Neurological Aspects OCP

1. Acquired Brain Injury
(ABI)
Traumatic
Brain Injury
(TBI)
Non-
Traumatic
Brain Injury
(NTBI)
CVA Tumor InfectionMVC GSW Fall

2. Traumatic Brain Injury (TBI)
 An injury caused by a bump,
blow, jolt to the head or
penetration to the brain that
disrupts normal brain function
Range from mild to severe
Recommended resource:
www.cdc.gov/TraumaticBrainInjury

3. TBI: Facts and Statistics
 ~1.7 million people sustain a brain injury annually in
the U.S.
 TBI is a contributing factor to a third of all injury-
related deaths in the U.S.
 Most TBIs that occur each year are concussions or
other forms of mild TBI.
 Medical costs (direct and indirect, such as lost
productivity) of TBI are estimated at over $80 billion in
the United States yearly.

4. TBI Statistics By Age and Gender
 Children aged 0 to 4 years, adolescents aged 15 to 19
years, and adults >65 years old are most likely to
sustain a TBI.
 Adults aged >75 years old have the highest rates of
TBI-related hospitalization and death.
 In every age group, TBI rates are higher for males than
for females.
 Males aged 0 to 4 years have the highest rates of TBI-
related emergency department visits.
Recommended resource: www.mayfieldclinic.com/PE-BrainTumor.htm

5. Leading Causes of TBI:
 Falls - 35.2%
 Motor Vehicle-Traffic Crashes
(MVC) and Traffic-Related
Incidents - 17.3%
 “Struck by/against” events -
16.5%
 Assaults - 10%

6. TBI and the Military
 Blasts are a leading
cause of TBI for active
duty military personnel
in war zones.
 TBI is the signature wound
of the wars in Iraq and
Afghanistan.

7. TBI: Signs and Symptoms
Recommended reference:
www.cdc.gov/traumaticbraininjury/pdf/BlueBook_factsheet-a.pdf

8. TBI: Signs and Symptoms
 Chronic headache/neck pain
 Difficulty remembering, concentrating, or making decisions
 Perpetual fatigue
 Mood changes
 Changes in sleep patterns
 Light-headedness, dizziness, or loss of balance
 Increased sensitivity to light or sounds
 Nausea/vomiting
 Blurred vision
 Loss of sense of smell or taste
 Ringing in the ears
http://www.cdc.gov/ncipc/tbi/Signs_and_Symptoms.htm

9. Acquired Brain Injury
(ABI)
Traumatic
Brain Injury
(TBI)
Non-
Traumatic
Brain Injury
(NTBI)
CVA Tumor InfectionMVC GSW Fall

10. Non-Traumatic Brain Injuries
 Cerebrovascular accident (CVA, or “stroke”)
 Brain aneurysm (also called a cerebral or intracranial
aneurysm)
 Brain tumor (benign/malignant, primary/secondary)
 Hypoxia or anoxia
 Infection – bacterial, viral, or other type

11. TBI vs. Non-TBI
 A TBI is a sudden injury to the head causing damage to the brain.
 Closed Head Injury – resulting from dynamic (acceleration/deceleration) or static
loading (crush injury).
 Penetrating (Open) Head Injury
 Acquired Brain Injury (ABI) – can contribute to problems with cognitive abilities, thought
coordination, communication difficulties, organizational skills and memory, physical
problems, social difficulties, and independent functioning
 Localized/specific injury or effects vs. diffuse/whole-brain injury or effects
 No two cases will be the same. Differences will depend on factors including –
 Location of the injury in the brain
 Areas/structures of the brain affected
 Pre-injury influences

12. Recommended resource: www.brainandspinalcord.org

13. Consequences of ABI
 Acute phase – often profound deficits
 Long-term effects – subtle to severe
 Research indicates that around 90% of those with severe ABI overcome
most of their physical difficulties within the first year.
 Problems common to all brain injuries include –
 Headaches
 Fatigue
 Epilepsy/seizures
 Although physical difficulties can present problems, it is the cognitive
difficulties and personality changes that are the most distressing, since
these have a greater impact on social, work, and family life.
 In the later stages - often viewed as a “hidden disability”
Recommended resources:
-http://www.lovethatmax.com/2008/11/what-happened-to-max.html
-www.braininjurynetwork.org
-http://www.strokesmart.org

14. Jermaine’s Story
www.youtube.com/watch?v=zsiWKRzkcDo

15. Brain Map
With a TBI, the brain may be injured in a specific location or the
injury may be diffused to many different parts of the brain.
Recommended resource: www.neuroskills.com/brain.shtml#map

16. Damage to the Cerebral Cortex

17. Damage to the Cerebral Cortex
Wernicke’s aphasia – receptive language deficit
Broca’s aphasia – expressive language deficit

18. The Story of Phineas Gage

19. The Frontal Lobe
Frontal lobe damage also seems to have an impact on divergent thinking, or flexibility
and problem solving ability.

20. The Frontal Lobe
• Vulnerable to injury due to its location/size
• Injury can come from direct impact to front of the head
• Most common region of mild-moderate TBI
• Can cause changes in personality, cognition (executive
function), physical abilities, and behavior

21. The Frontal Lobe

22. Damage to the Frontal Lobe
 Difficulty sequencing
 Perseveration
 Attention deficits
 Personality changes/ social behavior
 Difficulty with problem-solving
 Loss of spontaneity
 Uncontrollable emotional, social, and sexual behavioral
changes
 Poor initiation of voluntary movements
 Difficulty interpreting feedback from the environment
 Dysdiadochokinesia

23. The Parietal Lobe
 Near the back and top of the head
 Guides visual attention, touch perception, goal-directed
movements, and manipulation of objects

24. Damage to the Parietal Lobe
 Difficulty naming objects (anomia)
 Inability to focus visual attention
 Problems with motor planning (apraxia)
 Impaired spatial orientation and constructing things
(constructional apraxia)
 Left parietal damage can result in Gerstmann’s Syndrome:
 Difficulty with writing (agraphia) and math (acalculia)
 Inability to distinguish the fingers on the hand (finger agnosia)
 Right/left confusion
 Damage to the right parietal lobe can result in neglecting part of
the body or space (left neglect)
 May also result in denial of deficits (anosagnosia)

25. The Temporal Lobe
 Located on the side of the head, above the ears
 Involved in the primary organization of sensory input
 Highly associated with memory skills
 Hearing ability
 Memory acquisition
 Some visual perceptions
 Categorization of objects

26. Damage to the Temporal Lobe
 Difficulty understanding spoken words (Wernicke's aphasia)
 Disturbance of selective attention
 Difficulty identifying and categorizing objects
 Difficulty recognizing faces (prosopagnosia) and visually
locating objects
 Short-term memory loss
 Interference with long-term memory
 Changes in sexuality
 Persistent talking
 Increased aggressive behavior

27. The Occipital Lobe
 Located posteriorly, at the back of the head; not
particularly vulnerable to injury b/c of its location
 The center of the visual perception system
 Involved in visuo-spatial
processing, discrimination
of movement, and color
discrimination

28. Damage to the Occipital Lobe
 Vision defects (visual field cuts)
 Difficulty identifying colors
 Difficulty visually locating objects
 Hallucinations and visual distortions
 Word blindness
 Inability to recognize object movement
 Difficulty reading and writing
 Poor processing of visual information

29. The Cerebellum
 Located at the base of the
skull, just above the brain
stem, at the back of the head
 Involved in the coordination
of voluntary motor
movement, balance and
equilibrium, and the
regulation of muscle tone
 Relatively well protected
from trauma

30. Damage to the Cerebellum
 Impaired gross and fine motor coordination
 Loss of the ability to walk
 Poor postural control
 Inability to make rapid movements
(adiadochokinesis)
 Impaired control of eye movements (nystagmus)
 Tremors and/or dizziness
 Slurred speech
 The patient may appear to be intoxicated based on
symptoms.

31. The Brain Stem
 Deep in the brain, leads to the spinal cord
 Plays a vital role in basic attention, arousal, and consciousness. All
information to and from our body passes through the brain stem on
the way to or from the brain
 Like the frontal and temporal lobes, is located in an area near bony
protrusions making it vulnerable to damage during trauma.
 Controls breathing, heart rate,
swallowing reflexes, vision, and hearing.
 Controls sweating, blood pressure,
digestion, temperature, level of alertness,
and ability to sleep.
 Governs sense of balance (vestibular function)

32. Damage to the Brain Stem
 Impaired regulation of temperature, heart rate, and
respiration
 Difficulty swallowing food and drink (dysphagia)
 Difficulty with balance and movement
 Nausea and dizziness (vertigo)
 Impaired arousal and sleep regulations

33. Ataxia
 Results from impairment of the cerebellum or the
motor pathways leading to and from the cerebellum.
Ataxia is characterized by incoordination, impaired
sitting balance, and standing balance. It can occur in
the trunk and both the UE/LE.
 Trunk—impaired postural stability.
 UE—causes dysfunction of the gross and fine motor
coordination.
 LE—impaired ability to ambulate while maintaining
balance.

34. Postural Deficits
A result of imbalance in
muscle tone throughout
the body (pelvis, trunk,
head and neck, scapula,
and UE/LE)

35. Balance
 A highly integrated dynamic process
 Impacted after brain injury by muscular
weakness/spasticity, vestibular or proprioceptive
deficits, ROM deficits, and visual impairment
 Addressed by OT in functional terms

36. Sensation
 Clients with TBI may exhibit signs of absent or altered
sensation.
 Light Touch
 Sharp/Dull
 Proprioception
 Hot/Cold
 Pain
 Kinesthesia
 Two point discrimination
 Stereognosis
 Clients can also have altered smell/taste secondary to
cranial nerve injuries.

37. Dysphagia
 A difficulty in chewing and/or swallowing
 There is a higher incidence of oral preparatory, oral,
and pharyngeal stage dysphagia than esophageal
dysphagia.
 A patient may also demonstrate abnormal tone in the
oral muscles and/or abnormal oral reflexes.
 A patient may also demonstrate cognitive deficits
which will interfere with sequencing chewing,
swallowing, and breathing.

38. Behavior
 The first step to become more comfortable when
working with individuals with TBI is to understand
why they occur and how they manifest themselves.
 When working with an individual, you need to be
aware of the environment, a patient’s triggers, and
surrounding factors (ie. medication, family
involvement, time of day, type of activity, etc.).
 Often behaviors include a patient being combative,
agitated, disinhibited, or refusing to
cooperate/participate in treatment.

40. Acquired Brain Injury
(ABI)
Traumatic
Brain Injury
(TBI)
Non-
Traumatic
Brain Injury
(NTBI)
CVA InfectionMVC GSW

41. Classification of TBI
Loss of
Consciousness
(LOC)
Post-traumatic
amnesia (PTA)
Glasgow Coma
Scale (GCS)
MILD 0-30 minutes <1 day 13-15
MODERATE 30 minutes to 24
hours
>1 day to <7 days 9-12
SEVERE >24 hours >1 week 3-8

42. Four Phases of Life in TBI Terms
Survival Phase
Establishing and living a new life (Duration: lifetime)
Rehabilitation (or Recovery) Phase
Rehab Facility, SNF, Home (Duration: weeks to months)
Medical Treatment Phase
Acute Phase – gurney to ICU (Duration: hours)
Intensive Phase – ICU to acute hospital d/c
(Duration: days/weeks)
Pre-injury Phase

43. O.T. Evaluation
 Chart Review – Past medical history, diagnostic
information
 Physical Evaluation – ROM, muscle tone, posture,
sensation, transfers, ADLs and iADLs, motor abilities
(Apraxia)
 Vision & Hearing – also visual-motor integration and
visual perception
 Cognitive Evaluation
 Functional Status
 Emotional Status and Social Behavior
See p. 1057 (RT) for resources for assessment and outcome tools

44. Glasgow Coma Scale scores range from 3-15. A score of 8 or below indicates a
severe TBI, 9-12 moderate severity, and 13-15 a mild brain injury.
 Eye Opening Response:
 Spontaneous--open with blinking (4 points)
 Opens to verbal command, speech, or shout (3 points)
 Opens to pain, not applied to face (2 points)
 None (1 point)
 Verbal Response:
 Oriented (5 points)
 Confused conversation, but able to answer questions (4 points)
 Inappropriate responses, words discernible (3 points)
 Incomprehensible speech (2 points)
 None (1 point)
 Motor Response:
 Obeys commands for movement (6 points)
 Purposeful movement to painful stimulus (5 points)
 Withdraws from pain (4 points)
 Abnormal (spastic) flexion, decorticate posture (3 points)
 Extensor (rigid) response, decerebrate posture (2 points)
 None (1 point)
The Glasgow Coma Scale (GCS)
VIDEO:
https://www.youtu
be.com/watch?v=t
MGhpMai4cQ

45. Acute Subdural Hematoma

46. Videos: https://www.youtube.com/watch?v=hY2yKTT-q-k

47. Rancho Los Amigos Scale
Level I No Response: Total Assistance
Level II Generalized Response: Total Assistance
Level III Localized Response: Total
Level IV Confused/Agitated: Maximal Assistance
Level V Confused, Inappropriate Non-Agitated: Maximal
Assistance
Level VI Confused, Appropriate: Moderate Assistance
Level VII Automatic, Appropriate: Minimal Assistance for
Daily Living Skills
Level VIII Purposeful, Appropriate: Stand-By Assistance
Level IX Purposeful, Appropriate: Stand-By Assistance on
Request
Level X Purposeful, Appropriate: Modified Independent

48. Justin’s Story

49. Severe Disorders of Consciousness
As seen in the ICU:
• Trach
• ICP Monitor
• NG or G-tube
• Restraints
• Protocols for positioning
and stimulation
“The vast majority of individuals
who cross that one-year mark
without clear signs of
consciousness are not going to
recover consciousness after that.”

50. Transitioning from the Medical Treatment
Phase to the Rehab/Recovery Phase after TBI
Priorities:
 Medical stability
 Reduction of physical impairments
 Acquisition of basic self-care skills

52. Click here for
demo videos:
• Part 1
• Part 2

53. The Role of Occupational Therapy with Clients
with Severe Disorders of Consciousness
Restorative & Preventative Strategies
 ROM exercises
 Positioning protocols
 Tone alteration methods
 Reducing agitation by
normalizing/regulating the
environment
 Sensory stimulation (?)
 Family/caregiver education
and support
Intervention lays the foundation for later
focus on occupational engagement.

54. The Role of Occupational Therapy with Clients
with Emerging Functional Statuses after TBIStrategies to Promote
Alertness/Participation and “Just Right
Challenges”
 Optimizing motor function with
a purposeful/functional
foundation
 Improving strength and
endurance
 Targeting balance and more
automatic skills
 Maximizing freedom of
movement and access to making
choices while maintaining safety
 Addressing social-emotional
and behavioral challenges
 Consulting with
family/caregivers and rehab
team
“One step
forward,
two steps
back”

55. The Role of Occupational Therapy in Facilitating
Community Reintegration in Clients after TBI
Centered on improving the acquisition and application
of skills in the following areas:
 Physical abilities including functional mobility
 Cognitive functioning
 Social integration
 Productivity
 Perception of self
 Interpersonal relationships
 Independent living skills (ADLs and iADLs)
OT intervention in this phase typically involves relearning (remediating) and
learning new ways to do things (compensatory strategies).

56. Tips for Providing Intervention
 Allow time for rest.
 Keep the environment
and instructions simple.
 Set reasonable goals.
 Give feedback and
redirect when necessary.
 Provide choices and vary
activities.
 Remember: Many times
patients do not remember
the facts, but they
remember how they felt!!
An OT Intervention Session
Recommended resource:
http://tbirecovery.org/LongTermPhase.html

57. Ten Years Strong:
Nate’s Journey After TBI