traumatic brain injury (E2)

TBI

☆ damage to the brain caused by external factors

→ forces are generated when a moving object strikes the head or when the moving head strikes a stationary object

☆ TBI results in impaired cognitive abilities or physical functioning, and sometimes disturbs behavioral or emotional functioning

high risk activities

☆ boxing, football

→ high rate of diffuse brain injury

→ repeated brain trauma, multiple concussions

☆ motorcycling, bicycling, snowmobiling, rock climbing

→ helmets significantly decrease the risk of serious head injury

TBI may be a result from either an

☆ open or closed head injury

open (penetrating) head injury

☆ the skull is fractured and the meninges are torn

→ missiles (bullets)

→ sharp objects

→ blunt instruments (baseball bats, clubs)

closed (non-penetrating) head injury

☆ meninges remain intact and foreign substances do not enter the brain 

closed acceleration (moving head) head injury

☆ when the unrestrained (moving) head is struck by a moving object

☆ when the moving head strikes a stationary object

closed non-acceleration (fixed-head) head injury

☆ non-moving (fixed) head is struck by a moving object

☆ less damage than acceleration injury

closed head injury

☆ the anterior and inferior frontal and temporal lobes are most often injured

☆ this leads to widespread damage and some common traits among many TBI patients

primary consequences of TBI

☆ results of the forces exerted on the brain at the time of the injury

→ contusions (bruises)

→ lacerations (tearing of brain tissues)

→ axonal injury (stretching, tearing, and twisting of axons)

→ tearing of blood vessels (traumatic hemorrhage)

diffuse axonal injury

☆ damage to nerve-cell axons diffusely scattered throughout the brain substance

secondary consequences of TBI

☆ the brain’s physiological response to trauma

→ infection

→ hypoxia (oxygen deprivation)

→ edema (brain swelling)

→ increased intracranial pressure, causing herniation (shifted brain areas)

→ infarction (tissue death)

→ hematomas (bleeding - torn blood vessels)

severity of TBI

☆ mild TBI (mTBI)

☆ moderate TBI

☆ severe TBI

mild TBI

☆ patient initially loses consciousness for 15 min or less

☆ no memory loss or about the trauma/event

☆ patient may feel dazed, disoriented or confused

☆ AKA concussions

moderate TBI

☆ loss of consciousness from 15 min to a few hours, followed by a few days or weeks of confusion

☆ diffuse axonal damage spread throughout the brain and brainstem

☆ lacerations and contusions on the surface of the brain destroy brain tissue

☆ lacerated and torn blood vessels created hematomas

severe TBI

☆ loss of consciousness for 6 hours of longer

☆ extensive axonal damage throughout the brain and brainstem

☆ neuroplasticity contributes very little to recovery due to diffuse axonal damage throughout the brain

cognitive behavioral disturbances

☆ disoriented to time, person, situation, and place

☆ confused and agitated

☆ attention impairments

☆ memory impairments

→ pretraumatic memory loss

→ posttraumatic memory loss

☆ impaired cognitive skills

☆ executive function impairments

→ abstract thinking

→ reasoning

→ problem solving

→ inhibition

→ self monitoring

→ goal directed tasks

→ complex tasks

☆ socially inappropriate behaviors 

☆ reduced social-pragmatic skills

☆ slower processing speed

pretraumatic memory loss

☆ loss of memory for the events immediately preceding injury

posttraumatic memory loss

☆ loss of memory for the events immediately following injury

communication difficulties

☆ some aphasia-like

→ difficulty with word retrieval

→ decreased auditory comprehension

→ reading and writing deficits

☆ “confused” language

→ verbose, tangential

→ confabulatory (not true)

→ lacks logical sequence

☆ pragmatics 

→ inappropriate social interactions

→ difficulty with non-literal expressions

motor speech and swallowing problems

☆ dysarthria

☆ dysphagia

dysarthria

☆ speech disorder result of weakness or incoordination in muscles of the respiratory, phonatory, resonatory, or articulatory systems

prognostic indicators: impact assessment and treatment

☆ duration of coma

☆ duration of posttraumatic amnesia 

duration of coma

☆ deeper and longer lasting unconsciousness (coma) is associated with poorer eventual recovery

duration of posttraumatic amnesia

☆ the time following coma which the patient is unable to store new info and experiences in memory is inversely related to the patient’s eventual of recovery from TBI

rancho los amigos scale of cognitive levels-revised (RLAS)

☆ scaling baseline behaviors

☆ assessing recovery stages

scaling baseline behaviors 

☆ widely used scales that provide categories to which clinicians can assign brain injured patients based on patients’ cognitive and behavioral characteristics and independence level

assessing recovery stages

☆ clinicians assume that the time course of individual patients’s recovery follows RLAS levels

☆ some patients may stay in a particular stage for awhile, some move though stages quickly

stages of recovery (RLAS)

☆ total assistance-early stage (levels 1-3)

☆ maximal-moderate assistance-middle stage (levels 4-6)

☆ minimal assistance/level stage (levels 7 and above)

total assistance-early stage (levels 1-3)

☆ bed-bound, usually in ICU

☆ comatose or semi-comatose stages

☆ pt begins to respond to environmental stimuli minimally or inconsistently

☆ end of this stage, pt selectively responses to stimuli and follows simple spoken commands

☆ pts require intensive, full-time support

maximal-moderate assistance-middle stage (level 4-6)

☆ pts are alert and increasingly active but are confused, disoriented, and agitated. may try to get out of bed, exhibit aggressive behaviors

☆ most have difficulty organizing and executing even simple tasks

☆ end of this stage, pts are often oriented and less confused, and their behavior in familiar environments generally is goal-directed 

☆ pts require moderate but systematically decreasing levels of support 

minimal/assistance/late stage (levels 7 and above)

☆ at the beginning of this stage, pts have an adequate (sometimes fragile) orientation to important aspects of life 

☆ pt becomes increasingly dependent and adept at compensating for his or her residual impairments

☆ intervention focuses on refining skills needed for effective participation in everyday life

different aspects of assessment

☆ standardized assessments

→ choose assessments for TBI vs other neuro dx

☆ intervies and questionnaires

→ motivational intervies

→ patient reported outcomes

☆ observations in natural environment or contemplating specific types of tasks

→ ex: “party planning tasks”

cognitive linguistic quick test (CLQT)

☆ assessment of 5 areas

→ attention

→ memory

→ executive functions

→ language (naming)

→ visuospatial

☆ admin time is ~ 15-30 min 

cognitive impairments after brain injury

☆ aspects of cognition

☆ effect on behavior and language

aspects of cognition

☆ attention

☆ memory and learning

☆ organizing 

☆ problem solving

attention

☆ holding objects, events, words, or thoughts in consciousness

memory and learning 

☆ encoding: recognizing, interpreting, and formulating info

☆ storage: retaining info over time

☆ retrieval: transferring info from long-term to consciousness

organizing and reasoning

☆ analyzing and integrating and identification of relevant features of events; drawing inferences and conclusions; divergent thinking

problem solving

☆ identifying goals; considering relevant info and exploring possible solutions

rehab approaches

☆ restoration

☆ compensations

☆ accommodations

restoration

☆ repetitive exercises and activities designed to restore or improve damaged abilities

compensations

☆ tools and techniques (external aids) adapted to and used by the individual to allow functioning in spite of disabilities

accommodations

☆ changes in the shared environment of the individual which allow functioning in spite of disabilities

treatment considerations

☆ appropriate and realistic therapy goals

☆ stages of recovery

☆ individual differences

treatment for orientation

☆ instructions, prompts, and cues are given to help the patient understand who they are, what has happened to them, where they are

☆ cues are given to help patient ID the current hour, day, and year

pharmacological intervention

☆ medications are sometimes used to reduce patient’s agitated behavior

☆ sedative or antipsychotic drug to reduce agitation

☆ stimulant drugs to improve a lethargic pt’s alertness and attention and to facilitate rehab

☆ antidepressant medications 

awareness model

☆ anticipation

☆ emergent

☆ intellectual 

metacognition intervention

☆ behavior therapy

☆ counseling, psychotherapy

☆ strengths/weakness list

☆ self rating

☆ visual feedback

principles of cognitive-communicative rehab

☆ attention

☆ memory

☆ executive functions

☆ language skills

☆ extralinguistic skills

☆ pragmatics 

examples of cognitive-communicative rehab

☆ compensation/accommodations 

→ use external aids or modify environment to lessen the negative effects of impairments

→ use of appointment book or electronic device for impaired memory

→ taking resting breaks often for impaired attentkion

→ self monitoring

→ adjusting environment

appropriate and realistic therapy goals

☆ based on pts capacity and needs

☆ attention or memory deficits?

☆ functional needs?

☆ what is important to pt and family?

stages of recovery

☆ goals need to be appropriate to each stage of recovery

individual diffferences

☆ tailor each patients strengths, weaknesses, and interests

compensatory approaches

☆ memory 

memory

☆ external strategies 

☆ internal training

external strategies

☆ low tech (notebook, written planner, notes)

☆ high tech (computerized systems, apps)

internal training

☆ active listening

☆ restating