Traumatic Brain Injury: Understanding Recovery Process

1. Traumatic Brain Injury - III Scott S. Rubin, Ph.D. SPTHAUD 6464

2. Recovery • A multi-stage process • Continues for years • Differs for each person

3. Recovery

4. Recovery • Traumatic brain injury (TBI), stroke and other acquired brain injuries (ABI) have variable outcomes affecting many areas, each to a different degree. • Recovery from TBI or stroke takes years, often requiring extensive rehabilitation.

5. Recovery • Rehabilitation professionals need a way to find out which are the areas in greatest need of rehabilitation, to improve daily functioning and lessen the impact of the brain injury on family members.

6. Recovery • To discover where people are having problems, you should ask them. However, they may not be able to recall all problems on their own and may need to be asked about specific areas.

7. Recovery • Rehabilitation should be able to demonstrate gains to clients, family and funders.

8. GLASGOW OUTCOME SCALE • Good recovery: the capacity to resume normal occupational & social activities, although there may be minor physical or mental deficits. • Moderate disability: (disabled but independent) able to look after himself at home, to get out and about to shops & travel by public transport. Some previous activities, at work or in social life, no longer possible by reason of either physical or mental deficit.

9. GLASGOW OUTCOME SCALE • Severe disability: (conscious but dependent) needs assistance of another person for some activities of daily living every day. Ranges from total care to assistance with only one activity-dressing, going out to shop. • Vegetative State • Dead

10. The Prognosis • Interview with family (and patient?) • Extensive chart review • Weigh the factors…

11. Mild injury 0-20 minute loss of consciousness GCS = 13-15 PTA < 24 hours Moderate injury 20 minutes to 6 hours LOC GCS = 9-12 Severe injury > 6 hours LOC GCS = 3-8

12. Prognostic Variables • Post-Injury Factors • Early Medical Intervention • Early Rehabilitation • Long-term Supports • Individual Resilience, Effort, and Adjustment

13. Factors influencing outcome • Nature of Brain Injury • unilateral vs. bilateral/ brainstem • extent of brain damage • Premorbid health(physical & mental) • Family support

14. The Prognosis • Pre-injury Factors • Social Adjustment • Neurological integrity • Knowledge Base

15. Post Head Injury Behaviour • Premorbid Factors • mental constitution • personality • antisocial behaviour • alcohol/ substance abuse • family dynamics “It is not only the kind of injury that matters, but the kind of head” Symonds 1937

16. Recovery • Duration of Coma. The shorter the coma, the better the prognosis. • Post-traumatic amnesia. The shorter the amnesia, the better the prognosis. • Age.  Patients over 60 or under age 2 have the worst prognosis, even if they suffer the same injury as someone not in those age groups

17. Recovery • Knowledge of Disorder – needed to deal with treatment.

18. Recovery • Other Prognostic Indicators… • Standards you should know! • Class???

19. PHYSICAL Falls Pressure Sores Urinary infection Chest Infection Musculoskeletal Epilepsy DVT - deep vein thrombosis Constipation PSYCHOLOGICAL Communication dysphasia/intelligibility Cognition confusion/memory Behaviour agitation/apathy Emotion depression/lability Prevent complications

20. Delayed Consequences of TBI • Neurological Development • Increasing Failure • Restrictions

21. Permanence of change? • Physical recovery • Reeducation of the individual • Environmental modifications

23. Therapy Effectiveness? • Wilson (1997) provided direct evidence of the effect of compensatory cognitive devices (notebooks, wristwatch alarms, programmed reminder devices) on the reduction of EMF’s for persons with TBI

24. Therapy Effectiveness? • Helfenstein (1982) provides evidence that compensatory cognitive rehabilitation reduces anxiety, and improves self-concept and interpersonal relationships for persons with TBI

25. Review of Terminology: Memory • Short-term • Long-term and Active • Working memory • Learning, comprehending, and reasoning

26. Memory • Autobiographical • Episodic • Procedural • Topographical • Sensory • Visual • Auditory • Etc • continued

27. Memory • Lexical • Semantic – • Concept • units • Proposition • relationships • Schmata • Large pictures

28. Memory

29. Schemas • Schemas have Variables • The variables include concepts and propositions. • Schemas can embed one within another • Schemas represent knowledge at all levels of abstraction • Schemas represent knowledge rather than definitions

30. Communication and Memory • Automatic or Effortful Retrieval • Automatic – Include priming • Effortful • Slow interactions • Socially distracting • Repetition • Social breakdowns • Inefficient encoding • Impacts return to school/work • Missed appointments, medicines, activities • Social withdrawal

31. Types of Activation Types of Activation • Serial • Serial Activation of Systems • Parallel • Parallel Activation of Systems

32. Types of Activation • Bottom-up

33. Types of Activation • Top-down

34. Types of Activation • Horizontal Activation

35. Assessment in Traumatic brain Injury

36. Assessment • Assessment crosses all areas of speech, language, and cognition. • TBI patients don’t have aphasia… see other causes. • Quote Audrey Holland: TBI usually “don’t look like aphasia, sound like aphasia, act like aphasia, feel or taste like aphasia”

37. Assessment • Quote from Wertz • “Aphasic patients usually communicate better than they talk, and TBI patients frequently talk better than they communicate”. • Think about what you are evaluating

38. This just in… • SaveTerri.biz pointed out that further examination of the MRI reveals an anomaly in Schiavo's left cerebral hemisphere that closely resembles the Virgin Mary, triggering blog-a-lanch the likes of which the Internet has never seen.

39. Schiavo MRI

40. Evaluation • To Answer Consult • Chart Review • Interviews (pt and family?) • Screenings • Coma Scale? • Next up - Screenings

41. Screenings • What should you have in your lab coat? As we discuss each area of screening – think about what materials you need with you… now – on to the areas!

42. Evaluation - Screening • Orientation (or Mental Status) • Oriented X 3 • Following is in reverse order of vulnerability of disruption. • 1. Person • 2. Place • 3. Time

43. Evaluation - Screening • Language Screening – • Particular tasks to screen language… think about the specific behaviors used in aphasia categorization.

44. Evaluation - Screening • Motor Screening • Structures to examine? • Tasks? • What are you screening for? • i.e., the presence of what?

45. Evaluation - Screening • Right hemisphere Screening • Language aspects in right hemisphere? • Specific non-dominant hemisphere abilities • Attn? • Memory?

46. Evaluation - Screening • Derive Coma Level (if appropriate) Rancho? Glasgow?

47. Ross Information Processing Assessment • RIPA or RIPA-G • RIPA-2 (now standardized) • RIPA-G (geriatric) standardized • Materials needed: • Picture book • Test Form • See next slides for content

48. RIPA; RIPA-G • Areas of Assessment • Immediate Memory • Recent Memory • Temporal Orientation • Spatial Orientation • Orientation to Environment • Recall of General Info • Problem solving and Abstract Reasoning • Organization of Info • Auditory Processing and Comprehension • Problem Solving and Concrete Reasoning • Supplemental Subtests • Naming Common Objects • Functional Oral Reading

49. RIPA • + fairly quick test • + gives rough profile of patient’s processing skills • + scaled scores strengths and weaknesses within subjects and percentiles among other TBI patients • + reliable and valid with older adults, easy to administer

50. Communication Activities of Daily Living • CADL-2 • Standardized • Materials Needed: • Picture Book • Patient Response Booklet • Test Form • Areas of Assessment • Social Interaction • Divergent Communication • Contextual Communication • Sequential Relationships • Nonverbal Communication • Reading, Writing, and Using Numbers • Humor/Metaphor/Absurdity