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Common Symptoms of ABI: Emotional/Behavioral
Irritability
Quick to anger
Decreased motivation
Anxiety• Depression
Social withdrawal
Does not get the "gist" of social interactions
May comment on or react to things that seem random to others
Behavioral changes
COMMON SYMPTOMS OF ABI: Cognitive and Communicative
Self monitoring and awareness Feeling dazed or in fog Disorientation Confusion Difficulty concentrating Slowed information processing Difficulty learning new information Difficulty with memory
Difficulty juggling multiple tasks
Executive functions Difficulty with concentration and attention Impulsive Task initiation
Difficulty understanding or producing language (aphasia)Slurred, weak, spastic, uncoordinated execution of speech(dysarthria)Difficulty with motor programming of speech (apraxia)
Reading fluency and/or comprehension
Writing formulation, spelling
Social communication (turn taking, maintaining conversational topics)
Communicating in "socially unacceptable" ways (pragmatics)
What causes traumatic injury?
falls
motor vehicle and pedestrian-related accidents
collision-related (being struck by or against) events• violent assaults
Sport-related injuries and explosive blasts/military combat injuries
incidence of TBI refers
the number of new cases identified in a specific time period
2010, 2.5 million diagnosed with TBI
Some statistics show a person suffers a mild traumatic brain injury (mTBI) or concussion
seconds in the U.S.
Most likely to sustain a TBI
Older adolescents 15-19 years
Young adults age 20-24
Adults aged 65 and older
Adults aged 75 and older have the highest rates of hospitalization and death
prevalence
refers to the number of individuals who are living with are living with TBI and related deficits within a given period of time
mortality brain injury
53,000 deaths per year
284,000 hospitalizations
2,214,000 ED visits
Once an individual sustains a TBI, he/she, is:
3x more likely to have a 2nd injury
8x more likely to have a 3rd injury
Women have a 1.6x more likely to have a poorer outcome compared to males
are more likely to experience Post Concussive Syndrome (PCS)
Are more likely to be cognitively impaired
Are more likely to have decreased reaction time after a sports-related injury
Are more likely to be diagnosed with post-injury depression Have a greater incidence of PTSD following ABI
TBI due to impact
Closed injuries
Open injuries
Lacerations, contusions (bruises) or intracerebral
hemorrhage to the brain (focal injuries)
Lacerations, contusions (bruises) or intracerebral
hemorrhage to the brain (focal injuries)
Can include coup-contre-coup injuries (initial blow/event, subsequent blow/event)
Can include Diffuse Axonal Injuries (DAI) (more diffuse
damage due to a shearing of axons)
Open injuries
Breach of meninges or skull
Result in focal injuries (hematomas or hemorrhage)
TBI due to intertia
Non-impact injuries
Result from acceleration-
deceleration forces
Can also result in coup-contre-
coup injury
Can result in DAI injury
Mild -mTBI or concussion
Usually not life-threatening
Effects can be serious
Can occur in any sport or reactivity
Frequently not diagnoses or mis-diagnosed (under-diagnosed)
Brief or no LOC
AOC moment up to 24 hours
GCS score 13-15
Vomiting, HA, sensitivity to light and sound
PTA 0-1 day
Often CT unremarkable or normal structural imaging
Moderate
LOC 30 minutes - 24hours
AOC greater than 24hours based on severity/other criteria
Neuro signs (skull fx, bleeding, bruising)
GCS score 9-12 PTA 1-7 days Normal or abnormal structural imaging
Severe
LOC 24 hours +
AOC• GCS score 3-8
PTA greater than 7 days
Normal or abnormal structural imaging
Statistics of mTBI
2010, 2.5 million diagnosed with TBI concussion/mTBI (1.1-1.8 million)
Some statistics show a person suffers a mild traumatic brain injury (mTBI) or concussion every 21 seconds in the U.S.• 2,651,581 children 19 years and younger were treated for sports and rec-related injuries between 2001 and 2009 (CDC).• Since that time, there has been both increase in participation in sport/rec-related activities for kids AND better diagnosis for concussion, and therefore, that number has increased by 57% in recent years.
Grade 1 - mild
symptoms last for less than 15 minutes, with no LOC
Grade 2 - moderate
smptoms last longer than 15 minutes, with no LOC
Grade 3 - severe
LOC even just for a few seconds
CVA
Stroke or cerebrovascular accident used interchangeably
One of the 3 major neurological causes of death and disability
Third leading cause of death in the USA
25% occur in patients less than 65 years of age
Hemorrhage or bleed:
Occurs when a blood vessel
weakens, tears, or bursts and blood leaks into
surrounding tissue
occurs when a blood vessel weakens, tears, or bursts and blood leaks into surrounding tissue
Most often occurs at the junction of vessels
most often occurs at the posterior/anterior communicating artery or the origin of the MCA• Intracerebral and subarachnoid = ~15% of strokes• 30% acute mortality
Ischemic/embolic
occurs when a blood vessel is blocked by a blood clot(thrombosis) or a atherosclerotic plaque
MCA (most commonly involved artery on either side)
Supplies most of the lateral surface of the frontal, temporal, and parietal lobes
L - aphasia, AoS, verbal learning impairments
R - visual spatial impairments, nonverbal learning impairments, impaired awareness of deficits, pragmatics, attention
36% suffer depression- more severe in left sidedn strokes, especially deep frontal lesions
PCA
relatively rare, bilateral thalamic strokes can result in very severe deficits of attention, MEMORY, apathy, flat affect confabulation, amnesia) (occipital and temporal lobes)
ACA
Communicating- connects the anterior cerebral arteries; part of the Circle of Willis
Glasgow Coma Scale (GCS)
tool to assess impairment of conscious level in response to defined stimuli - used in acute care settings
high score = mild TBI
Best Eye Response. (4)
No eye opening
Eye opening to pain
Eye opening to verbal command
Eyes open spontaneously
Best Verbal Response. (5)
(1) No verbal response
(2) Incomprehensible sounds.
(3) Inappropriate words.
(4) Confused
(5) Oriented
Best Motor Response. (6)
1. No motor response
2. Extension to pain
3. Flexion to pain
4. Withdrawal from pain
5. Localizing pain
6. Obeys commands
Ranchos Los Amigos
Revised Levels of Cognitive Functioning tool used in acute rehab settings
Attention includes...
Alertness and arousal (sustained brainstem or diffuse bilateral subcortical injury)
Resisting interference (distractions, selective, thalamus and frontal lobes)
time dependent form of memory
Short-term ( and working memory)
temporary
Long-term Memory (permanent)
Content-dependent form of memory (long- term)
declarative learning (explicit memory, free recall)
episodic and semantic
Nondeclarative (implicit and cued recall) procedural
Nondeclarative
Acquired and used unconsciously
procedural memory (i.e., remembering to perform some
action, such as how to get out of a chair, swallowing techniques);
Declarative Memory
Conscious recollection of factual information recent episodic memory (i.e., remembering recent personal events such as one's birthday, a dinner party)." semantic memory (i.e., remembering facts such as names of people and objects, current year, city and facility of residence room number)
Everyday Memory
Ability to carry out everyday intentions
prospective memory (i.e., remembering future appointments, activities or tasks, such as looking at a calendar, taking medication)
explicit memory
medial temporal lobe, diencephalon
facts (semantics)
events (episodic)
implicit memory
procedural memory
skeletal musculature
classical conditioning
emotional regulation
priming
attention sight of lesion (sol)
brainstem, diffuse, subcortical, thalamus, frontal lobe
common dx attention
TBI, frontal lobe damage, focal and diffuse damage
Content affected attention
Focused and Sustained attention Selective, alternating,(divided attention
Encoding (SOL)
Frontal, temporal, occipital lobes, thalamus, diencephalon
encoding common dx
Korsokoff's Bilateral thalamic strokes
content affected for encoding storage and retrieval
Episodic and semantic
storage SOL
Hippocampus; bilateral medial temporal lobes
storage common dx
Anoxia Herpes encephalitis Early Alzheimer's
retrieval SOL
Deep in the midial temporal lobes, semi-passive loop "holds" info
retrieval common dx
TBI, frontal lobe damage
semantic
a structured record of facts, concepts and skills that we have acquired (general facts and knowledge)
Episodic
our memory of events and experiences in a serial form. It is from this memory that we can reconstruct the actual events that took place at a given point in our lives(personal facts and experience)
amnesia
partial or total loss of memory
caused by brain damage, disease, or psychological trauma
caused temporarily by the use of various sedatives and hypnotic drugs
•either wholly or partially lost due to the extent of damage that was caused
Post Traumatic Amnesia (PTA)
Loss of memory for events AFTER the injury
Cannot recall events from moment to moment
Period of confusion following coma
Difficulty storing or recalling events
better prognostic indicator than length of com
Retrograde
Loss of memory for events PRIOR to injury (one doesn't remember shortly before accident because info. was in STM and never reached LTM)
Ideation
when the concepts we wish to express are generated
Symbolization
when these concepts are put into a symbolic system congruent with the rules of the speaker's language
Translation
when these linguistic units or symbols are translated into neuromotor commands that result in the innervation of the motor nerves
Execution
the actual movements of the speech mechanism
impairment at the ideation level will result in
mental- verbal dysfunction(or mental confusion, dementia, DOC, delirium
impairment at the level of the symbolization will result in
aphasia
impairment at the level of translation with result in
apraxia of speech
impairment at the level of execution will result in
dysarthria
motor area
controls of voluntary muscles
sensory area
skin sensations (temperature, pressure, pain)
frontal lobe
movement, problem solving, concentrating, thinking, behavior, personality, mood
Broca's area
speech control
temporal lobe
hearing, language, memory
brain stem
consciousness, breathing, heart rate
parietal lobe
sensations, language, perception, body awareness, attention
occipital lobe
vision, perception
Wernicke's area
language comprehension
cerebellum
posture, balance, coordination of movememt
frontal lobe functions
is considered the emotional control center and the home of our personality
Neurological Disorders Associated with Cognitive Impairments
ABI, TBI/mTBI, stroke, DOC, RHD, epilepsy, hypoxia/anoxia, poisoning, encephalopathy, encephalitis, brain tumors, dementia, PPA, ALS, FTD, Parkinson's, MS, depression, delirium
acquired brain injury (ABI)
is an injury to the brain that is not hereditary, congenital, degenerative, or induced by birth trauma. Essentially, this type of brain injury is one that has occurred after birth. The injury results in a change to the brain's neuronal activity, which affects the physical integrity, metabolic activity, or functional ability of nerve cells in the brain. An acquired brain injury is the umbrella term for all brain injuries.
two main categories of ABI
Traumatic - injury caused by external force
TBI/ mTBI = concussion (falls, car accident, injury/trauma)
Traumatic
Injury caused by external force falls, assaults, MVA, sports and rec, AHT/SBS, GSW, work-related, physical abuse/violence, military actions
2 primary mechanisms: Impact and inertia coup/contrecoup
•2 subcategories: open(penetrating) and closed (non-penetrating) head injuries
Non-traumatic
CVA (ischemic/embolic or hemorrhagic) Infectious disease
Seizure disorders Electric shock
Tumors
Metabolic disorders (insulin shock, kidney function)
Anoxia (near-drowning, strangulation, choking, heart attack)
Toxins (carbon monoxide poisoning)
Neurological Disorders Associated with Cognitive Impairments
3 primary dimensions of the injury/event/diagnosis include:
1. The distribution (how much of the brain was
affected): focal lesions, multifocal lesions, and diffuse
brain injury
2. Severity
3. Type of underlying pathology (cause)
Focal lesions
stroke, tumors, brain abscesses, focal trauma/penetrating injury (GSW)
Multifocal
multiple, distributed occurrence, such as in MID (multiple strokes) or TBI
Diffuse brain injury
rotational OR diffuse
axonal injury (DAI) TBI, hypoxia, metabolic or
infectious brain issues
Primary Injury
Primary damage
Mechanical damage
Secondary Injury
Cascade of physiological events
Delayed non-mechanical
processes (metabolic changes, cell loss, etc)
Cognitive
Feeling mentally foggy, difficulty concentrating and remembering, repeats questios
emotional
irritability, sadness, more emotional, nervousness
Common Sytmoms of ABI: physical
Dizziness and balance issues Weakness (paresis, paralysis)
Nausea, vomiting, vertigo
Headaches
Changes in vision and visual processing
Changes in hearing and auditory processing
Sleep disturbances
Fatigue
Seizures
Sensory issues (sound and light sensitivity,issues with taste, smell and touch)
COMMON SYMPTOMS OF ABI: COGNITIVE and COMMUNICATive
Self monitoring and awareness Feeling dazed or in fog Disorientation Confusion Difficulty concentrating Slowed information processing Difficulty learning new information Difficulty with memory Difficulty juggling multiple tasks Executive functions Difficulty with concentration and attention Impulsive Task initiation
Difficulty understanding or producing language (aphasia)
Slurred, weak, spastic, uncoordinated execution of speech(dysarthria)Difficulty with motor programming of speech (apraxia)
Reading fluency and/or comprehension Writing formulation, spelling
Social communication (turn taking, maintaining conversational topics)Communicating in "socially unacceptable" ways (pragmatics)
COMMON SYMPTOMS OF ABI emotional/behavioral
Irritability
Quick to anger Decreased motivation
Anxiety
Depression
Social withdrawal
Does not get the "gist" of social interactions
May comment on or react to things that seem random to others
Behavioral changes
What causes TBI
falls
motor vehicle and pedestrian-related accidents collision-related (being struck by or against) events
violent assaults
Sport-related injuries and explosive blasts/military combat injuries
How common is TBI and mTBI
2010, 2.5 million diagnosed with TBI
75% were concussion mTBI
every 21 seconds in the US
13.5 million people live with long- term disabilities
57 increase in sport related injuries due to better diagnosis
who is more likely to have a TBI
males
women are ___ times more likely to have poorer outcomes than males
1.6 times
TBI due to impact
closed injuries
laceration, contusions (bruises) or intracerebral hemorrhage to the brain
open injuries
open injuries
Breach of meninges or skull
Result in focal injuries (hematomas or hemorrhage)
Lacerations, contusions (bruises) or
hemorrhage to the brain (focal injuries)
coup
diffuse axonal injuries (DAI)
TBI due to inertia
non-impact injuries
Result from acceleration- deceleration forces
coup- contre- coup injury
DAI injury
3 levels of severity of TBI
mild, moderate and severe
mild- mTBI or concussion
not life threatening
effects can be serious
Can occur in any sport or reactivity
not diagnoses or mis-diagnosed (under-diagnosed)
Brief or no LOC
AOC moment up to 24 hours• GCS score 13-15
Vomiting, HA, sensitivity to lightand sound• PTA 0-1 day
Often CT unremarkable ornormal structural imagin
moderate TBI
LOC 30 minutes - 24hours
AOC greater than 24hours based on severity/other criteria
Neuro signs (skull fx, bleeding, bruising)• GCS score 9-12• PTA 1-7 days• Normal or abnormal structural imaging