TBI and RHD

Under what age is TBI the most common cause of brain damage?

Under 40 years

What is the most common population you will see TBI in?

Young men in motor vehicle accidents

What is the prototypical TBI patient?

young, male, late teens, substance-use, lower SES, and premorbid personality issues (disinhibition)

True or false - causes of TBI vary between age groups

True

What is the most common cause of TBIs for older adults?

A fall

What are the risk factors for TBI?

Age (younger), sex (male), substance-use, low SES, personality issues, previous TBI, sports

What are the four factors contributing to heterogeneity in TBI symptoms and outcomes?

Injury variables, environmental influences, individual's reaction to injury, individual's preinjury characterisitics

True or false - open head injuries often produced more widespread impact

False - open head injuries are often focal in nature and therefore produce focal (specific) symptoms (ex - Gabby Giffords)

True or false - aphasia is common in closed head injury

False - Closed head tends to be more general, damage is more diffuse

What are the two most common contusion sites for closed head injury?

Orbitofrontal and anterior temporal regions

What is the difference between coup and contrecoup lesions?

Coup - contusions are directly below point of trauma
Contrecoup - contusions are opposite of point of trauma

What are widespread microscopic lesions in the brain from TBI called?

Diffuse axonal injury

What is one of the functions of the orbitofrontal regions mentioned by Janet?

Executive function

What are secondary effects of a closed head injury?

Edema (increasing intracranial pressure), hemorrhages (intracerebral or extracerebral), ischemic brain damage, post-traumatic epilepsy, and hydrocephalus

What is the take-home message about the effects of TBI?

TBI causes very complex series of brain events and this complexity results in LOTS of variability between cases in initial symptoms and recovery course

How is coma used to determine prognosis?

The length (duration) nof altered consciousness/coma can indicate how well the person will recover

What is the general trend for coma duration and recovery?

Shorter comas, better recovery

True or False - good recovery means that the person returned to the way they were before the injury

False - likely to never to return to the same level as before the injury

True or false - coma means fully unconscious

False - it is not an all or none term (subjective term)

What is a coma considered?

A continuum

How long was the guy in the brain damage movie in a coma?

About 7 weeks

What assessment tool is most commonly used to assess comas?

Glasgow Coma Scale

Why is the Glasgow Coma Scale considered insensitive?

Two cases can have the same scores, but very different outcomes - there isn't a wide range to categorize impairments

What is the range for severe injury on the Glasgow coma scale?

3-8

What is the range for moderate injury on the Glasgow coma scale?

9-12

What is the range for mild injury on the Glasgow coma scale?

13-15

What kind of memory loss typically occurs following a TBI?

Post-traumatic amnesia (anterograde amnesia usually)

What is the pattern between post traumatic amnesia and memory scores?

The longer the PTA the poorer the memory (recall) score later on (the duration of PTA can be used to determine severity of injury)

True or false - only the kind of injury matter in determining outcomes and severity for TBIs

False - the kind of head matters too (pre-injury charactersitics)

What are some pre-injury characteristics?

Age, SES, Substance use, Cognitive function, Personality, Mental health, Physical health

True or false - Older individuals with a TBI recover better than younger

False

True or false - Lower SES tends to mean less or reduced recovery

True

True or false - When alcohol is in your system at time of injury it has no affect on your brain responds to the injury

False - Alcohol increases bleeding and ischemic events when it is in your system during an TBI injury and has a specific effect in how the brain responds to injury - it negatively affects recovery

What categories of behaviour are considered when scoring using the Glasgow Coma Scale? What does the scoring mean?

Eye opening (scored 1-4), Motor responses (scored 1-6), and verbal responses (scored 1-5) - the higher the score the lesser the severity

What are examples of environmental influences?

Familial, social, cultural, and physical
This encompasses the familial and cultural attitudes towards disability and how it affects the expression of symptoms and outcomes.

What are examples of an individual's reaction to injury?

This includes psychological effects, coping abilities, motivation, etc., which can all affect their recovery

What is the Rancho Los Amigos Scale?

It is a standardized way of analyzing cognitive function post-traumatic injury. It gives us the stages of recovery. Typically an 10-level scale, but textbook is just 8 levels.

How does the Rancho Los Amigos Scale rate cognition?

It rates arousal, responsiveness, restlessness (difficulties laying down new memories so very disorientated), attention, memory, and ECF

Which levels of the Rancho Los Amigos Scale are linked to comas state?

The first 3 levels are linked to coma state

At what level of the Rancho Los Amigos Scale does post-traumatic amnesia start?

The confused-agitated level

True or false - Everyone with a TBI will progress through all the levels of the recovery stages (Ranchos Los Amigos Scale)

False - Not everyone progresses through all the levels

True or false - As memory reconsolidates, TBI patients become less confused

False - they become more confused

What are the 8 stage of Recovery for TBI?

1. No response
2. Generalized response
3. Localized response
4. Confused-agitated
5. Confused-nonagitated
6. Confused-appropriate
7. Automatic-appropriate
8. Purposeful-appropriate

Which level does this patient appear to be in: still in coma phase, awake not following commands, unable to localize or attend to voice, has responses to pain, but they are delayed, and they are not completely unresponsive

Generalize response (Level 2)

Which level does this patient appear to be in: they are restless and confused, they can complete simple tasks with structure, they have increased restlessness and agitation, their emotions are changing rapidly, and in terms of arousal they are alert, but speech is incoherent

Confused-agitated (Level 4)

Which level does this patient appear to be in: their amnesia is resolved and their day to day recall is improving, they have decreased problem solving abilities and their speech is effortful and choppy

Confused-appropriate (Level 6)

Which level does this patient appear to be in: They are not the way they were prior to the injury, but have come a long way from their initial post-injury state. They have an increasing awareness of and can acknowledge their impairments, and they have developed compensatory methods for their memory deficits.

Purposeful-appropriate (Level 8)

What stage of the Ranchos Los Amigos scale might an SLP work with?

Stage 6 and up

What are the effects of a TBI on the cognitive process of attention?

Attention difficulties include: slowed information processing, and poor sustained attention - which can significantly affect learning, memory, pragmatics and other functions)

What two types of memory are primarily impacted in TBI?

Semantic and episodic

True or false - memory is impacted in TBIs as much as it is impacted in AD

False - memory difficulties are not as severe in TBIs as AD

Why might a TBI patient have difficulties with memory?

Because of their difficulties with attention - new memories are not being laid down as they are not paying attention in the first place

What are the two most common effects of TBI on cognitive processes?

Attention and memory difficulties

What are the effects a TBI has on the cognitive process of visuospatial skills?

Visuospatial difficulties include: scanning, spatial disorientation, and interpretation of complex scenes

What are the effects a TBI has on the cognitive process of linguistic skills?

Linguistic difficulties include: isolated deficits in naming or comprehension of complex materials (often arising from attention difficulties)

True or false - it is rare to have a traditional form of language impairment following a closed head injury (i.e., TBI)

True - more common for open head injuries

What part of the brain is frequently impaired because of TBI injury?

Executive functioning

What are some of the executive function areas that may be affected by a TBI (this is not all of them)?

Regulation of drives/impulses, emotional regulation, empathy/abstract attitude, judgement, planning and sequencing behaviour, goral formulation, metacognition, problem solving, control of memory and attention etc.

What is metacognition?

Ability to reflect on cognitive abilities and employ strategies to help them (learn to appreciate difficulties and work around them)

When someone has memory difficulties and they chose to write things down in order to remember - what executive function is this?

Metacognition

What is one important system that is impacted through diffuse axonal injury?

Projections to the subcortical structures and limbic system are impacted which is important for arousal, motivation, and executive control

What are the effects of TBI on subcortical and limbic input?

Reduced arousal (flat affect/sleepy; exacerbates attention and memory deficits), changes in emotional and motivational responses (irritability, anger, anxiety, depression, etc.) and executive dysfunction

What structure is the most important in arousal?

The reticular formation

What structures are the most important in emotional and motivational responses?

The amygdala and hypothalamus (limbic system)

How might someone with a TBI acquire executive dysfunction?

Subcortical-prefrontal cortex connection damage

How can a TBI affect stored knowledge?

Impairs further development of stored knowledge (i.e., concepts, scripts, conventions, interaction rules) and previously learned knowledge which particularly affects social interactions

What are the three ways TBI might impact communication?

Non verbal (prosody, affect, fluency), propositional (topic selection and maintenance, quantity of information etc.), and interactional (turn taking, social skills)

What component of Hartley's Model for Social Communication relies on all the other components of the model?

Comprehension of communication

True or false - right hemisphere damage (RHD) is only a result of TBIs

False - can be a result of varying etiologies (i.e., stroke, tumors), but TBI is most common cause

What does it mean that the population of RHD patients is heterogenous?

Diverse because of the varying causes of RHD

True or false - many functions are only associated with the RH and do not involve both sides of the brain

False - Many functions traditionally that were associated with the RH actually involve bilateral connections

True or false - Prosody only involves the right hemisphere

False - it involves both sides of the brain

Following RHD, what are the most common cognitive deficits?

Attention, neglect, perception, and learning/memory

Following RHD, what are the most common motor and sensory deficits?

hemiparesis and dysarthria

What causes neglect?

Damage to the parietal area (most often in RH - causing left-sided neglect)

What is neglect?

Failure to report or respond or attend to stimuli on the side of the body opposite to lesion, despite adequate sensory and motor function

True or false - It is more common to have right-sided neglect than left-sided

False - left-sided neglect is more common, it is rare to have neglect from LH damage

True or false - neglect only manifests in the visual modality

False - any modality (visual, auditory, somatosensory)

What often accompanies neglect?

Anosoagnosia

What is neglect dyslexia?

Misreading or omitting beginning of words or words on the left side of the page

What is a way to draw attention to the left side of the page for someone with neglect dyslexia?

Add a stimulus to draw attention to other side - needs to be a new stimulus each time

How can neglect affect communication?

Not noticing half of the group making group communication complicated, and can affect functional communication as well (reading menus, bank machines, grocery stores, etc.)

How can RHD affect visuoperceptual abilities?

Prosopagnosia (difficulty recognizing faces), difficulty with spatial judgement (orientation, distance, depth), and difficulty with scanning and tracking (affects reading and moving attention)

How can RHD affect linguistic production?

Reduced level of informative content (lots of irrelevancies, repetitiveness, confabulation, intrusive comments)

How can RHD affect linguistic comprehension?

Insensitive to relationships among events, difficulty judging appropriateness of events, difficulties in understanding inferences (literal interpretations of metaphors and humour)

How might a patient with Broca's aphasia differ from a RHD patient (when describing an assessment picture)?

Broca's aphasia would grasp what is going on and understand the general idea, but would have difficulties expressing what is going on and use content words. While RHD would provide a lot of irrelevant information and struggle to grasp the overall understanding of a concept or idea

How might a RHD patient demonstrate interpersonal and pragmatic deficits?

Inappropriate turn-taking, poor topic maintenance, and inappropriate social conventions

True or false - deficits can occur in both linguistic and emotional prosody, but emotional deficits are less prominent

False - Deficits can occur in both, but emotional is more prominent

What is linguistic prosody?

allows you to add stress to certain words to clarify meaning (e.g., make a question vs a statement)

What is emotional prosody?

the emotional tone in a message, communicates emotion

If someone with RHD has an emotional prosody production deficit, how would their speech sound?

Flat, robotic, monotone (it would not match the speech content)

How do RHD patients convey emotion if there are prosody deficits?

An increased reliance on semantic information

How might someone with emotional prosody comprehension deficits have difficulties in conversation?

Unable to identify mood in others' speech, interpret sarcasm, and often difficulties interpretating gestures and facial expressions.

How might someone with linguistic prosody production deficits sound?

Reduced variation in intersyllabic and inter-word pause times, reduced use of stress (for emphasis), and reduced use of pitch (question vs. statement)

How might someone with linguistic prosody comprehension deficits have difficulties in conversation?

Difficulty distinguishing parts of speech form one another based on stress patterns and difficulties determining sentence type from prosody