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Tbi rehab family_lecture

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Tbi rehab family_lecture

  1. 1. Shepherd CenterAcquired Brain Injury Program
  2. 2. Introduction What is Neuropsychology? What happened to your loved one? Part 1:  Basics of the Brain  What happens with a brain injury Part 2:  Brain injury rehabilitation at Shepherd  Your entire rehab team  2 Tracks: Patient-specific  PREP (Pre-Rehabilitation Education Program)  Rehab Program  Discharge- What happens when you leave here?
  3. 3. Brain Anatomy Brain is soft & has the consistency of a Jello mold Fits relatively snuggly in the skull Attached to the skull by small veins and meningies Floats in Cerebral Spinal Fluid (CSF)  Provides a cushion, “shock absorber” Enclosed environment  Other than veins and arteries, there is only one exit—where brain stem exits the base of the skull to become the spinal cord  This is why we have the pressure problem
  4. 4. Brain Anatomy Surface of the brain is wrinkled with deep folds  Increase the surface area of the brain in a small space  Compact, efficient  Allows for more connections Cortical structures on surface Subcortical structures deeper in brain
  5. 5. Brain Anatomy Two relatively symmetrical hemispheres (halves) Contralateral Control  Left side of brain controls Right side of body, etc.
  6. 6. Brain Anatomy Neo-cortex or Cortical Structures  Each hemisphere divided into 4 lobes  Frontal, temporal, occipital, parietal  “Thinking” portion of the brain Subcortical Structures  Life sustaining structures/functions  Brain stem controls heart rate, breathing, temperature, arousal/wakefulness  White matter – communication between different brain regions  May be affected by focal damage or generalized mechanisms (swelling, compression, diffuse/shear injury, anoxia)
  7. 7. Brain Anatomy
  8. 8. Frontal Lobes• Common site of injuries due to bony shelf structures in skull• Facilitates executive functions/goal-directed thoughts: • Attention/concentration • Planning, organization, sequencing • Abstract reasoning/thinking/adjustment • Judgment/decision-making • Self-monitoring/stopping & starting • Personality/ Behavioral & emotional regulation• Motor strip at back of frontal lobe controls body’s ability to move itself • Weakness (hemiparesis) or paralysis (hemiplegia)• Some expressive language abilities
  9. 9. Injury to the Frontal Lobes Decreased initiation  Difficulty getting started  The “gas” is not working properly: “Abulia”  Cueing can help Disinhibition  Problem with “social filter”, opposite of initiation problems  colorful language, socially inappropriate behaviors  Can be difficult to remember it is due to brain injury  Not intentional, usually not directed towards any particular person  Unaware of inappropriateness of behavior  Or as recovery progresses, may become more aware, but still unable to control behavior= can lead to guilt
  10. 10. Injury to the Frontal Lobes Confabulation  Disorientation & confusion  “neurological lying” Perseveration  Repetitive topics, phrases, or behaviors Emotional lability (mood swings) Behavioral dysregulation Fatigue, over-stimulation, frustration Decreased insight and awareness  May deny physical and/or cognitive deficits Remember: your loved one is not doing it on purpose.
  11. 11. Parietal Lobes Sensory strip at front of parietal lobe, behind motor strip  Organized similarly to motor strip  Detects pain, touch, pressure  Senses where the body is in space, movements Visuospatial judgments Attention to entire environmental field  Inattention vs. neglect  “Left Sided Neglect”
  12. 12. Occipital Lobes Processes basic visual information Visual problems common after brain injury Input enters through eyes, but you “see” with your brain Many injuries affect vision  Double vision, blurred vision  Visual field cut
  13. 13. Temporal Lobes Auditory processing cortex  Recognizing/Discriminating between sounds Expressive and Receptive Language abilities  Expressive or Receptive “aphasia” Hippocampus facilitates memory storage  Short-term vs. long-term memories
  14. 14. Cerebellum Fine motor coordination and balance  Fluid motor movements  Eye-hand coordination, timing, adjustment  Posture, gait  Motoric memory (e.g., how to play an instrument, walk) Ataxia, balance problems when damaged Contains half of all neurons of the nervous system  Condensed; more neurons here than in the neocortex
  15. 15. Nomenclature Acquired Brain Injury (ABI):  Any injury that happens within the brain itself at the cellular level  Traumatic Brain Injury (TBI): Outside force impacts head hard enough to cause brain to move within the skull or the force directly hurts the brain Examples: motor vehicle collisions, falls, firearms, sports, physical violence, etc. Closed Head Injury vs. Open Head Injury  Non-Traumatic Brain Injury (TBI): Does not involve external mechanical force Examples: stroke, aneurysm, insufficient oxygen (anoxia/hypoxia) or blood supply (ischemia), infectious disease, AVM, etc.
  16. 16. Mechanisms of TBICoup-ContrecoupBack-n-Forth contact with skullDiffuse Axonal Injury•“Shear injury”•Results from rotating, twistingand tearing of axons of neurons•Tears capillaries & bloodvessels•Doesn’t always show upimmediately on CT scans•Usually present in TBI,especially MVA•Axons/neurons don’t repair, perse, and leads to cell death•Some neuroplasticity cancompensate
  17. 17. Diffuse Axonal Injury in TBI(What Grace has)
  18. 18. Neuropathology of TBI Contusions: Bruising  blood vessels in or around brain are damaged or broken Hemorrhage  bleeding from blood vessel leakage rupture Hematoma  Localized pooling of blood that occurs from hemorrhaging. Can be large or small
  19. 19. Neuropathology in TBI Edema  Swelling in brain tissue  Causes increased intracranial pressure (ICP)  Enclosed space: Increased pressure on all brain tissue Treatments:  Medically induced coma  Brain diuretic (reduce fluid/water)  Placement of shunt (drain)  Craniectomy (remove portion of skull bone to allow extra space for swelling)
  20. 20. Anoxia/Hypoxia Anoxic Brain Injury  Brain does not receive any oxygen. Cells in the brain need oxygen to survive  Anoxic Anoxia: no oxygen supplied to the brain  Anemic Anoxia: blood that does not carry enough oxygen  Toxic Anoxia: toxins that block oxygen in the blood Hypoxic Brain Injury  Brain receives some, but not enough oxygen Common causes:  Cardiovascular disease or trauma, asphyxia (e.g., drowning), chest trauma, electrocution, severe asthma attack, poisoning, substance overdose
  21. 21. Chemical Changes Brain is very efficient—produces at the cellular level only what it needs and needs everything it produces Brain injury may cause neurochemical imbalance  Neurotransmitters:  E.g., Serotonin  mood  Medications may be given:  Parlodel for arousal  Ritalin for focused attention & arousal  Mood stabalizers, antidepressents may be beneficial Damage to pituitary gland can result:  hormone disruptions,  sleep/wake cycles can be affected
  22. 22. Post-traumatic Amnesia (PTA) Patients with PTA may:  Not be able to lay down new memories  Be disorientated  Have a short attention span  Be agitated or have more mood swings  Perseverate on words, ideas, or activities  Need more structure  probably better working on one activity at a time  Have difficulty processing complex information about the accident  May not have the capacity to assign Power of Attorney  Power of Attorney vs. Guardianship
  23. 23. Neuropathology of Stroke Loss of brain function due to interruption in blood supply to all or part of the brain Results in depletion of oxygen and glucose in affected area Two types:
  24. 24. Neuropathology of Stroke Infarct: Area of damaged or dead tissue Ischemia: Lack of adequate blood flow Thrombosis: Solidified blood plugs/clots a blood vessel Embolism: A plug/clot brought through the blood from a larger vessel and forced into a smaller one where it obstructs circulation
  25. 25. Neuropathology in Stroke Aneurysm: Balloon-like expansion of blood vessel  Usually weak and prone to rupture  Risk factors: hypertension, arteriosclerosis, embolisms, or infections  Prior to rupture, may be treated with stent or clipping
  26. 26. Neuropathology in Stroke 3rd most common cause of death  After heart disease and cancer Risk Factors:  Hypertension  Smoking  High Cholesterol  Diabetes  Poor diet  Age (especially from 60’s on) Stroke Prevention:  Diet  Exercise (physician approved)  Smoking cessation  Medication compliance
  27. 27. Tracks at Shepherd Center PREP Program (Pre-Rehabilitation Education Program)  Rancho Levels 1-3, passive therapies to keep body conditioned, and ready for progression to full rehab  Stimulation for coma emergence Rehabilitation Program Dual diagnosis SCI patients  Patient has both a spinal cord injury and brain injury  They frequently co-occur (e.g., car accidents, falls, etc)
  28. 28. Rehabilitation Program Increase independence as much as possible Return to meaningful life Short-term goals (daily or weekly) Long-term goals (discharge home, return to work, etc) Relearn skills Learn new ways to do things, compensate Increase mental & physical endurance/stamina 3 hours of therapies daily (plus groups, outings, psychology) Reduced therapies on weekends for rest and family time
  29. 29. Rehabilitation Treatment Team The Rehab team works together:  Medical doctors  Nursing  Neuropsychology  Occupational Therapy (OT)  Physical Therapy (PT)  Speech and Language Therapy (ST/SLP)  Therapeutic Recreation/Other Therapists (TR)  Case Managers  Technicians  Nutrition  Chaplaincy/Spiritual Guidance/Therapy
  30. 30. Individualized Treatment Plan Occupational Therapy (OT)  Rehabilitation for arms, hands, fine motor skills, vision  Casting  Basic and advanced activities of daily living (ADL’s)  Showering, grooming, hygiene, dressing, toileting, home management skills, kitchen skills, money management, structuring routines  Assess for safety Physical Therapy (PT)  Rehabilitation for legs, torso, balance, walking and gait, sequencing movements, wheelchair training, transfers  Casting  Assess for safety
  31. 31. Individualized Treatment Plan Speech & Language Therapy  Swallowing, consistency of liquid and diet orders, safe eating behaviors, speech and language, cognition, memory, attention, functional problem solving Therapeutic Recreation  Fun activities to maximize progress toward goals and integrate skills  Practice what is learned in OT, PT, S&LT, Neuropsych, etc. Nutrition  Diet, weight, nutritional aspects of wound healing  Importance of/Education for nutrition habits for discharge
  32. 32. Neuropsychological Screening Formal, standardized assessment of thinking skills Targets major cognitive domains:  Attention/concentration, memory, visuospatial abilities, language, executive functioning  Mood functioning Findings & Recommendations  Ability/Capacity to make decisions, need for supervision, return to work/school recommendations, treatment and discharge planning  Baseline for comparative follow-up testing  Often used for disability claims
  33. 33. Power of Attorney vs. Guardianship Power of Attorney: Legal document that allows a person (the “principal”) to name another person to act in their place Patient must:  Be fully oriented  Demonstrate  Understanding of what PoA is  Full appreciation of the situation  Reliably identify whom they want to have PoA Positives: inexpensive; revocable; patient retains ability to manage their affairs when able to do so Negatives: some financial institutions don’t honor PoA; agents can abuse their power
  34. 34. Power of Attorney vs. Guardianship Guardianship: Legal process in which the court appoints an individual/association/corporation to act on behalf of another who has been declared incompetent or incapacitated  Applicable when patient is in acute stage of recovery  Patient’s rights are (temporarily) taken away  Emergency guardianship – required when consent for medical treatment is needed; hearing not required  Temporary vs. Permanent Guardianship  3-month temporary guardianship can be considered, as patient’s cognition may improve over time  However, it is expensive; process is lengthy; court hearing required
  35. 35. Discharge from Rehab Track Family Training Day Shepherd Pathways or other outpatient therapy clinics Importance of supervision  Due to deficits in judgment, memory, safety awareness, problem solving, insight into limitations, distractibility, impulsivity and behavioral regulation  Help make the environment safe, training (e.g., praise safe decisions, provide explanations, external memory devices, etc)
  36. 36. After Discharge Recovery does not end at discharge  First 6 months: most rapid recovery  Continued recovery for 1 – 2 years after injury Residual differences: cognitive, emotional, behavioral, interpersonal  Physical limitations are easier to see and to watch heal Retest cognitive functioning to identify changing strengths and areas for improvement
  37. 37. Ongoing Difficulties & Limitations Physical  Movement, coordination, balance  Stamina and endurance Cognitive  Safety awareness, impulsivity  Memory, Post-traumatic Amnesia, Confusion  New learning can be difficult Emotional and behavioral issues  Dysregulation, depression, anxiety, adjustment issues Other cognitive issues & difficulties
  38. 38. Factors That Can Affect Recovery Age Prior brain injury Previous health status Length of PTA Time since injury How much tissue was damaged Focal injuries are more resistant to recovery Language, executive functions, ataxia are more resistant Substance abuse, ETOH & smoking tobacco etc. Adaptive functioning before injury Positive Family involvement More therapy hours are not related to amount of recovery
  39. 39. Post-traumatic Epilepsy 10% risk with closed head injury 50% risk with open head injury Learn what to do Know when to call 911 Drinking alcohol increases risk May receive medications/medical management See attachment for “What to do in an emergency”
  40. 40. Substance Use Use of alcohol (in any amount) increases risk for seizures Drinking alcohol increases risk for falls  Second brain injury likely to be much more severe, even if actual injury is mild Substance abuse is more common after brain injury, even if not present before  More stress, losses  Fewer coping strategies  Poor decision making/judgment  Be more aware- patients may try to hide substance use
  41. 41. Family You know your loved one better than we do Your knowledge about their emotional and physical needs is valuable to us and to their recovery Your participation and involvement is helpful Feelings of loss, sadness, anger, guilt, and frustration are common and normal You do not have to go through this alone- help is available
  42. 42. Self Care is Essential You have to be healthy in order to be able to take care of someone else Break the stress response cycle  Rest, eat well, get some exercise  Practice whatever gives you strength, peace, hope Manage your physical & emotional energy  Asking for help is a valuable skill, not a weakness  Find people who will help you and then let them  Share your feelings with trusted others  This is your chance for a break before your loved one is discharged
  43. 43. Some Last Housekeeping Notes… Time off  Please respect visiting hours on the unit  Reduces distraction, provides structure, promotes independence, promotes rest  For your loved one  For other patients  For yourself Meal time expectations  No family/visitors during breakfast & lunch  1 family member/visitor during dinner