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Acquired brain injury (ABI) - ✅injury to the brain that is not hereditary, congenital, degenerative, or induced by birth trauma Traumatic Brain injury - ✅an alteration in brain function or other evidence of brain pathology caused by an external force Mild brain injury - ✅-AKA concussion -brief or no loss of consciousness -its presentation may demonstrate vomiting, lethargy, dizziness, and inability to recall what just happened Moderate brain injury - ✅-marked by unconsciousness for any period of time up to 24 hrs -will have neurological signs of brain trauma (skull fractures with contusion or bleeding and may have focal findings on and EEG/CT scan) Severe brain injury - ✅marked by a period of loss of consciousness of 24 hrs or greater Incidence/prevalence - ✅-13.5 million americans, 4.5% of population are living with brain injury -TBI is a contributing factor to a third of all injury-related deaths in the US -75% of TBI's that occur each year are mild TBI -2.5 million people sustain a TBI yearly Chronic conditions caused or accelerated by a TBI -
✅-aspiration pneumonia -seizures -septicemia -circulatory problems Continuum of care - ✅-acute rehab -post-acute rehab -long term home and community acute rehab - ✅-emergency department -icu -acute medical/surgical unit -specialty neuro trauma polytrauma post-acute rehab - ✅-comprehensive inpatient rehab hospital -sub-acute rehabilitation -transitional residential programming Long term home and community - ✅-home -snf -long term residential programming -outpatient and day treatment services -home and community based services -school and/or vocational rehab standards for rehabilitation facilities - ✅-person centered practices that focus on their health and safety
How to reduce disability from mTBI - ✅early intervention and management is the most effective way to reduce disability -rest and slow resumption of normal activities PPCS - ✅persistent post-concussive symptoms PPCS incidence - ✅10-15% have slow or incomplete resolution of symptoms PPCS treatment plan - ✅should: -begin asap -be symptom focused -be based off careful diagnosis -emphasize both functional resolution and compensatory strategies -provide an optimistic outlook and clear path for the patient to improve -be multidisciplinary CTE - ✅chronic traumatic encephalopathy -rare and progressive degenerative condition -DAI causes the release of Tau proteins and chronic inflammation -still working to identify who is at risk for CTE after mTBI -most do not develop CTE _____________ and ___________ compose the CNS - ✅brain and spinal cord brain -
✅-cerebrospinal fluid -meninges -composed of neurons (communicating) and glial (support/maintain neurons) cells neurons communicate via __________ - ✅synapses brain stem - ✅-three components (midbrain, pons, medulla) -located at the top of the spinal column -central point for all incoming and outgoing info and basic life functions midbrain - ✅-smallest part of the brain stem -involved in elementary forms of vision and hearing -plays a pivotal role in alertness and arousal Pons - ✅-rounded brainstem region between the midbrain and the medulla -connects the cerebellum and the cerebral cortex -essential for facial movement, facial sensation, hearing, and coordinating eye movements Medulla - ✅-merges with the spinal cord to create the base of the brain stem -serves as a control center for involuntary reflexes such as breathing, heart rate, blood pressure, swallowing, vomiting and sneezing -involved in many basic living functions--injury here is life threatening Reticular activating system - ✅-collection of nerve fibers within brainstem -modulates arousal, alertness, concentration, and basic biological rhythms
basal ganglia - ✅-receives input from the cerebral cortex, processes the info, and sends it back to the cerebral cortex -injury affects voluntary motor nerves causing slowness and loss of movement, tremor, and muscular rigidity cerebellum - ✅-located in the lower back section of the brain -coordinated and modulates all body movement -controls direction, rate, force, and steadiness of movements -injury causes problems with fine motor movement, trajectory of movement, balance and proprioception frontal lobe functions - ✅-planning -organizing -problem solving -judgement -impulse control -decision making -working memory temporal lobe functions - ✅-memory -language -hearing occipital lobe functions - ✅-visual processing -recognition of size, color, light, motion, and dimensions Spinal column -
✅-cervical spine (7) -thoracic (12) -lumbar (5) spinal cord - ✅-part of the cns -passes through the foramen magnum at the base of the skull into the vertebral canal -made of gray matter that is surrounded by white matter -31 pairs of spinal nerves types of imaging - ✅-computed tomography -magnetic resonance imaging -diffusion tensor imaging -functional mri CT - ✅-xray procedure that combines multiple x-ray images with the aid of a computer to produce cross sectional views and three dimensional images of the internal organs and structures in the body -used to identify anatomical changes (fracture, swelling, blood clot, hemorrhage) MRI - ✅-uses magnetic field, radio frequency pulses, and a computer to produce detailed pictures of organs, soft tissues, bone, and other internal body structures -provides better detail than a CT Diffusion tensor imaging - ✅-type of mri which uses the rate at which water diffuses between cells to provide information about the internal structures of the body -provides info about the connectivity of neural pathways Functional MRI -
✅-AKA dysautonomia -autonomic functions such as heart and respiratory rates, blood pressure, temperature, and perspiration are disrupted -may also present with muscle overactivity, posturing, dystonia, rigidity, and spasticity -usually resolves in early recovery DVT - ✅-deep vein thrombosis -occur when a blood clot forms in one or more of the deep vein in your body usually in the leg -can cause swelling, redness, of fever but can occur without symptoms -often occurs after immobility -without the use of prophylaxis a PE may occur and lead to death PE - ✅-pulmonary embolus -clot in the lungs Bladder issues - ✅-the brain is the control center for bowel and bladder function and when injured the regulatory systems in eliminating may be disturbed resulting in incontinence or accidents TBI and spinal cord overlap - ✅-SCI annual incidence is 12, -TBI present in 60% of individuals with SCI early post traumatic seizures - ✅-detection and treatment of EPTS are necessary in order to minimize the potential for secondary brain damage -occurrence of EPTS is a strong risk factor of the development of LPTS Cranial nerve damage - ✅may cause:
-visual disturbance -facial drooping -postural instability -dysphagia -autonomic dysregulation EPTS risk factors - ✅-severe brain injury -depressed skull fracture -penetrating head injury -hematomas -cortical contusion -post traumatic amnesia>24 hrs -chronic alcohol use -children and adolescent late post traumatic seizures - ✅-occur later than one week after initial head trauma -strong predictor of recurrent seizures lpts risk factors - ✅-similar to those for epts although they are less frequently seen in children and more frequently seen in people >65 years of age -the strongest risk factors are missle wounds, bilateral or multiple contusions and multiple craniotomies pain following TBI - ✅-can be in the form of orthopedic injury, headache, spasticity and contracture, heterotopic assification, myofasical pain, neuropathic pain or pain related to other medical conditions -can disrupt the rehab process with restlessness, agitation, non-compliance, and sleep disturbances -can be subjective and acute or chronic
✅-a subtype of tension type headaches associated with the temporal mandibular joint
- can be very debilitating causing patient to have difficulty with eating, talking Migraine treatment - ✅medications include: -triptans -non steroidal anti inflammatory drugs -ergot derivatives -atypical antipsychotics -narcotics dark, quiet room Spasticity - ✅-increase in tonic stretch with exaggerated tendon reflexes -sudden flexing or extending of a limb which is not voluntary -characterized by increased muscle tone, exaggerated tendon reflexes and clonus -occurs after damage to the upper motor neurons spasticity treatment options - ✅-remove irritating factors that may cause increased spasticity -oral antispasmodics -intrathecal baclofen pump -neurotoxins Heterotophic ossification - ✅-formation of new bone around joints as a consequence of trauma and/or immobility HO intervention - ✅-medications
-surgery may be required once the abnormal bone has maturated and maximal recovery has occurred hyperrfelxia - ✅involuntary exaggerated deep tendon reflexes contractures - ✅abnormal usually permanent condition of joints characterized by decreased range of motion, often in a flexed position, and fixation due to wasting away and shortening of muscle fibers and loss of skin elasticity pressure sores - ✅-form at areas of a bony prominence -are a concern for individuals with decreased mobility and their occurrence is correlated with dependence on others for ADL's -can be prevented by keeping skin dry and clean, changing position every 2 hours, using pressure relieving devices Perceptual deficits - ✅Body Schema/Body image -unilateral neglect -anosognosia (lack of awareness of paralysis) -right/left discrimination -somatoagnosia (lack of awareness of body structure and body part relationship) Spatial relation -form discrimination -spatial relations disorder -vertical disorientation -depth and distance perception Agnosia (inability to recognize) -visual object agnosia
✅-keep skin healthy -keep lungs and airway clear -keep bladder and bowel healthy Autonomic dysfunction syndrome - ✅-occurs in 15-33% of persons with severe TBI -an imbalance in the autonomic nervous system -signs are: dystonia, agitation, tachycardia, diaphoresis, hyperthermia, hypertension, tachypnea fatigue - ✅-the awareness of a decreased capacity for physical and mental activity due to imbalance in the availability. utilization, and restoration of resources needed to perform activity -it is a phenomenon no well understood so there are no well established treatments primary fatigue - ✅caused by injury or disease which affects the brain centers that control arousal, attention, and response speed secondary fatigue - ✅occurs from factors that exacerbate fatigue: -sleep disturbances -pain -stress -anxiety -depression measures of fatigue - ✅The Visual Analogue Scale for Fatigue (VAS-F) -Assesses fatigue and energy at a single point in time The Fatigue Severity Scale (FSS) -Assesses the impact of fatigue on daily function using 7 point scale
The Barrow Neurological Institute Fatigue Scale (BNI Fatigue Scale) -Assesses the difficulty level of energy and alertness The Global Fatigue Index (GFI) -Assesses four domains of fatigue-severity, distress, impact on activity and timing of fatigue The Causes of Fatigue Questionnaire (COF) -Assesses the extent to which physical and mental activities may cause fatigue causes of sleep disruptions - ✅-daytime napping -pain, depression, anxiety -possible disruption of the circadian rhythm and melatonin synthesis -changes in REM sleep treating sleep disturbances - ✅-lifestyle modifications -relaxation training -sleep hygiene education -medication -devices for apnea psychological fatigue - ✅-a state of weariness related to reduced motivation, prolonged mental activity or boredom that occurs with chronic stress, anxiety or depression -the is relevant as a high proportion of people with brain injuries experience depression and anxiety Interfering factors with cognitive function - ✅medical stability -medical issues, such as metabolic, pulmonary, endocrine, and sleep dysfunction can compromise cognition
✅-site and severity of damage -intelligence and learning style -pre-injury characteristics of personality -the current environment Behavior assessments - ✅-can be indirect (interview or fam) or direct (functional assessment) -direct are more reliable functional assessment - ✅-the goal is to understand the function the behavior serves for the individual in a situation -identifying the function of a particular behavior within a specific situation of interest is essential to the development and implementation of an effective behavior change procedure -a good assessment should include a list of behaviors that will be targeted for decrease and increase Principles of applied behavior analysis - ✅-goal is to discover variables that reliably influence behavior to predict behavior or promote behavior change -must consider the environment, the individual, and the target behavior behavior program elements - ✅-assess behavior -define target behavior -collect data -change behavior intermittent reinforcement - ✅-a particular response sometimes produces a reinforcer -produces greater variability in topography of behavior -utilized to promote generalization and maintenance of behavior -behavior is highly resistant to extinction -think hourly pay and slot machines
negative reinforcement - ✅-there is the removal of a stimulus -this increases the likelihood that the response will occur again negative punishment - ✅-there is a removal of a stimulus -this decreases the likelihood that the response will occur again positive reinforcement - ✅-there is the addition of a stimulus -this increases the likelihood that the response will occur again positive punishment - ✅-there is the addition of a stimulus -this decreases the likelihood that the response will occur again stability triangle - ✅-provides a guiding philosophy for the development of a comprehensive treatment plan -3 areas must be addressed in order for overall stability (medical stability, promote stable behavior, develop stable activity plan) an operational definition - ✅-behavior must be observable, measurable, and specific -consider topography and intensity -topography is what the behavior looks like physically -intensity is a description or measure of force Neuropsych assessment purpose - ✅provide a detailed description of the individuals abilities, strengths, and weaknesses, in various areas of functioning -completed in a standardized fashion using manualized procedures and normative data
