Curiosity, Dialogue, and Knowledge
To address short-term memory it is better to address underlying processes, this is the only strategy that allows you to evaluate and treat the entire problem.
Diplopia, double vision, is a commonly found problem with TBI clients; you can treat this by having client’s wear prism glasses.
Vision problems in general are very common with TBI.
You need to know this information because it can affect how you treat and the activates you do.
Strong correlation between length of time in a coma, and the severity of a TBI.
Slow process in recovery.
Hard to treat brain with drugs because of the blood brain barrier.
It is estimated that there is 1 TBI every 20 seconds, there are 1 million plus TBI’s every year.
TBI is called the silent epidemic.
Males ages 15-29 years old.
Male TBI occurs 3x more than female TBI.
Female TBIs often happen because they were the passenger of a male driver or were struck by a car driven by a young male.
Areas of Concern
# of TBIs in children under 4 are increasing.
And the # of TBIs in elderly people over 75 is increasing.
MVAs (motor vehicle accidents) are the primary cause of TBI; the increase of TBI caused by falls is true for the pediatric and elderly population.
Shaken baby syndrome
The 2 major mechanics that cause TBI are: 1. the impact of a moving object hitting a stationary head, and 2. the moving head hitting a stationary object.
This can often result in skull fracture, a simple line fracture of the bone or depression of skull – if this tears into the dura mater of the brain it’s an Open Head injury.
Depression of the skull that doesn’t tear the dura mater is called a Closed Head Injury.
The most serious injury is a penetrating injury because foreign objects can enter through the wound and can cause infection – also damage from bruising of the brain, swelling and lacerations cause further problems.
The more serious of the two main mechanics of head injury is #2, a head in motion striking a stationary object.
Coup – head striking a stationary object.
Contra coup – snap back, rebound of the head and the head hitting another stationary object in the opposite direction.
The brain is encased in meninges and CSF, these act as shock absorbers and as a buffer, but are not 100% effective.
Common Sites for Coup and Contra Coup Injury
Frontal lobe is the most common for the coup injury.
Temporal lobe is the most common for the contra coup injury.
Axonal shearing (aka DAI or diffuse axonal injury) – occurs when the head strikes the stationary object at an angle and causes the soft brain to torque itself and twist – axons will twist and stretch till they can’t anymore and they will tear, the more severe axonal shearing is the longer and deeper they will be in a coma.
The brain is plastic, the plasticity is better the younger the person is.
This is good for children with TBI.
When one area is impaired, another area takes over its jobs, better prognosis for children with TBI.
Controversy exists over whether or not therapy is effective or if recovery is just from spontaneous recovery.
Subdural hematomas – bleeding in the subdural space, often requires emergency surgery because it can be fatal. They are less frequent.
Epidural hematoma – this is a clot that forms between the skull and the Dura matter of the meninges. Result of a CHI, and are less frequent than subdural hematomas.
The most fatal two hematomas:
1. Subarachnoid hematoma occurs from a clot in the sub arachnoid space in the meninges
2. intracranial hematoma (most common) is the accumulation of blood within the brain itself, due to multiple bleeds
Because of the traumatic nature of TBI, other physiological problems manifest themselves often, such as:
Apnea – impaired respiration
Decreased level of consciousness
When coupled with vomiting you have a real danger of aspiration
Also because of the trauma that results in a TBI the EMT will assume at the scene of the accident that the patient also has a cervical spine injury so they will stabilize the head and neck.
Shock is rarely seen in TBI, the best indicators of shock are an increased heart rate accompanied by decreased blood pressure.
Shock is very serious, if the a TBI patient is in shock then the ER people know there are other accompanying injuries.
Lowest score is a 3 best score is a 15
Score of 8 or less indicates this is a severe TBI
9-12 moderate TBI
13-15 mild TBI
GCS is a combination of 3 subscales
Scale 1 evaluates eye opening
Scores are 1,2,3,4 – 4 best
Evaluates if the patient is able to open eyes on command
Scale 2 evaluates motor response
Scores fall between 1-6, 6 best
6 indicates client is able to follow and obey various movement commands that they hear
Score of 1 indicates there is no motoric response even to pain
To test for pain, they pinch very hard by the clavicle
Scale 3 evaluates the patient’s response to verbal questions
Score 1-5, 5 best
5 indicates the client is oriented to PPT and situation
1 indicated they are unable to orient or don’t
ICP monitor – intra cranial pressure monitor
When the brain begins to swell the ICP increases
Secondary injuries can result in more serious deficits than the actual TBI itself
Secondary injuries are the body’s response to the injury
ICP is one of the most serious of these secondary injuries
The skull is hard and you don’t want your brain pushed up against it
Naso-gastric tube for feeding
CVP – central venous pressure, blood pressure of the Venus system, the blood returning after its been used, VENOUS system returns blood to liver to be cleaned.
Arterial line- between elbow and wrist, because at the level of the wrist the artery is closest to the surface.
Arteries were designed to be further inside the body, because if you sever an artery you will bleed to death.
They will check blood gases with this line.
This procedure hurts really bad, because it’s so deep, they have to search to find it.
Foley Catheter- device for removing urine
Heart Rate will be monitored by EKG
Client is surrounded by machines
Usually grammar is intact (syntax).
Pure linguistic deficits are fairly rare.
TBI is often the cause of a resulting dysarthria (muscle weakness), spastic dysarthria or flaccid dysarthria most common, but you may see combined symptoms of both.
Patients often have early comprehension deficits – may or may not resolve.
Reading comprehension problems are prominent.
Anomia is the most common and most persistent deficit in terms of speech and language. Even after they have gone through rehab, the most common complaint is a persistent word finding problem – can be mild or severe.
One of the primary things that separates a TBI from a stroke is poor pragmatics.
Can be mild to severe disturbance in social interaction.
They are unable to inhibit themselves, so they will say exactly what they are thinking.
There is often disturbed conversational turn taking.
There are problems choosing appropriate topics of which to speak.
They will go off topic (tangential) and sometimes their responses are irrelevant to the question.
They can talk a lot so they have problems being concise, verbose.
Aside from the speech problems and the pragmatic deficits, the real assessment and the real rehabilitation will revolve around their executive system.
The executive system for the most part has its neurologic foundation in the frontal lobes and the limbic system.
The limbic system provides pleasure and positive reinforcement for a job well done.
It is also the limbic system that will divert the frontal lobes from achieving desired goals.
Because the two most common areas of damage are the frontal lobes and the temporal lobes, the executive system is nearly always compromised.
The executive system has 4 main responsibilities:
1. It provides you with and awareness of your strengths and limitations, typically based on your experiences.
In order for you to appreciate the difficulty of a task, you have to be able to compare the task with your strengths and weaknesses.
2. Based upon this awareness of your strengths and weaknesses your executive system allows you to:
Set reasonable goals
Plan and organize your behavior in order to achieve that goal
Initiate and begin performing that behavior to achieve that goal
Inhibit behavior incompatible with achieving the goal
Monitor and evaluate your performance towards achieving the goal
Be able to flexibly revise plans and solve problems given the amount of difficulty that you are experiencing so that you can still achieve the goal
All of these assume a self-awareness of your weaknesses!
It is not unusual for TBI clients to have very big plans that are not appropriate, because the TBI client has deficits in that particular area in this part of the executive system.
3. Your executive system allows you to assume an non-egocentric perspective.
Your executive system helps you understand that you need the help of other people and that they need your help to help them achieve their goals.
4. Your executive system provides you with the ability to think abstractly and logically so that you can transfer skills from training to application.
For the most part, the major assessment instruments assess various components of the executive system because for any meaningful rehabilitation to take place, the executive system has to be available and used.
All TBI assessment also evaluate memory –this is often a major problem for TBI survivors.
All different types of memory are involved.
All assessments agree that anyone coming out of coma will have post traumatic amnesia (PTA).
they will not remember the accident that caused the TBI or what happened immediately before what caused the TBI
they will have problems with short-term memory
deficits in any of these areas cause a domino effect and they effect other higher areas
Visuoperceptual and related disorders
Facial recognition deficits
Impaired affective auditory comprehension (receptive aprosodia)
Neuropsychiatric disorders (happen rarely)
Visual hallucinations – rare
Secondary mania –rare, rushing around
Acute confusional states- every now and then confused
Paranoid hallucinations- fairly rare
Capgras’ syndrome- rare
Due to R hemisphere injury the client believes that those around him (wife, children ect) have all be replaced by impostors that look just like them
They will tell the doctor, I know that it looks just like her but I can tell you that is not my wife
At the center of it, they typically explain this to themselves because the impostors want something, paranoid
For many people assessment can take a long time.
What you are going to do in assessment will depend on where they emerge from a coma or a loss of consciousness.
Rancho Los Amigos Scale (RLAS)- you need to be familiar with this, because what you can do (and when) is based on where they emerge.
Positive correlation of length of coma and severity of deficits.
These ten stages of the RLAS came from years of observation of people emerging from comas
Three stages: Early, middle, and late stage of recovery.
Important for you to remember not everyone will make it into the late stage of recovery, because the severity of their injuries limit progress, and when they plateau they may not improve significantly past this.
It’s very individualized and there is no time limit on these, they don’t stay in RL 1 a certain amount of time, just how their brain begins to recover.
Assessment in The Early Stage:
Level 1: No meaningful response from the client- comatose.
As they emerge upwards into level 2, they have very generalized responses to stimuli: pain, hearing, touch, no localization.
Brainstem response, very primitive.
Level 3: As they emerge into this level the responses become more localized and specific, if they stop here they may be reclassified from being in a coma to being in a persistent vegetative state – this is not worse than a coma. People in this state have basically normal sleep wake cycles, they may localize to sounds, may visually track you, but none of these responses involve nor do they reflect higher cognitive function, these are all very primitive responses, if you stroke their cheek they may smile, may yawn, unfortunately family members often take these as signs of recovery, if they get better they are signs, but if they don’t they are just in a persistent vegetative stage.
Assessment in the Middle stage:
Level 4- they are confused and they are not fully conscious yet, not oriented to place
They sleep a lot and wake up, but they are also in a very agitated state, can lose their cool very easily, if they can they may start throwing things, they are agitated partly because they are so confused. It’s like they are in a dream world, they just don’t want to be bothered.
Often time families will ask, “Cant you give them something to keep them calm so we can help them?” – generally speaking acute care facilities wont do this.
For two reasons-
1) The staff is trained on how to handle agitation behaviorally
2) If they do give them medication, it may mask signs that they are emerging into level 5,or 6. Depending on how long they are medicated and they need to be able to evaluate the clients progress upward into the RLAS levels.
RLAS 5 – the agitation is significantly decreasing, much calmer and much less prone to outbursts
They are still confused and not oriented but it’s better.
They are becoming increasingly more clearheaded now.
But they can have some inappropriate behaviors and verbalizations.
RL 6- still confused
But they are appropriate
Behavior is very automatic
They will wave back, they will say hello
Behavior becomes increasingly more purposeful
Behavior is being done to achieve something
Level 9 and 10
Improving more and more
Little or no supervision at all
Overall goal for early stages: attempt to develop consistent and purposeful response to communication stimuli
Levels 1 and 2 You typically won’t have any access to the patient, because they are so severe.
You start to try to stimulate the client.
Identify the exact position to facilitate alertness and responsiveness.
Identify the best mode of response , vocal, verbal, or behavioral entirely based on what the client is or is not able to do based upon injuries.
Identify the best environment for this type of stimulation to take place- for the most part the best environment is a quiet place in which you are the most interesting thing in the room, no window, art work, tv ect. Because attention is not an easy thing to obtain.
In a few cases this is not what you want, you may want a very stimulating environment (day/activities room with all kinds of people, noise, etc.) for this kind of client this environmental stimulus helps them maintain their alertness.
Having a positive relationship with the staff is important, because you will be asking them lots of questions.
Identify types of responses that can be elicited by the client- it may be as low-level as localizing to sound, but you have to start somewhere and stimulating is the key word at this point, you want to enhance and maintain alertness.
They may only be able to localize to sounds, track visuals, follow commands like eye blinking, but you have to start somewhere.
Because they are emerging from a coma they will be confused, therefore use familiar stimuli for them, pictures of family, familiar music, items they used in their occupation, and highly familiar things.
Monitor responses carefully!
What are the best stimuli?
Are you asking too much or too little?
Train the family and staff in how to provide the kind of stimulation that you have identified throughout the day
Many times it’s good to place suggestions around the room:
Approach the client slowly.
We want a calm atmosphere!
Tell them who you are and why you are there.
Remind them of who they are and why they are here.
This level is agitation (level 4)
Overall goal is to develop appropriate responses to communication stimuli and to stimulate basic cognitive linguistic skills
Techniques for someone in level 4 is different from 5, and 6 because they are in a very agitated state.
For people in level 4, this can be very difficult for everyone, therapists, clients, family and staff.
Be calm, soothing and reassuring in all interactions.
Don’t make any abrupt movements, slow everything down, talk slow.
Try to be the model of calmness for the client and family.
Only do very familiar activities with the client at this point, trying to introduce new tasks may just result in agitating the client.
At the first sign of agitation remove all stimuli, get them away from client under table or on the floor and stop whatever you are doing
As you are more familiar with your clients, you will be able to spot the first sings that agitation is beginning.
The best way to minimize agitation is to engage the client in familiar structured activities that are very, very familiar.
As soon as the client begins to emerge into level 5 and 6 you can become less structured and you can provide more stimulation.
The primary goal is to help clients to orient to their environment and structure their environment.
Reminding the client to use clocks and watches, introducing calendars, appointment books, schedules and such, will be important, but you have to do all this at the client’s pace- you cant bombard them with this.
Develop the client’s ability to attend to tasks for an increasing length of time.
Because of their attention problems, you need to have a lot of activities so you can change activates a lot.
Focus on improving organization of information and the processing of new information.
Best way to do this is to always tie new information to previously learned information.
Develop plans to facilitate carryover into functional tasks.
If the client is ambulatory, a very functional thing to do is to have the client transfer themselves to another location (without help from you), go from speech to their room or to another therapy.
They have to be able to use this daily or they will forget it.
All these techniques are done in a hierarchy.
Overall goal is to continue to develop clients ability to effectively communicate as well as they can at this post-traumatic level and to be as independent as possible, these are all team goals.
Begin assessing cognitive and language deficits
Equal importance is to determine what the clients strengths are, bc you are going to need these strengths to help improve those deficits, you cant ignore them you need to identify them and use them
Assess and plan intervention for any speech motor problems – dysarthria or apraxia
Help the client develop abilities to process, store, and recall new information of increasing length and complexity, by beginning to focus on analysis and integration of information and how to use it functionally.
It’s very helpful to teach them to be concise, by helping them to effectively organize information so that their expression is clear and to the point, because one of the major problems they have in the late stages has to do with being verbose and irrelevant or being tangential – going off on tangents.
You will often need to facilitate the clients awareness of their deficits.
Many times individuals that have been through a TBI lose their self-reference of how they were before the injury.
To their way of thinking, they may think this is how they were before the accident.
You must go over the assessment, and point out areas of deficit and weaknesses and you want to play up the strengths, but make the clients aware of their deficits.
Practice carryover of these skills in functional environments- take your clients to the mall or to the movies.
5 MOST COMMON DEFICITS
Post traumatic amnesia will improve.
Remember the hierarchy of attention deficits.
INFORMATION PROCESSING DEFICITS
This is related to memory deficits and attention deficits.
INFORMATION ORGANIZING DEFICITS
If you can’t organize information you can’t do much with it.
It’s as if the filing system has all been thrown up in the air in the middle of the room.
Without these abilities – your ability to remember is also impaired.
All of the above skills serve as a foundation for executive function.
Without this you cannot operate independently and succeed.
The assessment and treatment for someone with TBI doesn’t just include cognitive and language workbooks, you aren’t going to get anywhere unless you have a long-term treatment plan.