound impairment at a lower blood alcohol concentrations than those noted above (see below).

The effects of acute alcohol intoxication on the central nervous system can have a significantly more profound effect on someone who already has pre-existing neurologic dysfunction secondary to a TBI. Although no neuropathologic changes per se have been associated with acute intoxication in humans, there is recent animal literature that indicates that as little as 24 hours of high binge-like alcohol exposure is enough to elicit signs of alcoholinduced brain damage in adult rats (Hayes, Deeny, Shaner & Nixon, 2013). Alterations in the neuronal membranes due to the incorporation of ethanol (Goldstein, 1983) and central neurotransmitter aberrations (Nagey, Casso, Diamond, & Gordon, 1989; Charness, Simon, & Greenberg, 1989; Valenzuela, 1997; Mukherjee, Das, Vaidyanathan & Vaudevan, 2008) have been clearly demonstrated in both animal and human subjects.

Acute ethanol intoxication may worsen already existing post-injury behavioral sequelae including: cognitive functioning, akathesia, aggressiveness, irritability, and impulsivity/disinhibition. From a cognitive perspective, a variety of post-traumatic neuropsychological problems may be further compromised including: staying on task, mental processing speed and flexibility, learning, problem solving, attention, concentration, judgment, and reasoning (Peterson, Rothfleisch, Zelazo, 1990; Norton & Halay, 2011). From a neurophysical standpoint, acute intoxication adversely affects all motor behaviors, from the simplest to the most complex including ambulation, speech, eye movements, complex motor control and postural control (Adams & Victor, 1989; Peterson, Rothfleisch, Zelazo, 1990). Acute alcohol poisoning, a medical emergency, occurs when there is a dangerously high blood alcohol concentration which is typically associated with coma induction or respiratory depression (Vonghia, Leggio, Ferruli, et al, 2008). It is not uncommon that patients with TBI, who do not even drink, report

having been stopped by police for suspicion of alcohol intoxication due to their neurophysical impairments.

Chronic effects of alcohol on the central nervous system have been well documented (Charness, Simon & Greenberg, 1989; Harper & Kril, 1990; NIAAA, 2004; Harper, 2009).

Aside from numerous other health risks associated with long term use of alcohol, chronic, heavy alcohol consumption impairs brain development, causes brain shrinkage, dementia, physical dependence, neuropsychiatric and cognitive disorders, as well as causes distortion of brain chemistry. Work by Ponsford et al has shown that post-TBI alcohol use (at any level) within one month of assessment was associated with poorer performance on measures of executive function at 6-9 months post injury (Ponsford, Tweedly & Taffe, 2013) At present, the literature is inconclusive regarding whether moderate alcohol consumption increases the risk of dementia or decreases it. Evidence for a protective effect of low to moderate alcohol consumption on age related cognitive decline and dementia has been suggested by some research, however, other research has not found a protective effect of low to moderate alcohol consumption (see Ridley, Draper and Withall, 2013 for a nice review of this topic). Some evidence suggests that low to moderate alcohol consumption may speed up brain volume loss. Chronic consumption of alcohol may result in increased plasma levels of the toxic amino acid homocysteine; which may explain alcohol withdrawal seizures, alcohol-induced brain atrophy and alcohol-related cognitive disturbances. Alcohol’s impact on the nervous system can also include disruptions of memory and learning such as occurs with “blackouts” (Wikepdia, 2013).

Given the neuropathology associated with TBI; specifically, primary injury due to focal cortical contusion (with greatest propensity for frontal and temporal parenchyma) and/or diffuse axonal injury, as well as, some degree of secondary brain injury in many cases, it would seem unwise for anyone with a brain injury to consume alcohol on a chronic basis. This word of caution carries more weight given the occurrence, in alcoholics, of significant neuropathologic changes with chronic ethanol consumption, including: brain shrinkage, loss of frontal cerebral cortical neurons, and cerebellar degeneration (NIAAA, 2004). Studies have shown that chronic alcohol use can result in pre-frontal white matter loss as seen in Wernicke’s Korsakoff syndrome (although ultimately, this latter condition is caused by thiamine deficiency and not alcohol itself). Studies have shown particular involvement of the corpus callosum with correlations being noted between the structural changes and cognitive performance. The neuropathology of white matter loss in chronic alcoholics has been theorized to be associated with disruption in both myelination and axonal integrity (Harper, 2009). It has also been shown that neuronal loss occurs in specific regions of the cerebral cortex; in particular, the superior frontal association cortex, cerebellum, and hypothalamus. Atrophy of the cerebellum tends to involve the anterior superior cerebellar vermis and quantitative pathologic studies have shown that there is a preferential loss of Purkinje cells in the vermis that correlates with clinical manifestations of imbalance and ataxia (Harper, 2009). There is also some interesting research looking at the vulnerability of the right hemisphere to the effects of chronic alcohol use. Individuals with a history of chronic alcohol use often present as emotionally flat and may have difficulties with the same tasks that individuals with damage to the right hemisphere present with.

Even with the above in mind, with abstinence, even in chronic BRAIN INJURY PROFESSIONAL

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alcoholics, there is functional and structural recovery within three to four weeks of cessation of use. Cerebral atrophy has also been shown to reverse after the first few months of sobriety (Bartsch, Homola, Biller, et al 2007; Zahr, Mayer, Rohlfing, et al, 2010; Ridley, Draper, Withall, 2013).

Alcohol, Seizures and TBI

Probably one of the most controversial issue facing clinicians is the matter of alcohol consumption and concerns regarding lowering of seizure threshold following TBI. Animal and human studies suggest that the long-term and acute effects of alcohol on the central nervous system are disparate and often opposite. Over the short term, alcohol tends to have antiepileptic properties and likely has more of a pro-convulsant profile over the long term (Gordon & Devinsky, 2001). It is generally believed (and often “preached as neurological dogma”) that individuals with documented seizure disorders will experience problems with seizure control if they use alcohol; however, this is not confirmed by the experimental studies that have tested this hypothesis (Hauser, Ng, & Brust, 1988).

Several studies have shown that small to modest alcohol intake does not increase seizure frequency or significantly alter blood levels of AEDs (Gordon & Devinsky, 2001); although, intake of alcohol with CNS depressants such as phenobarbital can certainly be dangerous. Some have advocated that patients with epilepsy should be allowed to use alcohol in small amounts (1-2 drinks per occasion and.no more than 3-6 drinks per week); however, exceptions may include patients with a history of non-compliance with antiepileptic medications, prior history of alcohol or other substance abuse or those with alcohol-related seizures. Furthermore, individuals who are unable to control their impulse to drink and/or are not compliant with recommended restrictions should be counseled to not consume alcohol. It should also be noted that AEDs side-effects can be similar to those of alcohol leading to increased side-effects. Individuals with epilepsy who drink moderate to heavy amounts of alcohol (3 or more than 4 drinks per occasion) should be warned that they are increasing their risk of breakthrough seizures. The greatest risk of seizing following moderate to heavy consumption of alcohol occurs within a short period of time after consumption (i.e. 6-72 hours) (Epilepsy.com, 2013). Withdrawal from moderate to heavy alcohol use in conjunction with sleep deprivation or missed antiepileptic medication dosing can be especially dangerous in terms of lowering seizure threshold and causing breakthrough seizures (Leach, Mohanraj, Borland, 2012).

The rare situations where ethanol can act as a convulsant drug and the mechanisms, whereby, long-term neurotoxic effects of alcohol may lead to chronic epilepsy have been poorly studied although seizures usually occur in individuals of abused alcohol for extended periods of time (i.e. greater than 10 years) and need further clarification (Gordon & Devinsky, 2001; Leach, Mohanraj, Borland, 2012; Epilepsy.com, 2013).

Medications and ETOH after TBI

Drug interactions with alcohol may be additive, synergistic or antagonistic. Two types of alcohol medication interactions are generally referred to: pharmacokinetic (in which alcohol interferes with the metabolism of the medication) and pharmacodynamic (in which alcohol enhances the effects of medication, particularly in the central nervous system as related to sedation). Pharmaco22 BRAIN INJURY PROFESSIONAL

kinetic interactions generally occur in the liver were both alcohol and many other medications are metabolized frequently by the same enzymes (Weathermon & Crabb, 1999; Pharmacist’s Letter, 2008). Ethanol ingestion may be contraindicated in conjunction with various medications including anti-depressants, anxiolytics, benzodiazepines, neuroleptics, certain anti-seizure medications and lithium carbonate (see below), among many others. A good resource for alcohol drug interactions can be found through the National Institute on Alcohol Abuse and Alcoholism (NIAAA) pamphlet entitled “Harmful interactions: mixing alcohol with medicines” (NIAAA, 2007).

Induction of hepatic enzymes with chronic alcohol ingestion can alter drug levels of agents that are hepatically metabolized.

Acute ethanol intoxication may cause serum levels of certain drugs to rise secondary to competition for binding sites. Alcohol can also interact with over-the-counter and herbal medications, a phenomenon often not considered by practitioners. Additionally, extended release coatings can often be dissolved by alcohol leading to rapid increases in serum levels of the drug in question. Lastly, due to its diuretic effect, ethanol can potentially cause lithium toxicity (NIAAA, 2007). The additive sedative effects of ethanol with many pharmacologic agents must also be taken into consideration as it can adversely affect safety in driving, operation of equipment, and other activities (Drug Interaction Facts, 1990; Zasler, 1991).

Greater Alcohol Sensitivity Following ABI

The reason why individuals with TBI are often more susceptible to the effects of ethanol may be due to alterations in CNS membrane permeability, neurochemical alterations, or some other, as yet, unidentified factor(s). Given the frequency of his clinical finding, it is surprising that there is no published medical research examining this potentially very important phenomena.

Impact of Alcohol Use on Recovery after Brain Injury

Alcohol, as well as other agents, may impede neurologic recovery following brain injury (Brailowsky, Knight, Blood, et al, 1986; Goldstein, 2003; Baratz, Rubovitch, Frenk, et al, 2010); thereby, providing evidence in support of encouraging abstention during active neurorecovery. More research is obviously needed to clarify the potential detrimental effects of ethanol on early neural recovery processes following ABI as well as how, if at all, ongoing use may interfere with neuroplastic changes associated with neurorehabilitation efforts regardless of whether these efforts are neuromodulatory, pharmacological or otherwise.

From a functional standpoint, alcohol has the potential to be depressogenic, reduce sexual performance/satisfaction, decrease testosterone production in men and interfere with psychosocial reentry. As noted by Corrigan and Mysiw (2013), substance abuse following TBI has been associated with additional complications including decreased work reentry rate, lower subjective well-being, as well as increased likelihood of suicide, seizures and premature mortality due to any cause. Lastly, as with other types of substance abuse significant use of alcohol can be an economic stressor for the individual with brain injury who may have limited economic resources available.

Alcohol and Risk of Recurrent TBI and Mortality

It is well documented that much of the morbidity and mortality associated with traumatic brain injury is linked to alcohol con-

sumption (Kraus, Morgenstern, Fife, et al, 1989). Additionally, individuals who have sustained a traumatic brain injury have been shown to be a statistically higher risk of having another brain injury alcohol issues aside. Given the aforementioned facts, it is not difficult to see how the individual after TBI who consumes alcohol is likely at higher risk for recurrent brain injury than one who does not (Salcido, O’Shanick, Costaich, & Conder, 1990). Accidents with alcohol are typically related to vehicular mishaps, falls, or fights/assaults (Cryan, Cathain, Curtis, et al, 2010) and such injuries are often associated with fatal brain injuries. Additionally, several studies have shown that late mortality after TBI is strongly associated with substance abuse, particularly alcohol (Pentland Hutton & Jones, 2005). The aforementioned facts should be sufficient justification for more conservative recommendations, rather than more liberal ones, regarding alcohol use following traumatic brain injury.

There is no simple answer to the question of whether persons after TBI should consume alcohol or not. Hopefully, the aforementioned discussion will enlighten professionals about some of the controversies, challenges and caveats germane to this important topic. Ultimately, professionals showed approach recommendations on this topic on an individual basis and in this author’s opinion not necessarily take an automatic and dogmatic stance that alcohol is absolutely contraindicated in any amount after TBI. If recommendations ultimately are that the person with TBI can have an occasional alcoholic beverage then patients, caregivers and/or family should be informed about ways to minimize morbidity as much as possible secondary to continued alcohol use. The Model Systems Knowledge Translation (MSKT) publication “Alcohol use after traumatic brain injury” has some very reasonable recommendations for reducing the potential harm associated with alcohol use that all professionals should be familiar with (MSKTC, 2011). Professionals should also be familiar with resources available for those individuals who have substance abuse issues, including alcohol abuse, and want to address them and/ or what to do for patients who have more intractable issues with substance abuse (MSKTC, 2011 and this issue of BIP for further information).

Goldstein L, Neuropharmacology of TBI-induced plasticity. Informa Healthcare. 17(8): 685-694, 2003.

Gordon E. Devinsky O, Alcohol and Marijuana: Effects on Epilepsy and Use by Patients with Epilepsy.

Epilepsia. 42(10): 1266-1272, 2001.

Harper C, The Neuropathology of Alcohol-Related Brain Damage. Alcohol & Alcoholism. 44(2): 136-140, 2009.

Harper CG. Kril J, Neuropathology of Alcoholism. Alcohol & Alcoholism. 25: 207-216, 1990.

Hauser WA. Ng SK. Brust JC. Alcohol, Seizures, and Epilepsy. Epilepsia. 29: S66-S78, 1988.

Hayes DM. Deeny MA. Shaner CA. Nixon K, Determining the threshold for alcohol-induced brain damage: new evidence with gliosis markers. Alcohol Clin Exp Res. 37(3): 425-434, 2013.

Jain R. Balhara YP, Impact of alcohol and substance abuse on adolescent brain: a preclinical perspective. Indian J Physiol Pharmacol. 54(3): 213-34, 2010.

Kraus, J. F., Morgenstern, H., Fife, D., et al (1989). Blood Alcohol Tests, Prevalence of Involvement, and Outcomes Following Brain Injury. American Journal of Public Health, 79,294-299.

Leach JP. Mohanraj R. Borland W, Alcohol and drugs in epilepsy: pathophysiology, presentation, possibilities, and prevention. Epilepsia. 53(4): 48-57, 2012.

Model Systems Knowledge Translation Center (MSKTC). Alcohol use after traumatic brain injury.

2011.

Mukherjee S. Das SB. Vaidyanathan K. Vasudevan DM, Consequences of Alcohol Consumption on Neurotransmitters – An Overview. Curr Neurovasc Res. 5: 266-272, 2008.

Nagy LE. Casso D. Diamond I, et al., Regulation of adenosine transport by acute and chronic ethanol exposure. FASEB Journal. 3: A431, 1989.University Press.

NIAAA, 2007, NIH publication No. 03-5329, accessed 4/1/13, http://pubs.niaaa.nih.gov/publications/Medicine/ medicine.htm.

NIAA, October 2004, accessed 4/1/13, http://pubs.niaaa.nih.gov/publications/aa63/aa63.htm.

Norton F. Halay L, Cognitive Brain Deficits Associated With Alcohol Abuse: Treatment Implications. The AABSS Journal. 15, 2011.

Oscar-Berman M. Marinkovic K, Alcoholism and the Brain: An Overview. Alcohol Research & Health. 27(2): 125-133, 2003.

Pentland B. Hutton L. Jones P, Late mortality after head injury. J Neurol Neurosurg Psychiatry.

76(3): 395-400, 2005.

Peterson JB. Rothfleisch J. Zelazo PD. Pihl RO, Acute alcohol intoxication and cognitive functioning. J Stud Alcohol. 51(2): 114-22, 1990.

Ponsford J. Tweedly L. Taffe J, The relationship between alcohol and cognitive functioning following traumatic brain injury. J Clin Exp Neuropsychol. 2013.

Ridley NJ. Draper B. Withall A, Alcohol-related dementia: an update of the evidence. Alzheimers Res Ther. 5(1): 3, 2013.

Salcido R. O’Shanick G. Costaich J. Conder R, Recurrent traumatic brain injury. Archive of Physical Medicine and Rehabilitation. 71: 764, 1990.

Tom WC. Alcohol related drug interactions. Pharmacist’s Letter/Prescriber’s Letter. 24(1):240106:111, 2008.

Valenzuela CF, Alcohol and Neurotransmitter Interactions. Alcohol Health & Research World.

21(2):144-147, 1997.

Vonghi L. Leggio L. Ferrulli A. Bertini M. Gasbarrini G. Addolorato G, Acute alcohol intoxication.

Eur Journ of Internal Med. 19(8): 561-567, 2008.

Weathermon R. Crabb D, Alcohol and Medication Interactions. Alcohol Research & Health. 23(1): 40-54, 1999.

Wikipedia, http://en.wikipedia.org/wiki/Long-term_effects_of_alcohol. Accessed 4/1/13.

Zahr NM. Mayer D. Rohlfing T. Hasak MP. Hsu O. Vinco S. Orduna J. Luong R. Sullivan EV. Pfefferbaum A, Brain injury and recovery following binge ethanol: evidence from in vivo magnetic resonance spectroscopy. Biol Psychiatry. 67(9): 846-854, 2010.

Zasler ND, Neuromedical aspects of alcohol use following traumatic brain injury. JHTR. 6(4): 78-80, 1991.

References

About the Author

Conclusions

Adams RD. Victor M. (Eds.): Alcohol and Alcoholism. In: Principles of Neurology. McGraw Hill Information Services Company, New York, NY. Pages 870-888, 1989.

Alfonso-Loeches S. Pascual M. Guerri C. Gender differences in alcohol-induced neurotoxicity and brain damage. Toxicology. 2013.

Baratz R. Rubovitch V. Frenk H. Pick CG, The influence of alcohol on behavioral recovery after mTBI in mice. J Neurotrauma. 27(3): 555-563, 2010.

Bartsch A. Homola G. Biller A. Smith S. Weijers HG. Weisbeck GA. Jenkinson M. De Stefano N. Solymos L. Bendszus M, Manifestations of early brain recovery associated with abstinence from alcoholism. Brain. 130(1): 36-47, 2007.

Brailowsky S. Knight RT. Blood K. Scabini D, Gamma-aminobutyric Acid Induced Potentiation of Cortical Hemiplegia. Brain Research. 362-322, 1986.

Charness ME. Simon RP. Greenberg DA, Ethanol and the Nervous System. New England Journal of Medicine. 7: 442-454, 1989.

Corrigan JD & Mysiw WJ. Substance misuse among persons with traumatic brain injury. In: Brain Injury Medicine: Principles and Practice. Second edition. N. Zasler, D. Katz, R. Zafonte (Eds.). New York. Demos Publishers. 1315-1328, 2013.

Cryan J. Cathain NO. Curtis M. Xassidy M. Brett FM, The contribution of alcohol to fatal traumatic head injuries in the forensic setting. Ir Med J. 103(10): 303-305, 2010.

Drug Interaction Facts and Comparison, Division of JB Lippincott Co. St. Louis, MO., 1990. Epilepsy.com, 11/20/06, S. Schachter (ed.), accessed 4/1/13, http://epilepsy.com/epilepsy/provoke_alcohol Goldstein DB (Ed.): Pharmacology of Alcohol. New York: Oxford University Press, 1983.

Nathan Zasler, MD, FAAPM&R, FAADEP, DAAPM, CBIST is the Medical Director for the iWalk gait retraining programs at Sheltering Arms Hospital in Richmond, Virginia. He is also CEO & Medical Director of Concussion Care Centre of Virginia, Ltd., as well as CEO & Medical Director for Tree of Life Services, Inc., an internationally recognized long term care and transitional Neurorehabilitation program in Richmond, Virginia. Dr. Zasler is board certified in PM&R and fellowship trained in brain injury medicine. He is an affiliate professor at the VCU Department of PM&R and an adjunct associate professor for the Department of PM&R at the University of Virginia, Charlottesville. He is a fellow of the American Academy of Disability Evaluating Physicians and a diplomat of the American Academy of Pain Management. Dr. Zasler has published over 150 peer reviewed abstracts and articles, and has authored over 50 book chapters. He has lectured extensively on TBI related neuromedical issues and is internationally recognized for his work in brain injury medicine. He currently serves as the chairperson of the International Brain Injury Association. He is co-chief editor of two peer reviewed international scientific journals: “Brain Injury” and “Neurorehabilitation.” Dr. Zasler was the recipient of the Sheldon Berrol Clinical Service award from BIAA in 2011 and once again recognized by “Best Doctors” that same year.

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UNIVERSITY OF NORTH FLORIDA JACKSONVILLE, FLORIDA

10.4.13

STATE WIDE TBI CONFERENCE

The Toral Family Foundation (TFF) in partnership with UF Health will host the “TBI: Changing the Game Conference” — an event to educate, inspire and connect medical professionals on the topic of Traumatic Brain Injuries (TBI) and it’s relevancy to all practicing clinicians.

KEYNOTE SPEAKER Sanjay Gupta, MD

Cheif Medical Correspondant, CNN

Toral Family Foundation

@Toralfamfound #ChangingTheGame (855) TORAL.FF (855) 867.2533 www.toralfamilyfoundation.org

24 BRAIN INJURY PROFESSIONAL

Acute Hospitalization – The book depicts common brain injuries through medical quality illustrations. It provides explanations of diagnostic tests, common equipment used in the ICU, and the acute hospital stage of brain injury rehabilitation.

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Visit our website for more information, to arrange a facility tour, or to make a referral.

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The substance use and brain injury bridging project: How to Catch a Hot Potato

by Carolyn Lemsky, PhD, C.Psych.

The Substance Use and Brain Injury Bridging Project (SUBI) grew out of the need to increase the capacity of the health care system in Ontario to better manage a group of clients who were falling into the great divide that existed between community based brain injury and addiction services. At first glance, the SUBI partners: Community Head Injury Resource Services of Toronto and the Centre for Addictions and Mental Health (CAMH), is an odd pairing – a community-based brain injury provider with only a couple of health care professionals and a large, academic medical center dedicated to addictions and mental illness. The important thing about our first meetings in 2004 was that everyone around the table wanted to end the game of referral hot-potato that begins when a complex client is identified as having both a brain injury and problematic substance use. The challenge was to figure out what we could do to create meaningful change without new resources for specialized programming.

The first Ministry of Health and Long-term Care funded project allowed the SUBI team to develop cross-training materials and a brain-injury friendly adaptation of the CAMH inpatient treatment program. The Ohio Valley Centre for Brain Injury Prevention and Rehabilitation was generous enough to allow us to include adapted versions of their materials in our 178 page manual. These materials were expanded somewhat to include introductory information on harm reduction, relapse prevention, stages of change, motivational interviewing, twelve-step programs (AA), suggestions for case management and goal setting. We also included information about brain 26 BRAIN INJURY PROFESSIONAL

injury that was geared towards people working in addictions settings. This information was provided in tabular format, organized according to: presenting issues, Information about cognitive compensation, cognitive and behavioural difficulties and suggestions for their management. The treatment program adaptation was documented in the form of a client workbook.

The workbook is not intended as a program in and of itself, but rather, in the absence of evidence-based practices suitable for use in the community, it was our attempt to give specific examples of how existing practices in addictions could be modified for people with neurocognitive impairment. For example, most chapters include self-assessment questionnaires as a means of supporting clients who have difficulty responding to open-ended questions and each section encourages the client /provider dyad to create individual notes to document the session.

The knowledge transfer project, funded by the Ontario Neurotrauma foundation, supported the actual cross-training workshops. We understood that our first challenge was to encourage partnerships between brain injury providers and addictions providers. As it turns out, it was in our first workshop presentations that the real learning began. We conducted training—both using telehealth distance options and in-person—and reached roughly 1,200 frontline providers over the course of three years. Although we wanted groups of ABI providers and Addictions Providers together, approximately 85% of our attendees were from the field of ABI. Lessons learned The first step in training is to encourage trainees to examine their thoughts and feelings about substance use

and about brain injury. The first groups of providers that we trained acknowledged that they had very negative images of the ‘other’ population. We found that openly discussing stigma and incorporating video and live presentations of clients telling their stories helped to break down stereotypes which were remarkably similar in groups of addictions and brain injury providers—that the unknown population would be dangerous, aggressive, unpredictable and unable to make a change. Our clients benefited from the opportunity for self-advocacy, and so, we believe, did program development.

Screen first, and then they will come to training. Another significant barrier seemed to be a belief on the part of brain injury providers that people with brain injury and substance use were not already in their case loads. The year or two of abstinence that often follows moderate to severe injury means that rehabilitation services have faded before the real difficulties with substance use actually appear. Instead of referral to brain injury services, clients who began to use substances in a harmful way were more likely to be referred to addictions services. Despite education regarding international studies, it wasn’t until the screening project began in their home programs that frontline brain injury and addictions providers began to take more interest in the training we were providing. Having homegrown data seems to have done the trick. Our preliminary findings at CAMH are very much in keeping with those reviewed in (Corrigan in this issue). Approximately 22% of people presented for care related to their substance use reported one or more brain injuries with loss of consciousness. Our preliminary analyses also suggest that these individuals are at significantly greater risk for repeated episodes of addictions care and as noted by Corrigan (this issue) exhibit more psychiatric symptoms.

The SUBI client Workbook is straight forward enough to enable brain injury workers to have useful discussions with clients who would not accept referral to addictions treatment, but it isn’t a treatment program. The workbook provides specific examples of how to present information in a manner that is easier for people with ABI to digest. We continue to emphasize that the workbook is a way to get started, but individualized treatment plans that include an emphasis on the Figure 1

development of meaningful life goals and skill building seem to be essential elements of treatment.

Feedback from an initial survey of 60 ABI and addictions providers indicated that, since the Client Workbook illustrates how to provide cognitive compensation, it would potentially be useful in working with clients who have cognitive impairment directly related to substance use as well as those with identified ABI. They also reported that the Manual ‘de-mystifies’ working with ABI and, as a result, that they are now more willing to accept these individuals into their practice. ABI providers commented that the Provider Manual was useful in providing guidance about policies to help retain in their services people who are actively using drugs. They also reported that the Provider Manual and Workbook had proved useful in attracting addictions partners and encouraging working with(rather than dismissing or referring) people with active addictions issues.

Conducting workshops for a full day or more, in person seemed to be a worthwhile investment. Those providers who attended full day or two day workshops reported more change in their practice than downloaders, conference presentation attendees or those who received one or two hour distance training.

Progress

When we started in 2006 we knew of two programs that provided services to people with brain injury and substance use other than the nascent efforts at CHIRS. By 2010 when we re-surveyed the providers who had participated in a train the trainer event there were 6 local area health networks in the process of developing group programming and partnerships and one had actually hired an addictions counselor. Two new formal treatment partnerships were developed during the course of the project, and 5 informal partnerships that allowed for cross-referrals in consultation were identified. The pattern that we observed was that the smaller jurisdictions (with the lowest number of providers) were most likely to find a partner and report actual shared care occurring with individuals. In smaller communities it was clear that all of the social services were working with the same group of complex individuals. Partnership made sense. For the mid to large urban centers, the two biggest barriers to service development that were identified Client overview: Each phase of the SUBI group has different goals were attracting addiction providers to partner as partners and getting sufficient attendance at group programming.

An example of one of the better reported outcomes form the project was the partnership that developed between a methadone clinic and a supported housing provider in a rural municipality about a two hours from Toronto.

Before training, the housing provider had refused to accept people with brain injury if they were still using. They also had a policy of kicking people out if they were known to be using at which point many became homeless, without intervention, and often returned to shelters and the court system. Beginning on the day of SUBI training, the principles at each agency (including a local physician and judge) began to talk about how they might BRAIN INJURY PROFESSIONAL

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Figure 2

support each other with harm reduction and intervention. She reported that since the training, “we’re more aware and more tolerant. People will tell us what they’re really doing because they know we’ll try to help anyway.” In my discussion with the local supportive housing provider three years later they continue to use the SUBI materials to start the discussion about substance use with clients who need it. They are surprised that the character of their residences has not changed, despite the fact that they continue to engage with some active substance users.

The local addictions provider and methadone clinic continue to collaborate-offering individual and group based intervention— together.

Our current funded project is designed to meet three challenges: 1. Motivate the participation of local addictions providers with ABI screening initiatives. In Toronto ABI providers are too few to manage the total number of cases that are generated by screening initiatives.

2. Pilot test a model of community based services that can be implemented within available resources. We wanted the model to translate Corrigan and colleagues work on engagement, and incorporate elements of cognitive and psycho-social rehabilitation along with specific interventions for addiction. The model had to allow for serving clients at varying stages change, awareness of impairment and degree of impairment.

3. Develop a psych-educational programming designed for the families of people living with brain injury. Support for families anxious to assist their family members to sustain their post injury abstinence. How to help their family members who continue to use, and what to expect from treatment programs.

We are currently piloting a program that includes a four meeting assessment and planning period after which the client is rewarded with a gift certificate in the manner described by Corrigan (Corrigan and Bogner 2007).

Treatment plans may include attending the SUBI intensive treatment cycle or individual counseling, shared care with CAMH or any combination. Clients set goals related to their engagement in the intervention, their substance use and their life. Intensive 28 BRAIN INJURY PROFESSIONAL

case management and access to a variety Tasks for the Facilitators of CHIRS services including volunteer and mentoring opportunities, recreational programming and supported employment can be included in care plans. There is also a group based on the principles of structured relapse prevention offered once per week as well as an open step meeting conducted by AA, but with the support of an ABI worker as needed.

The salient features of the group intervention are that the it is limited to only 7 participants. Meta-cognitive routines, cognitive compensation, mindfulness and other specific coping strategies are integrated into the presentation of materials. Participants receive a wooden bead for each group attended, a strategy that the first participants indicated directly influenced their attendance during the early weeks of the program. The content of the groups is described in Figure 1.

Clinical objectives are described in Figure 2.

Our early outcomes suggest that our clients are making significant changes in their substance use, with a minority choosing to pursue abstinence and going on to engage in AA as a long-term support system. All of the initial six participants in the intensive group program had previously participated in mainstream addiction programs and reported that they found the SUBI group’s format increased their participation and retention of information. All of the clients demonstrated reduced harms associated with their substance use, increased the amount of time spent in productive activity, reduced social isolation and expressed satisfaction with the care they received. We believe that we have a model that we can sustain within our resources. Our future plans are to continue with the pilot, study the programs’ outcomes and economics and then look for opportunities to scale the intervention to the varied conditions in the rural and urban settings in Ontario.

About The Author

Dr. Carolyn Lemsky is a neuropsychologist with over 20 years of experience working in rehabilitation settings in the U.S. and Canada. For the past 15 years she has been the Clinical Director at Community Head Injury Resource Services of Toronto—a Ministry of Health and Long-Term Care funded agency designed to promote community re-integration of persons living with the effects of acquired brain injury. CHIRS is also home to an active clinical research program related to co-morbid mental health and problematic substance use. Dr. Lemsky has contributed book chapters and juried articles to the brain injury rehabilitation literature and is a frequently invited speaker at conferences and workshops in Canada and the US. For the past six years she has been the director of the Substance Use and Brain Injury Bridging Project a partnership with the Centre for Addictions and Mental Health and CHIRS. In that role she has provided leadership on the SUBI Research to Practice Network, and for the past year the mental health and brain injury partnership -- projects funded by the Ontario Neurotrauma Foundation.

References

Corrigan, J. D. and J. Bogner (2007). “Interventions to promote retention in substance abuse treatment.” Brain Inj 21(4): 343-356.

The client workbook can be downloaded at www.SUBI.ca

“Our goal is to provide the highest quality, individualized transitional and long term care for persons with acquired brain injury.”

Nathan D. Zasler, MD Founder, CEO & Medical Director Tree of Life Services, Inc.

Chief Editor Nathan D. Zasler, MD

www.Tree-of-Life.com 1-888-886-5462 • Fax 804-346-1956 Administrative Offices BRAIN INJURY PROFESSIONAL 29 3721 Westerre Parkway, Suite B • Richmond, Virginia 23233

legal spotlight Funded. Unfunded. Represented.

“Healing is a matter of time, but it is also a matter of opportunity.”

– Hippocrates

Not everyone heals the same because not everyone has the same opportunity. What does that mean? Before you are tempted to think that this article will address perceived social injustices or shed light on the current Healthcare reform debate in America, you will be relieved to discover that it does not.

So what do I mean? I have found in the 20 years of representing persons with brain injury that recovery is often a matter of time and opportunity. Several factors are associated with improved outcomes following a brain injury. Early medical intervention is the most significant. It is virtually indisputable that there is a clear survival benefit to a patient with a severe TBI who arrives to the trauma center within the ‘golden hour’.

Other important factors which influence recovery are neuroplasticity (the brain’s ability to re-wire itself and the basis of many cognitive and physical rehabilitation practices); community resources; caregiver support and in many cases, early legal intervention. I would like to discuss the latter since it may be the least understood factor which can influence the recovery of a patient/ client with a Traumatic Brain Injury (TBI).

Most of you would agree that insurance and financial issues remain perhaps the single greatest barrier to medical care for the catastrophically injured. Therefore, the ‘opportunity’ to receive comprehensive medical care for a moderate to severely injured TBI patient is directly related to the patient’s access to financial and insurance resources to fund that care. However, whether it’s an insured patient with a seemingly ‘good’ insurance policy or an uninsured patient with comparatively fewer options, barriers to care persist.

In either case, families soon realize that there are varying limitations on the type, scope, quality and length of care which is available to their loved one with a severe TBI. For example, even under the best health insurance policies, coverage for rehabilitation services is usually limited to approximately 30 days. To be sure, this is wholly inadequate to meet long term rehabilitation needs. What opportunities exist to fund the long term healthcare needs of a loved one with a TBI? Early legal intervention allows many families via the civil justice system to access financial resources to pay for comprehensive care, treatment and services which can run into the millions of dollars over a lifetime. If a brain injury law firm does not get involved early on, a unique opportunity may be lost by the family to protect their loved ones ability to pursue a legal claim which can be the difference between receiving the full spectrum of necessary care and services or to be discharged home to an overwhelmed family member often ill equipped to manage their care.

The timing of when the brain injury legal team is hired is crucial. For example, in most legal cases there are witnesses to an automobile accident. Over time though, usually in just a few days: witnesses become reluctant to help, evidence such as road markings and skid marks wear and disappear. Physical evidence such 30 BRAIN INJURY PROFESSIONAL

as vehicles and their steering, braking and safety systems can be compromised, lost or be destroyed. Additionally, when a TBI is caused by the negligence or fault of a company, the companies’ insurance carrier will immediately dispatch its own team to the accident scene.

By waiting just a few days to hire a brain injury lawyer, the family of a TBI patient, unwittingly allows the insurance company to gain a tactical advantage which almost always results in a decided disadvantage to the patient/client.

Over the years I have learned that there is a direct correlation between access to financial resources and improved outcomes in persons with TBI Just like a trauma team plays a significant role in managing the TBI patient’s injury in the acute phase, early legal intervention plays an important role in preserving the TBI patient’s ability to access the financial resources necessary to fund their long term medical needs.

When the uninsured single mother of a 6 year old boy struck by a distracted delivery driver anxiously waits outside the PICU, opportunity comes in the form of a warm smile and gentle embrace of a kind nurse. Opportunity may also arrive as a caring lawyer dedicated to helping mother and son get on the road to recovery.

The best opportunities for recovery are afforded to those families whom have the benefit of medical and legal professionals working together with a singular purpose: Healing.

About the Author

Frank Toral is the Senior Partner of Toral Garcia Battista, a Florida-based law firm focusing on brain and spinal cord injury cases. Frank is a passionate advocate for brain and spinal cord injury survivors and their families and has served in various leadership and advisory roles with multiple organizations including Brain Injury Association of Florida, Brain Injury Association of America, Sarah Jane Brain Foundation and the University of Florida Presidents Council. Frank received his Bachelor of Science in Political Science from the University of Florida and his Juris Doctorate from Shepard Broad Law School at Nova Southeastern University.

Frank is a frequent speaker and contributor on Brain injury topics and issues and has also authored the handbook Brain Injury: Where do we go from here? Frank founded the Toral Family Foundation whose mission is to collaborate with the healthcare community to improve the lives of all persons with a brain or spinal cord injury through research, education and access to resources.

Redefining possible.

Transforming lives since 1956.

Craig Hospital in Denver is dedicated exclusively to specialty rehabilitation and research for people who have sustained spinal cord (SCI) and traumatic brain injuries (TBI). Craig helps rebuild lives, leading to unsurpassed outcomes, independence, and productivity. These outcomes also result in high levels of satisfaction, value, and cost savings for patients, families, employers, insurance companies, and society.

Craig’s focused expertise and in-depth programs, extraordinary longevity of physicians and staff, family inclusion, and real world skills training all contribute to the success of our patients. Craig is more than a hospital — it is a powerful culture of healing and a remarkable integration of medicine, rehabilitation, education, recreation, and life.

As a premier leader in the field of rehabilitation for more than five decades, Craig Hospital serves patients from all 50 states and several other countries. Craig is federally designated as a NIDRR Model Systems Center for SCI and TBI, and is the TBI National Statistical Database. Craig has been ranked in the Top 10 Rehabilitation Hospitals for 23 consecutive years by U.S. News & World Report, and has twice consecutively achieved the highly coveted Magnet® Recognition. In 2011 and 2013 the American Nurses Association ranked Craig No. 1 in the Rehabilitation Hospital category in the U.S. for nursing quality, based on key performance measures. In 2012 Craig was ranked the No. 3 Best Work Place in Denver by The Denver Post. Craig is also pioneering cutting-edge research and advances in adaptive technology. The Peak Center at Craig Hospital, a model wellness and fitness program, opened in 2011.

As a non-profit, independent hospital, the Craig “family” delivers the highest quality of rehabilitation treatment available anywhere.

Ask anyone who has ever been associated with Craig Hospital and you’ll receive a consistent answer: Craig Hospital is special.

3425 South Clarkson Street | Englewood, Colorado 80113 | 303-789-8000 | www.craighospital.org

BRAIN INJURY PROFESSIONAL

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literature review Brain Injury Medicine, Principles and Practice.

By Nathan Zasler, Douglas Katz, & Ross Zafonte, 2013.

Demos Medical Publishing.

It is no surprise that Dr.s Zasler, Katz, and Zafonte have once again produced the exceptional gold standard reference manual on brain injury, Brain Injury Medicine, Principles and Practice, a second edition of their widely celebrated original text from 2008. With the proliferation of issues in brain injury, this book will help to guide us in keeping pace with evidence based medicine and best practices regarding the biomechanics of injury, neuroplasticity, neuroimaging and neurodiagnostic testing from acute care to post-acute treatment, community re-entry and life care planning.

Nearly 200 of the field’s recognized experts have contributed or co-authored chapters in this edition and several thousands more are referenced. From the forward by Dr. Harvey Levin to the overview chapters on US and international health policy (Berube & Turner-Stokes), brain injury epidemiology and public health issues (Coronado, McGuire, Faul, Sugerman, & Pearson), acute rehabilitation (Ivanhoe, Durand-Sanchez, & Spier), behavioral analysis and treatment (Karol), after hospital rehabilitation (Malec), and medical/clinical legal issues (Ameis, Zasler, Martelli, & Bush). This book captures the best of academicians, researchers and practitioners and chapters on Neuroimaging Correlates of Functional Outcome (Bigler & Maxwell), and special populations such as TBI in the Elderly (Levine & Flanagan), Sports-Related Concussion (Collins, Iverson, Gaetz, Meeham and Lovell), persons with disorders of consciousness (Giacino, Katz, Garber, & Schiff) and military TBI (Meyer, Jaffee, & Grimes) provide thoughtful summaries of some of the most contemporary challenging clinical issues in our field.

As noted by the authors, the updated edition provides expanded “transdiciplinary” editorialship by including experts in neuropsychology, neuropsychiatry, and neurosurgery with the addition of Dr. Jeffery Kreutzer, Dr. David Arciniegas, and Dr. Ross Bullock to round out the comprehensive coma to community focus of the

manual. Five new sections have been added: Acute Care, Pediatric TBI, Special Senses, Autonomic and Other Organ Systems, and Post-Trauma Pain Disorders. Twenty-five new chapters covering health policy, international systems of care and research, military TBI and accreditation to site a few, will help round out the reader’s understanding of the multitude of issues surrounding brain injury. The format of the book; including the text, a conclusion, key clinical points, key references and complete references for each chapter allows for efficient use as a go-to manual for physician, clinicians, researchers, attorneys, families and significant others, advocates, and those with a brain injury.

As we attempt to better understand brain injury as a chronic condition impacting the individual across their life span, this book lays out the full landscape of issues surrounding brain injury.

Having this solid basis of understanding the complexities of brain injury calls for us to continue to challenge ourselves to develop ever further treatments and support services to produce durable functional changes that mesh with the demand for increased cost efficiency.

While not a page-turner and not a book you can even physically hold as you read, this preeminent work is one that all those working in brain injury should have access to. Given that this second edition is a five year follow up to the first, we can only hope that the editors have a couple more future editions in them.

About the reviewer

Dr. Debra Braunling-McMorrow is the President and CEO of Learning Services. She serves on the board of the North American Brain Injury Society. Dr. McMorrow is a past chair of the American Academy for the Certification of Brain Injury Specialists (AACBIS) and has served on the Brain Injury Association of America’s board of executive directors. Additionally, Dr. McMorrow has served on several national committees, editorial boards, and peer review panels. Dr. McMorrow has published in numerous journals and books and has presented extensively in the field of brain injury rehabilitation. She has been working for persons with brain injuries for almost 30 years

BRAIN INJURY PROFESSIONAL

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bip expert interview Interview with John D. Corrigan, PhD Professor, Department of Physical Medicine and Rehabilitation, The Ohio State University John D. Corrigan, PhD, is a Professor in the Department of Physical Medicine and Rehabilitation at Ohio State University, and Director of the Ohio Valley Center for Brain Injury Prevention and Rehabilitation. He is the Project Director for the Ohio Regional Traumatic Brain Injury Model System and chairs the Executive Committee of the TBI Model Systems Project Directors. He is Editor-in-Chief of the Journal of Head Trauma Rehabilitation. He has served on the Advisory Committee to the National Center on Injury Prevention and Control at the Centers for Disease Control and Prevention, and is a former member of the boards of directors of the Commission on Accreditation of Rehabilitation Facilities (CARF) and the Brain Injury Association of America. Dr. Corrigan has received many awards for his service and research in the field, including the Brain Injury Association of America’s William Fields Caveness Award and the 2007 Robert L. Moody Prize.

The relationship of substance abuse and traumatic brain injury (TBI) has been long recognized. You have been a major contributor to the research literature. How did you become interested?

In the 1980’s we were developing our outpatient programs and had a couple of individuals who were in dire need of substance abuse services.

However, no matter what we did, we could not get them access to local treatment facilities. I used to say, “even with money falling out of their pockets,” we couldn’t get them through the door.

From that experience we realized that making a referral was not so simple, and it certainly gave us caution about just giving someone a phone number and expecting the rest would take care of itself. We decided we needed a more systematic way to identify our clients with substance abuse issues and to explicitly strategize the process for getting treatment. The new emphasis led to our systematically screening for substance abuse, and wow, our jaws dropped as when we realized clients needing these services were more the rule than the exception. There had obviously been an unspoken “don’t ask, don’t tell” policy going on. One thing led to another, and in 1991 we opened our outpatient treatment program for dually diagnosed with TBI and substance use disorders. That program is still operating today.

were dually diagnosed with severe mental illness and substance use disorders absorbed many resources but still had very poor outcomes. The outgrowth was a new treatment model called Integrated Dual Diagnosis Treatment (IDDT). I can’t do justice to this model in this conversation, but let me just say that many of the issues faced in that dually diagnosed population are similar to what we face with those dually diagnosed with TBI and substance use disorders, and, concomitantly, some of the treatment ideas that were incorporated in IDDT are very applicable to our population. Indeed, the substance abuse treatment program we operate at Ohio State uses many of the principles of IDDT. The second example is a treatment approach that grew out of general medicine that was developed to address excessive alcohol consumption in persons who were developing liver disease. Called Screening and Brief Intervention (SBI), it was adopted for trauma care and, more recently, several research groups have been attempting to adapt the principles of SBI for persons with TBI. I think we have a ways to go before SBI is as efficacious with our patients as it is in the general population, but I think it holds promise as a technique that can be used in many settings by professionals who are not trained in chemical dependency.

Since you’ve been researching the field of substance abuse and TBI what advances have you seen in patient care?

The advances that come to mind are both innovations that have come from fields other than brain injury rehabilitation. In substance abuse treatment it was recognized that persons who

What are the biggest challenges clinicians face in getting treatment for substance abuse in their patients who have suffered a TBI? While there have been improvements in making substance abuse treatment more physically and financially accessible, I believe we still have a

34 BRAIN INJURY PROFESSIONAL

ways to go before most substance abuse treatment is “neurologically accessible” for persons with TBI. By that I mean there are several ways in which substance abuse treatment, as typically delivered, results in barriers for people with neurologic impairments. Most obvious is that there is a minimum cognitive demand, depending on the treatment approach, that a person with a TBI may struggle with––this is especially the case with group treatment and in milieu approaches like Therapeutic Communities. In any treatment, chemical dependency counselors may not distinguish between behavior reflecting motivation and that arising from frontal lobe damage (e.g., why an appointment is missed). There are other examples, but these provide a sense of what I mean by “neurologically accessible”.

What are the unique issues that TBI patients face regarding successful substance treatment?

Studies to date that compare the general population of persons receiving substance abuse treatment to those in treatment who have had a TBI suggest several systematic differences that serve to make treatment more complicated.

Substance abuse clients with TBI started using earlier in life, are more likely to have psychiatric co-morbidities and require more time and assistance to assure that changes made are maintained. This last one is tricky, and poorly understood in chemical dependency treatment circles. To put it simply, when treatment would normally appear to be done, more supports may be needed for persons with TBI. They have an even greater disconnect between the intention to be sober and success in implementing it.

What are some of the core components that are needed in a substance abuse program for persons who have suffered a TBI? This is a complicated question; and probably too complicated for this format. But the short answer is that It depends what setting an intervention takes place. I believe there are many opportunities for addressing substance misuse and actual substance use disorders depending on the person and the resources of the treatment providers. Jenny Bogner and I have described a 4-quadrant model for conceptualizing the opportunities for intervention based on severity of TBI, severity of the substance problem and the setting where the person is encountered. In each quadrant of the model interventions are a lot like what would be done normally in addressing substance abuse; but in each case there is the necessity to accommodate the effects of TBI. Long story short, 90% of what is done in substance abuse treatment also applies when a person has a TBI; but, that last 10% is what makes the treatment effective for this population. The only unilateral prohibitions I would

make are that confrontation is not likely to create a teachable moment for persons with, TBI and Antabuse (disulfiram) is not recommended for discouraging alcohol consumption as it may not deter ingesting the alcohol anyway, and thus can be a serious medical threat.

What are future directions that researchers and clinicians need to explore to improve treatment outcomes for this patient population?

Clinically, I think we still have some awareness to increase––both in the brain injury rehabilitation field and the chemical dependency field. There are missed opportunities for more education and better interventions that could be implemented in the treatment provided by both fields. At the same time, there is a tremendous opportunity for greater collaboration between rehabilitation and substance abuse providers.

Cross-training, cross-consultation and co-location of professionals can be very effective and is very low cost. For the most complex individuals with TBI and substance use disorders there is a

need for integrated treatment models that could be developed through collaboration among brain injury and chemical dependency professionals. A good starting point would be that all patients/clients in brain injury rehabilitation are screened for a history of substance abuse, and all clients in substance abuse treatment are screened for a history of TBI. In research, the opportunities are nearly infinite. There is a pressing need for comparative effectiveness studies of proven substance use disorder treatments when applied to persons with TBI. Developing and testing the efficacy of treatment accommodations for neurological impairment in SBI, CBT or milieu based treatments is another genre of research needs. I would also like to see more basic research looking at how damage to frontal areas of the brain predispose and/or exacerbate addiction. Finally, I believe the developing field of neuromodulation may present unique opportunities for restoring a person’s ability to self-control behavior––we have not even conceptualized all the opportunities in this arena.

Canoeing at Vinland’s main campus in Loretto, Minnesota

drug & alcohol treatment for adults with disabilities Vinland Center provides drug and alcohol treatment for adults with cognitive disabilities, including traumatic brain injury, fetal alcohol spectrum disorder and learning disabilities. We make all possible accommodations for cognitive deficits and individual learning styles.

Located in Loretto, Minnesota — just 20 miles west of Minneapolis.

(763)479-3555 • VinlandCenter.org BRAIN INJURY PROFESSIONAL

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non-profit news NORTH AMERICAN BRAIN INJURY SOCIETY Tina Trudel, PhD, the program chair of the North American Brain Injury Society’s 11th Annual Conference on Brain Injury, is putting the finishing touches on what is shaping up to be an outstanding educational event. The conference will be held September 18-21, 2013, at the InterContinental Hotel in New Orleans, Louisiana, and will address a wide range of brain injury topics from basic science to practical clinical issues to public policy and healthcare reform. The meeting will open with a special pre-conference workshop on state of the art neuroimaging chaired by John Silver, MD, Barry Willer, PhD and John Leddy, MD. As usual, the medical conference will be held in conjunction with the Annual Conference on Legal Issues in Brain Injury.

The full programs for both conferences are now available on line at www.nabis.org.

Brain Injury association of america The Brain Injury Association of America (BIAA) is accepting nominations for the William Fields Caveness Award for research and the Sheldon Berrol MD Clinical Service Award. Forms are available from www.biausa.org/announcements/biaa-professional-awards-nominations and are due on July 10, 2013. Awards will be presented at ACRM’s fall meeting in Orlando, Fla. BIAA is actively lobbying for reauthorization of the TBI Act (H.R. 1098) to continue and expand the state and protection and advocacy grant programs as well as the critical work of the Centers for Disease Control and Prevention. Please contact your congressional representative and ask him/her to co-sponsor the bill. BIAA and the Brain Injury Research Center of Mount Sinai recently completed an investigation on how schools are meeting the educational needs of children with TBI. Please visit http://www. biausa.org/biaa-position-papers.htm to download an electronic copy of the report, which includes recommendations for better identifying and tracking students with TBI. BIAA is also supporting the Youth Sports Concussion Act of 2013, introduced by the co-chairs of the Congressional Brain Injury Task Force, Rep. Bill Pascrell (D-NJ) and Tom Rooney (R-FL). We are delighted Sen. Mark Kirk (R-IL) and Sen. Tim Johnson (D-SD) introduced S. 1027, which will improve, coordinate and enhance rehabilitation research at the National Institutes of Health. BIAA met with each Senator’s staff in February to discuss the importance of access to care for individuals with brain injury. During the first quarter of 2013, BIAA had a large increase in website visitors, jumping from an average of 50,000 visitors per month to 85,000. Calls to our National Brain Injury Information Center also increased. Already this year, we’ve had requests for help from all 50 states and 16 different countries; 20% of inquiries relate to a non-traumatic injury, such as a tumor or hypoxic injury. Please visit our website for information about our webinars and other programs and services.

DEFENSE CENTERS OF EXCELLENCE Visual dysfunction associated with mild traumatic brain injury (mTBI) can be the result of trauma to the eye and/or the orbit 36 BRAIN INJURY PROFESSIONAL

(eye socket) and/or from neurologic injury following concussion, blast exposure or other head trauma. Visual dysfunction is a common co-occurring disorder of mTBI and has a significant impact on the lives of affected service members and veterans. The human visual system is highly complex and vulnerable at numerous points to concussive events. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) and the Defense and Veterans Brain Injury Center (DVBIC) have produced a reference card and clinical recommendation as tools to assist primary care providers with evaluating and providing appropriate referrals for patients with suspected eye or vision problems following mTBI. The reference card: • Explains the assessment and management of visual dysfunction associated with mTBI • Describes and displays the clinical algorithm addressing red flags (potentially life threatening) and yellow flags (requiring follow-up), identifying comorbidities, basic visual assessment and referral options The clinical recommendation: • Assists providers in the diagnostic process • Offers an approach for the medical primary care provider to identify patients with mTBI who may benefit from further eye or vision evaluation and care, as well as recommendations on minimum vision testing • Provides pathways for specialty referrals for patients complaining of visual disturbance following mTBI How to order the reference card and clinical recommendation: • An electronic version of the reference card and clinical recommendation are available from the DVBIC website at • dvbic.org/material/assessment-and-management-visual-dysfunction-associated-mtbi-clinical-recommendation • Hard copies can be ordered via the dvbic.org shopping cart For more information, please visit dvbic.org or email info@ dvbic.org

INTERNATIONAL BRAIN INJURY ASSOCIATION The official Call for Abstracts for the Tenth World Congress on Brain Injury is now open! Members of NABIS and all multidisciplinary brain injury professionals are encouraged to submit their original research to what is expected to be one of the most important brain injury events ever held in the United States.

The abstract submission deadline is October 11, 2013, and the Congress itself is scheduled for March 19-23, 2014, in San Francisco, California. All accepted abstracts will be published in IBIA’s official journal, Brain Injury. The Congress scientific committee will determine the most appropriate format for the presentation, either oral platform or poster. In addition to the oral and poster sessions, the Congress will feature a host of world renowned invited speakers, panels and workshops providing attendees with state-of-the-art research on brain injury research, assessment and treatment. Members of NABIS should note that they are entitled to register for the Congress at the discounted IBIA member rate. For more information, visit www.internationalbrain.org.

NATIONAL ASSOCIATION OF STATE HEAD INJURY ADMINISTRATORS We invite you to the National Association of State Head Injury Administrators 24nd Annual State of the States (SOS) in Head Injury Meeting “From Model T’s to Modern Times: Emerging Trends in Brain Injury” being held October 7-10, 2013, in Detroit, Michigan at the Dearborn Inn. The SOS Meeting is the only annual national gathering which provides professional devel¬opment opportunities among state government program adminis¬trators specifically in the field of traumatic brain injury. The Meeting will feature keynote speakers presenting on issues impacting brain injury and state services, national trends, and federal policy. The pre-conference, “Brain Injury, Violence and At-Risk Populations” will focus on shedding light on the connections of pediatric, adult and older adult violence and brain injury and learning how states can foster connections within these areas of focus.

For a detail agenda and registration of the conference activities, visit www.nashia.org. NASHIA, its partners, and the Congressional TBI Taskforce continue their efforts on the reauthorization of the TBI Act which includes: • • •

The Health Resources and Services Administration (HRSA) to provide funds to states to develop TBI programs that improve access to service delivery for individuals with TBI. Funding to Protection and Advocacy services in each state to ensure legal services are available for individuals with TBI. Funding to Centers for Disease Control and Prevention

Restore-Ragland

(CDC) for surveillance, outreach, and prevention efforts specific to TBI, including the creation and dissemination of treatment guidelines.

Remember to contact your legislators to support this vital piece of legislation! Information on state TBI programs, NASHIA technical assistance, and other resources may be found at www. nashia.org

UNITED STATES BRAIN INJURY ALLIANCE The United States Brain Injury Alliance (USBIA), in preparation for several meetings with the congressional staff working on the reauthorization of the TBI Act, conducted a needs assessment of its 20 state member organizations to identify the most pressing needs faced by people with brain injury and their caregivers. Data collected is meant to facilitate discussion among stakeholders and policymakers about gaps in services and support for those affected by brain injury. The results of the findings are available at: www.usbia.org. In addition, USBIA is pleased to welcome Steven Shapiro, Esq. to its Board of Trustees. Mr. Shapiro is a shareholder of the Denver firm of Fleishman & Shapiro P.C. and is past President of the Brain Injury Alliance of Colorado. His combined wealth of knowledge and experience will strengthen USBIA’s commitment to improving lives of children and adults by preventing brain injuries, increasing awareness, promoting understanding, and building support.

Restore-Roswell

Restore-Lilburn

Restore Neurobehavioral Center is a residential, post acute healthcare organization dedicated exclusively to serving adults with acquired brain injury who also present with moderate to severe behavioral problems.

Services range from intensive inpatient neuro-rehabilitation and transitional community re-entry services to long term supported living services. Restore Neurobehavioral Center, located in a suburb north of Atlanta, is the site of our inpatient post acute neuro-rehabilitation program as well as one of our supported living sites. We operate two other community living sites, Restore-Lilburn (GA) and Restore-Ragland (AL).

www.restorehealthgroup.com 800-437-7972 ext 8251 BRAIN INJURY PROFESSIONAL

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legislative roundup The only thing which saves us from the bureaucracy is its inefficiency.

— Eugene McCarthy In between House and Senate hearings investigating the Administration’s actions on various issues Congress is considering the annual appropriations bills, the “Help Sick Americans Act”, a pediatric research bill, among other issues. In March, Congress funded federal government, which included sequestration – across the board cuts -- through the remaining of this current fiscal year, which ends September 30th. As the result of sequestration, approximately $80 billion has been cut in spending for non-exempt discretionary (annually appropriated) and non-exempt mandatory spending programs. Whether to continue sequestration with regard to FY 2014 appropriations for federal programs beginning October 1 is being debated. The President’s budget calls for elimination of the sequester and replace it with specific spending cuts, as well as revenue increases.

The President has also proposed $100 million in funding for Brain Research through Advancing Innovative Neurotechnologies (Project BRAIN) initiative to increase our understanding of the human brain in order to help people suffering from Alzheimer’s disease, Parkinson’s disease, autism, epilepsy, schizophrenia, depression, and traumatic brain injury. Should the initiative be funded it would be conducted through the National Institutes of Health (NIH), Defense Advanced Research Projects Agency (DARPA), and National Science Foundation (NSF).

The President also proposed increased funding for brain injury research to be conducted by the NIH’s National Institute of Neurological Disease and Stroke (NINDS) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The request for FY 2014 funding for NINDS is to support a prospective, observational, multi-center study of 5,000 adults and children with TBI. The agency would also conduct a study of 1,000 children to specifically evaluate the effectiveness of six major critical care guidelines for severe, pediatric TBI that are based on expert opinion rather than compelling experimental evidence. The FY 2014 budget proposal for NICHD includes funding to engage in a new, comprehensive effort to accelerate research on the epidemiology, diagnosis, and treatment of concussion, or mild TBI, across the life span.

The Centers for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control (NCIPC) FY 2014 budget requests include an increase of $20 million to expand the National Violent Death Reporting system; $10 million in new funding to conduct research into the causes and prevention of gun violence; and an increase of $5 million for the Rape Prevention and Education program through Public Health Service Evaluation funds to support the evaluation of interventions and strategies to prevent sexual violence.

Meanwhile, the House has passed the National Pediatric Research Network Act of 2013 (H.R. 225), which authorizes the NIH NICHD to establish up to 20 National Pediatric Research 38 BRAIN INJURY PROFESSIONAL

Consortia to conduct pediatric research on rare diseases or conditions through basic, clinical, behavioral, or translational research and the training of researchers in pediatric research techniques. The legislation requires each pediatric research consortium to assist the CDC in the establishment or expansion of patient registries and other surveillance systems as appropriate and upon request by the CDC. The House has also prioritized passing the “Help Sick Americans Act”, which would defund the Prevention and Public Health Trust Fund, established in the health care reform bill, and use a share of the funds instead to help provide health care coverage to individuals with pre-existing health conditions. The high risk pools established in the health care reform bill were meant to help provide coverage for individuals with preexisting conditions until 2014 when coverage will begin through the Exchanges. The Administration suspended enrollment in the pools earlier this year after costs were higher than projected.

In March, the Congressional Brain Injury Task Force Co-chairs, Congressmen Bill Pascrell (D-NJ) and Tom Rooney (R-FL) announced the introduction of the Traumatic Brain Injury Reauthorization Act of 2013 (H.R. 1098) reauthorizing appropriations for FY 2014 -- FY 2018 for: (1) CDC projects to reduce the incidence of TBI, and to support TBI surveillance systems or registries; (2) grants to states and American Indian consortia to improve access to rehabilitation and other services; and (3) grants to state protection and advocacy systems to expand services to include persons with TBI. Initially passed in 1996, it is anticipated that the bill will be heard by the House Subcommittee on Health in the fall.

As the Senate failed to ratify the U.N. treaty on the Convention on the Rights of Persons with Disabilities last December, disability organizations are working to get the measure adopted. Although the treaty has been ratified by 130 countries, the United States -- a leader on disability rights -- has failed to do so. Over 500 national disability organizations and 22 veteran service organizations have joined in support for ratification. To learn more about the treaty go to the U.S. International Council on Disabilities website.

About the Editor

Susan L. Vaughn, S.L. Vaughn & Assoc., is the Director of Public Policy for the National Association of State Head Injury Administrators and consults with the Brain Injury Association of America on state policy issues. She retired from the State of Missouri in 2002, after working nearly 30 years in the field of disabilities and public policy. She served as the first director of the Missouri Head Injury Advisory Council, a position she held for17 years. She founded NASHIA in 1990, and served as its first president.

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Legal Representation Care Management Brain Injury Attorneys “In every serious injury case we have the opportunity to help make a difference in the recovery and the quality of life of our clients and their families that goes far beyond the legal scope.”

-Frank Toral, Esq., Senior Partner

Improving Lives through Caring, Commitment and Community Toral Garcia Battista Attorneys at Law firmly believe that the responsibility of a law practice is not simply a successful settlement but rather providing an individual who has suffered a lifealtering injury, the resources needed to lead a greater quality of life. Focusing on Traumatic Brain Injuries and Spinal Cord Injuries, the TGB firm structure supports care management in the medical and social elements of the clients’ situation through the employment of a team that includes a Registered Nurse and Licensed Clinical Social Worker.

The legal and care management team works collaboratively to address the comprehensive needs of the client and facilitate navigating the complex system of care.

The Toral Family Foundation, a 501(c)3 nonprofit organization based in Ft. Lauderdale Florida, is committed to collaborating with the healthcare community to improve the lives of all persons with a brain or spinal cord injury through research, education and access to resources. www.toralfamilyfoundation.org

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