TBI Exam
Complications
Edema • Herniation: shift of the brain through or across regions to another site, e.g., brain stem through foramen magnum • Ischemic damage due to displacement • Traumatic hydrocephalus & increased intracranical pressure Skull Fractures
Causes of TBI
MVA Falls Firearms Other (assault, sports, etc.)
Focal brain damage in TBI - contusions
• Contusions: Coup / Contra-Coup o Coup Injuries Damage to the brain at the point of direct impact to the skull The first contact - i.e.hitting head on dashboard; the coup is the bilateral frontal o Contracoup Injuries Injuries located on the side of the brain opposite to the direct impact i.e. the occipital lobes (as it bounces pack o **need to consider prominences - most often in the frontal and temporal • Tears of cortical surface on bony projections of ant. and middle cranial fossae o Epidural (between skull & dura) o Subdural (between dura & arachnoid) o Subarachnoid (between arachnoid & pia) o Intracerebral (within the brain tissue) • Or bruising • Not typically in rotational injuries
Explanations for attention deficits
• Decreased inhibition o Irrelevant information remains active and interferes with processing • Slowing o Perceptual, motor & cognitive speed slows o Products of past processing lost before they are needed for next task
Memory tx - external aids
compensatory strategies o Environmental & contextual manipulations (increase lighting, decrease distractions, eye contact (ties in with attn) , predictable schedules are good for procedural learning) o Adaptive devices (e.g., memory books, labels, reminders, graphic organizers, calendars, electronic devices) (e.g.,McDonald et al., 2011; Svoboda et al., 2012) o Sohlberg and Mateer (1989) memory book, calendar training, procedural learning o Svoboda and Richards (2009) Smartphone to increase recall of memories o McDonald et al. (2011) Google Calendar to improve prospective memory (remembering things in the future)
Attn External Aids
compensatory strategies o Environmental manipulations (simplify environment, increase lighting, decrease distractions) o Adaptive devices (e.g., reminders)
Incidence and Prevalence
o 1.5 million in the US each year o Death due to TBI 52,000 each year, most before reaching the hospital o Long-term Disability due to TBI 80,000 to 90,000 each year • Prevalence (survivors) o 2.5-6.5 million (NIH) o Approximately one-third of adults hospitalized with TBI need help with daily activities one year after their discharge
Falls
o 20-30% of TBIs o 0-4 yrs. & > 75 yrs. o Men=women in falls o Risk factors for 0-4: Not fully developed motoric ability Falling out of windows o Older adults: Winter = icy Shower Coordination = less, weaker, proprioception Medication, nutrition, eyesight (depth perception)
MVA
o 50% of TBIs o Leading cause among whites in U.S. o 15-19 y.o. o 2.4:1 male: female ADHD/LD with males = could contribute to higher incidence
Penetrating Injuries
o Comes from outside and goes through the skull and enters the cerebrum o Missiles: bullets, stones, fragments etc. o Injuries and deficits tend to be focal o Destroys tissue directly in the path, but also around the path o Through-and-through wounds -- entry and exit o Penetration at the lower levels of the brainstem > death from respiratory and cardiac arrest o About 80 percent of patients with through-and-through injuries die at once or within a few minutes o Swelling, edema
Closed Head Injury
o Concussion o Chronic Traumatic Encephalopathy o Blast Injury Acceleration Injury (moving head trauma) Non-acceleration Injury
Focus of rehabilitation
o Education (family & patient) o Behavior management o Cognitive training o Community reentry
Incidence of Concussion
o Estimated 1.6 to 3.8 million concussion yearly per CDC o Some studies suggest that females are twice as likely to sustain a concussion as males o Sports, MVA, Accidentally being stuck, assaults, etc. o Estimated that only 1 in 6 concussions are diagnosed
Attn Simulated Functional Tasks
o Finding phone numbers, navigating a map o +/- distraction
Memory tx - simulated functional tasks
o Finding phone numbers, navigating a map o +/- distraction
Positive Behavior Supports
o Focus on positive consequences o Set up positive experiences....and repeat them Easy tasks with high level of success before any difficult task Sufficient assistance so that few errors are made Positive communication alternatives to challenging behavior (e.g, "I need a break.") o Provided in natural environment (home, work, school) by natural communication partners (family, work staff, peers)
Early Ax - Observation Rating Scales
o Glascow Coma Scale (GCS) o JFK Coma scale More for Ranchos 2/3 Going in periodically to see progression and tracking data on responsiveness If going down may be due to secondary medical sequalae; need to alert We would administer as a team with other professions and evaluate with other professionals to see progression
Symptoms of Post Concussive Syndrome
o Headache (85%) o Dizziness (70-80%) o Neck pain o Vision disturbances o Balance disruption o Tinnitus o Light/sound sensitivity o Loss of smell/taste o Sleep disturbance o Fatigue o Cognitive deficits • We can't determine the length of these symptoms based on initial presentation
Prognosis of Concussion looks like
o Improvements can frequently be seen in patients' symptoms in 2-4 weeks. However, it is not uncommon for symptoms to last 3 months or longer. In some cases, improvement may require a year or longer
Phase 1 of Concussion
o Initial impact caused by linear and rotational biomechanical forces that pull and twist neurons
Affective Changes
o Irritability o Restlessness o Anxiety o Depression o Mood Swings o Aggression o Reduced tolerance o Emotional Lability
High-Level Cognitive-Linguistic Assessment
o Medical Records Review o Patient Interview o Patient SO/Caregiver Interview o Combination of Formal and Informal Testing Measures o Observations of approaches to tasks/behaviors/symptom management
Cognitive Deficits of Concussion
o Memory - short-term memory, working, memory, new learning o Attention - difficulty with sustain, selective, alternating, and divided attention o Processing - slowed processing speed o Slowed Critical Thinking (executive functioning skills) o Limited cognitive endurance o Language - word-finding o Executive Functioning - Initiating, Planning, Organizing, Self-Monitoring, Time Management, Reasoning
Memory tx - re-integration
o Positive Everyday Routines
Attn Re-integration
o Practice in the real world
Informal Assessments Memory
o Recent memory: orientation, current events o Remote memory: personal history
Early Assessment: Direct Behavioral Observation Responsiveness
o Reflexive o Automatic o Generalized/ stereotypic o Purposeful o To command o Interactive
Who's involved
o Speech-Language Pathology o Neuropsychology o Physical therapy o Occupational therapy o Vocational rehabilitation o Counseling o Social work o Therapeutic recreation o Education
Acceleration Injury
o Sudden acceleration or deceleration of the head, brain & brainstem moving head strikes a stationary object stationary but unrestrained head head is struck by a moving object unrestrained head abruptly changes direction (e.g., whiplash) o Two types of acceleration result in different types of injury Linear acceleration: Angular acceleration:
Phase 2 of the Concussion
o The second injury involves the multiple neuropathologic processes that could evolve over a period of minutes to days. This explains why some symptoms may present hours or days after initial injury. o The brain is more vulnerable to a second concussion during this time of cell imbalance and energy crisis.
Formal Assessments Memory
o Wechsler Memory Scale (WMS IV, 2009) o Cognitive-Linguistic Quick Test (CLQT)—a few sections (verbal, visual) o Rivermead Behavioral Memory Test Assesses practical memory, remembering appointments, recognizing faces.
Neurological Changers in Concussions
o When neurons are pushed and pulled violently, the brain goes into an overactive state causing chemical imbalance. This results in decreased blood flow to the brain. o In order for the cells to restore homeostasis, they have to work harder to produce energy. o Potassium ions rush out of the cell and calcium rushes in.
The pt learns in CRT
o his/her specific cognitive impairments o to identify cognitive impairments in functional situations o tools/strategies to better manage cognitive deficits o to anticipate, prevent, and/or modify behaviors prior to functional breakdown of performance o In addition - symptom management skills
Attention Tasks with TBI
selective - distractable sustained - impaired alternating - slow to shift; impaired performance working memory - impaired
Lower Levels of Consciousness states
• Minimally Conscious State: (MCS +/-). inconsistent but reproducible responses to commands o [Coma Vigilant >>Vegetative State (continuous vs. permanent) >>] • Unresponsive Wakefulness: Eyes open to verbal stimuli, sleep-wake cycles exist, chew/swallow reflexively (Equivalent to Ranchos Level 2) • Coma: Eyes closed, nonresponsive (Ranchos Level 1) • Brain death: Flat EEG; unable to maintain cardiac or respiratory function or temperature control (chronic) • Tracking in JFK Coma scale • Use real objects, 1 step simple commands to establish reliable responses, choices, some want/needs
TBI Definition
• A nondegenerative, noncongenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairments of cognitive, physical and psychosocial functions with an associated diminished or altered state of consciousness • Has a very distinct recovery process
Concussion
• A transitory brain injury due to either a direct blow to the head or an indirect blow to the body (blasts) resulting in a disruption of the normal brain activity. • May or many not involve loss of consciousness (<10%) • A concussion is a subset of a mild brain injury (mTBI) o A trauma induced alteration in mental status that may or may not involve loss of consciousness o Confusion and amnesia are hall marks of concussion and may occur immediately after the blow to the head or several minutes later o Concussion equals mTBI but not all mTBI equal a concussion
Sample Goals for CRT
• Attention o The patient will anticipate possible situations and environments in which attention may break down and implement learned strategies and modify their approach • Internal Memory o The patient will use internal memory strategies for appropriate tasks to improve the encoding and retrieval process. o • External Memory o The patient will learn how to organize, maintain, and review a personal planner to track immediate and prospective plans. o • Executive Functioning o Patient will learn how to take a larger task and effectively and efficiently break the target task into smaller, more manageable parts. o o Goal-Plan-Do-Review o Time Management - Backward Chaining (end goal and work backwards) • Information Processing o Patient will learn how to improve reading comprehension skills by incorporating the SQ3R approach to reading. • Symptom Management o The patient will work within symptom threshold in order to better manage current symptoms and reduce overall headaches.
Aspects of attention
• Automatic (subconscious) • Controlled (voluntary) (Schiffrin & Schneider, 1977) • Modality/Sense o Auditory o Visual o Olfactory o Tactile o Kinesthetic
Higher Levels of Consciousness
• Conscious/Alert: Awake & oriented x 3 (person, place & time) (Level 6) • Confused: Disoriented, slow responses (Level 5) o Level 5 typically where you start treatment; level 3 tends to be too inconsistent; level 4 sometimes agitation gets too much in the way • Delirium/Acute confusional state: Disoriented, agitated, misperceives sensory stimuli, visual hallucinations, hyper- & hypoactive (Level 4) o Level 4 = agitated (both internally and externally) and confused o Not aware of safety o 1:1 aide permanently assigned o Now able to speak - may not be appropriate or productive • Lethargy/Somnolent: Drowsy, tangential or incoherent • Obtundation: Difficult to arouse, slow, sleepy • Stupor: Respond only to vigorous stimulation, only groan, grimace, mumble, or move restlessly • [Minimally Conscious State] • *Moving up states
Diffuse brain damage in TBI
• Neurons stretch and tear (linear acceleration) • Neurons twist and sheer [but don't break] (angular acceleration) • Diffuse Axonal Injury (DAI) o Axons swell, separate at swelling & degenerate o Spotty and microscopic damage, not seen on CT or MRI o Repair/collateral sprouting potential in milder cases • Often don't see diffuse damage in neuroimaging - typically assumed due to cause of the injury and presentation
Working Memory
• Not information that you're storing for STM or LTM • i.e. paying/calculating tip, remembering phone numbers, shopping list
GCS Scoring
• Observation • Score best response • Ratings o 13-15 =mild o 9-12 = moderate o 3-8 = severe • Coma/reduced consciousness = 3-8 (cannot score lower than a 3) • Measures "depth of coma" and severity of TBI • Charted frequently • Length of coma used as prognostic indicator • All physician done but important to know • Know ratings • Known to be a prognostic indicator
Assessing Memory
• Parameters to consider o Modality: Verbal vs. Non-verbal o Visuospatial sketchpad/phonological loop o Time frame: Immediate (ST, working), Recent, Remote o Recall vs. Recognition
Intervention tips (delirium & similar levels of consciousness)
• Patient and family education • Frequent reorientation • Personal environment • General environment • Close monitoring/reassess frequently
Treating Disorientation
• Person, place, time • Individual and/or group • Environmental prompts • Passive vs. active • Environmental control • Person - themselves (age, happened to them, in school, family members) and the family (defensive) patient/family education/counseling • Place - where they are (may be posttramautic amnesia) • Time - season, time of day • Numerous re-orientations • First objective - pt will be oriented x3 100% of the time • For orientation - calendar, whiteboards, books • Errorless learning, teachable moments, how to find out the answer rather than just telling them that they're wrong
Early Tx
• Pharmacologic o Edema o Seizures • Surgical o Hematoma excision o Skull fracture repair • Behavioral o Coma (sensory stimulation) Sensory stim - not proven to be efficacious, can still counsel family, but is NOT a formal tx approach o Delirium o Disorientation o Personality, mood & behavioral changes
Blast Injury
• Proximal causes: Improvised explosive devices (IEDs); land mines • 4 subtypes o Primary: pressure wave o Secondary: missiles o Tertiary: displacement of victim o Quaternary: burns, toxins • Loss of Consciousness: 36% • TBI/CNS symptoms: Headache, dizziness, irritability, irrationality, poor concentration, memory problems, apathy, lethargy, depression, anxiety • Other symptoms: ears, eyes, lungs
Emerging/Higher level Patients
• Quick review of higher cortical functions • Global Assessment: FIM, RLAS • Evaluation & treatment of cognitive domains o Attention & memory o Speech & language o Executive functions & awareness
Limited Cognitive Stimulation
• Reduce work/academic loads • Reduce driving • Avoid overly stimulating (light/noise) environments • Reduce electronic media
Memory impairments following TBI
• Retrograde (pretraumatic) amnesia: Minutes or less in TBI o So much time before the TBI • Anterograde (post-traumatic amnesia, new learning): days > weeks or longer • Procedural memory: relatively spared • Anterograde and retrograde amnesia have an acute onset and resolve at varying rates, both within an individual and from person to person. • In general memory deficits in TBI are one of the lasting residual problems.
Ranchos Los Amigos Scales
• Revised • Progression • 7 going into 8 discharge to outpatient • 8-9 outpatient tx • 10 reintegrating back to "normal" life
Orientation and Disorientation
• Sets the stage for everything else • Two most basic things at ranchos 5 - orientation and attention
Principles of Cognitive Rehabilitation
• Strive for effortless behavior • Errorless learning is ideal for success • Person-centered rehabilitation • Self-awareness • Generalization
Lower Levels of Consciousness
• Tends follow a predictive/systematic pattern (in terms of stages) according to level and brain damage • Counsel the family to talk to the patient, not about the patient - if need to talk about it go outside the room • Cannot provide treatment at the coma level (can last variable about time - is unpredictive in terms out getting "out") OR at Level 2 b/c very reflexive responses • The extent of the coma is sometimes predictive of a better recovery • MCS tends to be where we get referrals; might start to consider recovery to establish baseline behaviors/skills; assessment
Memory
• The acquisition, storage and retrieval of new information. • Learning = acquisition • Memory = persistence and storage of information over time Forgetting = losing stored information or having difficulty retrieving itq
Glasgow Coma Scale (CGS) (Teasdale & Jennett, 1974, Lancet, 2, 81-84)
• Upon admission to the ER • ~APGAR score • Lowest score is a 3 = means they're in a coma • Eye Responses o No eye opening (1) o Eye opening to pain (2) o Eye opening to verbal command (3) o Eyes open spontaneously (4) • Verbal Responses o No verbal response (1) o Incomprehensible sounds (2) o Inappropriate words (3) o Confused (4) o Oriented (5) • Motor Responses o No motor response (1) o Extension to pain (2) ("decerebrate" posturing) o Flexion to pain (3) ("decorticate posturing") o Withdrawal from pain (4) (general withdrawal) o Localizes pain (5) (appropriate withdrawal of limb, body part) o Obeys Commands (6)
Immediate memory assessment
• Verbal: digits, words • Non-verbal: Knox cubes, WAIS/WMS blocks o Forward & backward
Concussion *from laura
• Violent shaking of the brain, resulting in functional impairment • Causes: Fights, falls, crashes, sports • Sex ratio: Male 2:1 • Signs & symptoms o Physical: Headache, nausea, balance, visual fatigue, light/noise sensitivity, dazed o Cognitive: "Foggy," decreased concentration, forgetfulness, confusion, slow o Emotional: Irritability, sadness, nervousness, emotional o Sleep: Drowsiness, sleeping more/less, difficulty • Can result in impaired consciousness or coma • Categories o Simple concussion: progressive recovery in 7-10 days o Complex concussion: recovery takes longer than 10 days or is complicated by recurrence of symptoms, extended loss of unconsciousness, etc. o Grade 1: Confusion resolves < 15 minutes, no LOC o Grade 2: Confusion lasts > 15 minutes, no LOC o Grade 3: Any LOC o Often described by use of adjectives and modifying features rather than those categories
Dx Assessment of Concussion
• Woodcock Johnson IV (WJIV) • Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES) • Cognitive Linguistic Quick Test (CLQT) • Test of Everyday Attention (TEA) • Behavioural Assessment of the Dysexecutive Syndrome (BADS) • Wechsler Memory Scale(WMS-R) • Boston Diagnostic Aphasia Exam (BDAE)
Recent memory Assessment (new learning)
• Words o Word lists o Common objects o Paired Associates • Visual o Visual figure memory - designs o Complex Figure Task (Rey) o Hidden objects in space • Memory for faces • Story recall • Visual auditory learning subtest in the woodcock Johnson test of cognitive ability
Working Memory Ax
(Immediate storage + processing) • Backward digits/months/days • Digit/month ordering • Listening span (responding to truth of sentence while remembering the last word of the sentences in a set for later recall)
Nonacceleration Injury
(fixed head trauma): moving object strikes a restrained head
JFK Coma Scale
- Form the John F Kennedy rehabilitation hospital in NJ - More for Ranchos level 2 and 3 (opposed to coma) - Trying to determine how well they're following visual or auditory information, motor, communication, arousal etc - Not used daily, about every 5-6 days to see if they're progressing - Track data - Expect some variability - If there is a decrease then there is some secondary sequellae etc or some other medical issue happening to cause the decrease (variety of issues) - Completed by SLP - We use this for monitoring progress - But we need to know information about GCS as well - Areas of rating: o Auditory Function scale: o Visual function scale: o Motor function scale: o Oromotor/Verbal function scale: o Communication scale: o Arousal state: o Total score
Metacognition
: Thinking about one's own thinking and knowledge • Throughout treatment, patients are taught to think about HOW they think • The patients are encouraged to demonstrate understanding strategies, how to modify them to fit different situations, and be able to continually evaluate the overall success of the strategy
Memory tx - restorative
Direct memory training, repetitive exercises o Depth of processing tasks (rehearsal & mnemonics) Rehearsal Chunking, organizing Visual associations (he has a mustache, his name begins with M) Semantic elaboration/chaining (making up a story) ?other mnemonics o Spaced retrieval o Memory games (e.g., Simon, Concentration)
Atten Metacog
: Awareness, self-evaluation, discussion of strategie
Levels of Attention
Arousal Alertness, readiness to respond (starting to be awake) - Ranchos 2 Orientation - Ranchos 3 Selection/focused - Ranchos 4/5 Sustained - ranchos 5/6 Alternating - Ranchos 8/9/10 Divided - Ranchos 8/9/10
Memory tx - metacog
Awareness, self-evaluation, discussion of strategies o PQRST (narratives) (Wilson, 1987) (Preview, Question, Read, State, Test)
Assessment of Alternating Attention:
Changing Focus
Retrospective Memory
Declarative -semantic -episodic Procedural -action related
Attn Restorative
Direct attention training, repetitive exercises * hierarchal o Sustained - simple cancellation tasks o Selective - cancellation tasks with distraction o Alternating - cancellation task with change-orders interspersed o Divided - cancellation task with 2 different simultaneous criteria
Brain Damage - memory
Hippocampal damage: impaired formation of new declarative memories Frontal lobe damage: Inattention, poor STM • b/c the central executive isn't choosing to hold onto the information to be stored in STM Damage to the diencephalon (thalamus, hypothalamus): Impaired learning and retrieval • Impaired new learning and retrieving it - b/c it was never stored in the first place
Ranchos Levels
Level 1: No Response, Total Assistance Level 2: Generalized Response, Total Assistance Level 3: Localized Response, Total Assistance Level 4: Confused-Agitated, Maximal Assistance Level 5: Confused-Inappropriate, Non-agitated, Maximal Assistance Level 6: Confused-Appropriate, Moderate Assistance Level 7: Automatic-Appropriate, Minimal Assistance for Routine Daily Living Skills Level 8: Purposeful & Appropriate, Standby Assistance Level 9: Purposeful and Appropriate, Standby Assistance on Request Level 10: Purposeful and Appropriate, Modified Independent
Ranchos Los Amigos I-III
Level 1: No Response, Total Assistance (coma) o NR to visual, auditory, tactile, proprioceptive, vestibular or painful stimuli - Level 2: Generalized Response, Total Assistance o Responds to external stimuli with physiological changes generalized, gross body movement - Level 3: Localized Response, Total Assistance (minimally responsive) o Withdrawal or vocalization to painful stimuli; responds inconsistently to simple commands
Ranchos Los Amigos 4-7
Level 4: Confused-Agitated, Maximal Assistance o Alert and in heightened state of activity o Unable to cooperate with treatment efforts - Level 5: Confused-Inappropriate, Non-Agitated, Maximal Assistance (*** start therapy) o Able to respond appropriately to simple commands fairly consistently with external structure and cues - Level 6: Confused-Appropriate, Moderate Assistance o Attend to highly familiar tasks in non-discriminating environment for 30 minutes with moderate redirections o Shows carryover for relearned familiar tasks (e.g., self-care) o Consistently follows simple directions - Level 7: Automatic-Appropriate, Minimal Assistance for Routine Daily Living Skills o Does familiar tasks in a non-distraction environment for at least 30 minutes with minimal assistance o Monitors accuracy and completeness of each step in routine personal and household ADLs o Unrealistic planning for future o Unable to think about consequences of a decision or action o Overestimates abilities o Unaware of others' needs and feelings o Unable to recognize inappropriate social interaction behavior
Tx of Attn
Metacognitive Restorative External Aids Simulated Functional Tasks Re-integration
Tx of Memory
Metacognitive Restorative External Aids Simulateed Functional Tasks Re-integration
Severity ratings for TBI DSM V
Mild TBI Moderate TBI Severe TBI Loss of consciousness <30 min 30 min-24 hours >24 hours (coma for at least 1 day) Post-traumatic amnesia <24 hours (after accident) 24 hours-7 days >7 days Disorientation and confusion at initial assessment (GCS) 13-15 (not below 13 at 30 minutes) 9-12 3-8
Sub-categories of traumatic brain injury (TBI)
Penetrating Injuries Closed Head Injuries
Attn deficits in Tbi
Selective - Distractible Sustained- Impaired Alternating/Divided - Slow to shift, impaired performance Working Memory - Impaired
Attn tasks and age effects
Selective - Span - Little effect Sustained - Vigilance - Decrease with age (elderly people have trouble sustaining attention and holding it through a task) Divided - Dual tasks - Aging effects individuals in dual tasks (aging effect on 1 of the 2 tasks - 1 task can stil be done well) Working Memory - Storage and processing - Storage is okay; storing and processing causes problems
Attention Tasks Normal
Selective - span - little age effects sustained - vigilance - decrease with age divided - dual tasks - interference with age working memory - storage and processing - storage ok with age, storage and processing causes problems
Assessment of sustained attention:
Trail Making
Linear Acceleration/Translational Trauma
propels head on a linear path [and comes back - front/back or side/side] • Translational trauma: injuries at site of impact and opposite (coup-contrecoup)
Angular Acceleration
rotation of head and brain/twisting of midline structures (basal ganglia, brain stem) • Tends to be worse - tends to have a higher relationship to a loss of live/more damage
Cognitive Rehabilitation Therapy (CRT)
• Designed to help individual develop skills and learn compensatory strategies to improve how they function at home and at work as it relates to their cognitive deficits (e.g. problems with attention, learning new information, memory, and problem-solving). • The goals of CRT, as defined by the National Institutes of Health are to "enhance the person's capacity to process an interpret information and to improve [his/her] ability to function in aspects of family and community life." • "Although CRT may incorporate interventions directed at the person's emotional and psychosocial functioning when these issues relate directly to the acquired ...dysfunction, they are not the service's sole focus." o Language - Receptive and expression language skills o Speech - Dysarthria/motor Speech o Dysphagia - Swallowing Concerns o Cognition - Attention, memory, decision making/problem solving, and information processing • 1x/week for approximately 1month
Instructional Approaches in Cognitive Rehabilitation
• Direct instruction o explicit practice, clinician presentation of new material, modeling and sequencing of steps, systematic feedback • Metacognitive instruction o focus on self-monitoring and self-assessment; comparing performance with goals • Spaced retrieval o uses implicit memory & errorless learning • Creating positive routines o task analysis to prevent erroneous responses/maladaptive behaviors
Associated features supporting diagnosis of TBI (DSM-5)
• Disturbances in emotional function (e.g., irritability, easy frustration, anxiety, affective lability) • Personality changes (e.g., disinhibition, apathy, suspiciousness, aggression) • Physical disturbances (e.g., headache, fatigue, sleep disorders, vertigo, tinnitus, hyperacusis, photosensitivity, anosmia, reduced tolerance for medications) • Neurological symptoms (e.g., seizures, hemiparesis, visual disturbances, cranial nerve deficits) • Orthopedic injuries
Early Assessment: Direct Behavioral Observation Domains
• Domains (italicized for other professions) o Communication o Swallowing (often an NG tube at first) o Cognition o *Physical status o *Positioning o *Tone o *Endurance o *Functional attention o *Safety o *Bowel/bladder o *Skin integrity o *Respiratory/tracheostomy
Post Concussive Syndrome
• Effects last for a variable time (seconds, minutes, hours.....longer) • No evidence of structural changes on CT or MRI • Mild form of diffuse axonal injury • 3 or more: headache, dizziness, fatigue, irritability, difficulty with concentration and performing mental tasks, impairment in memory, insomnia, reduced tolerance to stress, emotional excitement or alcohol • Presence of cognitive, physical or emotional symptoms of a concussion lasting longer than expected, with a threshold of 1 to 6 weeks of persistent symptoms after a concussion to make the diagnosis • Neuroimaging (CT or MRI) typically do not detect damage. • Impact on widespread regions of the brain • Acute clinical symptoms largely reflect functional disturbance rather than a structural injury
Principle of choice & control: prevent the problem before it happens (Ylvisaker)
• Eliminate provocation for negative behavior e.g., unreasonable demands • Ensure orientation to setting and task (e.g., daily routine) • Teach functional alternatives to negative behavior • Establish scripts and positive social roles • Reduce stress by ensuring that tasks can be accomplished • Manage anxiety (teach relaxation) • Decrease sensitivity to stressors
IDEAL Candidates for CRT
• Exhibit high level cognitive impairments • May be working or planning to go back to work or school • Have some awareness that cognitive deficits are impacting functioning in the home and/or workplace • Capable of assuming responsibility to take the strategies learned during therapy and implement them in everyday life. This includes completion of home assignments and regular attendance
Patient Recommendations of Concussions
• Follow up with Neurologist to better elucidate etiology of current strength and weakness profile • Follow up with a neuropsychologist to receive a comprehensive neuropsychological evaluation • Follow up with a psychologist/social worker who provides cognitive behavioral therapy (CBT) • Participate in a course of cognitive rehabilitation therapy (CRT) to address cognitive concerns revealed in the initial assessment.
Assessment through the continuum of care to independence
• Functional Independence Measure (FIM) • Rancho Los Amigos Scale (Level of Cognitive Functioning Scale) • Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)
Mechanism of brain damage in TBI
• Going 80 mph (i.e., the car, you, all of your internal organs) • Hit a tree; car stops • You keep moving until something stops you • Windshield stops your head • But your skull/brain keeps moving • CSF can't absorb enough energy to prevent your brain from being injured • So inner surface of cranium stops your brain • The resulting blow to the cerebral matter sends "shock waves" though it • Brain will continue to "rock/bounce" back and forth on the brain stem until the energy has dissipated
Elements of a description of a traumatic brain injury
• How it happened o motor vehicle accident (MVA), gunshot wound (GSW), fall... • Primary injuries that happen at the time of trauma o e.g., +/- skull fractures, location of impact • Secondary injuries that evolve subsequent to the initial trauma o e.g., Hydrocephalus • Neurological o e.g., Focal vs. diffuse; contusions, hematoma
Assessment of Selective Attention: Ignoring irrelevant information
• Letter or digit cancellation • Digit-symbol substitution • Looking for attention rather than left neglect in RHD • - Distractability
Linear/Acceleration Concussion
• Linear Acceleration Concussion • Rotational Concussion: A concussion can be caused by rotational forces, which twist the brain - causing diffuse axonal shearing.
Informal Dx Measures of Concussions
• Math Problems o Short term memory and problems solving • Deductive Reasoning Skills o Information processing, memory, attention • Sequencing Tasks o Making eggs/constructing a cohesive sentence • Reading Tasks o Time to read, processing, attention • Approaches to formal Diagnostic Assessments
