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?
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
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
Brain Anatomy Two relatively symmetrical hemispheres (halves) Contralateral Control Left side of brain controls Right side of body, etc.
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)
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
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
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.
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”
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
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
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
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.
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
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
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)
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
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
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
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:
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
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
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
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)
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
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
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
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<, Neuropsych, etc. Nutrition Diet, weight, nutritional aspects of wound healing Importance of/Education for nutrition habits for discharge
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
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
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
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)
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
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
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
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”
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
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
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
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
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