Assessments of TBI Flashcards
Initial thoughts- TBI Assessments
- there is no such thing as a typical brain injury
- brain injury can occur at any age
- there is no uniform set of symptoms characteristic of all TBIs
- there are some commonly seen consequences of brain injury
1. cognitive deficits
2. perceptual deficits- sensory
3. physical deficits
4. behavioral/emotional deficits
Cognitive deficits (8)
- attention deficits (basis for all)
- memory disorders
- language impairments
- impaired abstraction and judgment
- capabilities (inflexibility)
- decreased speed, accuracy, and consistency
- defective reasoning processes
- susceptibility to internal/external stressors (greater)
internal stressor- drive to suceed, fatigue
external stressor- deadlines- sometimes tbi patients don’t perceive the stressors
Perceptual Deficits
- decreased acuity or increased sensitivity in vision, hearing, or touch
- vestibular deficits (balance=equilibrium)
responsible for vestibular (toe, cerebellum, vision, EPS, semicircular canals) - spatial disorientation- proprioception
- disorders of smell and taste-anosmia
(taste receptors on the epiglottis)
Physical Deficits
- disorders of ataxia, spasticity, and tremors
- musculoskeletal disorders (pain/discomfort in the bones, joints, muscles, or surrounding structures; can be acute, chronic, focal or diffuse) (pt involved)
Emotional and behavioral deficits
- irritability
- impatience
- poor frustration tolerance
- dependence- worse with aphasia
- denial of disability
- emotionally liable (cry, laugh)
Prior to direct assessment…
- obtain as much information as possible (i.e., chart review)
- GCS- not over time- it is a point in time
- review type and severity of the brain injury
- date of onset
- identify the cerebral areas affected (subcortical, cerebellar?)
- investigate the client’s medical history
- pre-trauma personality and pre-morbid status
- recent CT scans and MRIs (radiology report)
- additional neuromedical variables (extended coma, cerebral hemorrhage, etc)
TBI vs Aphasia vs ? 1
- speech/language characteristics resulting from TBI often resemble aspects of aphasia
- prominent aphasia-like symptoms include anomia, circumlocution, paraphasia, and perseveration
- dysarthria (especially spastic dysarthria) (cortical)
- look at language and pragmatics
- dysphagia
- You can have aphasia and TBI
TBI vs Aphasia vs ? 2
- the primary objection to making a diagnosis of aphasia (saying the Pt has aphasia) is that the pragmatic and language behaviors associated with a true aphasia differs from those associated with a TBI
- CVA = aphasia: results in mild to severe language deficits while retaining most social and pragmatic functions
- TBI = essentially normal receptive/expressive language; communication difficulties are related to cognitive deficit components
Assessment Areas (9)
- general cognitive/intellectual abilities
- language functions
- visuospatial, visuomotor, and visuoconstructional abilities
- attention and concentration
- learning ability (both verbal and nonverbal modalities)
- memory ability (both verbal and nonverbal modalities)
- motor functioning
- higher cognitive functioning
- emotional functioning
- remember the roles of the neuropsychologist
*** Don’t forget to assess language when doing cognition
s/l batteries (useful for TBI)
- Assessment of Intelligibility of Dysarthric Speech
- BDAE and MTDDA- Boston diagnostic aphasia assessment, minnesota
- Boston Naming Test
- BTHI- Brief test of head injury
- EOWPVT and ROWPVT
- PPVT
- Scales of Cognitive Ability for TBI or SCATBI
- Token Test- following directions
- WAB- Western aphasia battery
- RIPA (pediatric, adult, and geriatric)- Ross information processing assessment
“hard/soft” neurological signs 1
- hard signs give clear evidence of neurologic dysfunction
- soft signs are correlated with but do not confirm neurologic dysfunction
- correlation is not equal to causation**
- soft signs are not unusual for any child under 8y because they reflect an immature central nervous system
- soft signs are more often present in children w/developmental disabilities and those w/TBI than typically developing children
“hard/soft” neurological signs 2
- hard/soft signs are difficult to interpret without additional information from your comprehensive evaluation
- diagnoses should not be based solely on the presence or absence of one or more neurologic signs
“hard” neurological signs
- include but are not limited to:
1. abnormal infantile reflexes in non-infants (Babinski reflex, rooting, etc) (UMN) - confirm neurological dysfunction
- rooting reflex
2. disrupted motor function in one or more areas (unilateral paralysis or paresis)
3. disrupted sensory function in one or more areas (loss of vision)
4. dysarthria (slurred speech) that is not due to medications or physical injury
5. apraxia of speech or limbs
6. aphasia
Soft neurological signs 1 (5)
- include but are not limited to: (if the child is less than 8, not a definite neuro issue)
- hyperkinetic motor overflow (constant movement of extremities)
- impulsivity (responding prior to thinking or being given all info)
- distractibility both internally (daydreaming) and externally (environmental sights and sounds)
- inattention or difficulty focusing on one’s work
- heavy use of concrete thinking based on stimulus features (bus is yellow w/wheels as opposed to a vehicle or means of transportation)
Soft neurological signs 2 (5)
- slowed processing speed
- simultaneous movements of opposite limbs or digits that are unintended based on the task
- uncoordinated movements; slow motor movements
- immature grasp of writing instrument and difficulty drawing
- late milestone development
flow of assessment I
Simple to complex tasks-
- orientation
- automatics- 1-20, ABCs, DOW, MOY (can challenge by counting by 2s or 5s of months backwards)
- following directions
- organization
a. sequencing
b. categorization
i. rapid naming
ii. convergent/divergent naming
iii. similarities/differences
iv. which one doesn’t belong and why
flow of assessment II
- math
—word problems
- auditory processing
- memory
- functional problem solving
- multifactor problem solving
- deductive/inductive reasoning
- divergent thinking/abstract reasoning (verbal absurdities, humor)+
- convergent thinking; drawing conclusions
- reading passages
levels of consciousness
- alert
- lethargic
- apathetic
- aggressive
- fluctuating
KNOW THESE***
recovery issues
- your role will change based on your setting
- you will have to adapt your evaluations and treatments to fit the needs of your pt’s
- recovery can be categorized into three stages:
- early
- middle
- late
early stage goals 8
- acute phase (will require maximum therapeutic support)
- determine:
— can your pt comprehend commands and questions?
— can your pt make needs known?
— is your pt’s cognitive skills adequate for communication?
— is there a need for coma management techniques?
— presence of dysphagia?
— family education needs?
— role(s) of family in therapy
— staff education regarding pt’s needs
middle stage goals
- client may appear more “normal” (moving up in RLAS)
- is the client ready to return to the community; support or independently
- determine:
- —type and level of cognitive-communication breakdown
—-any compensatory strategies
—-best methods family can use to assist client
—-what about:
——–caring for children, independent functioning, management of finances, societal expectations
—-questions may arise about client’s competency
—-take note of delayed response times (latency periods), perseveration, failure to note errors, difficulty following instructions
Late Stage Goals
- discharge: focus is no longer centered on formal testing but on real-life situations
(rehab and home based therapies)
Traditional vs. functional tasks (daily life)
Pediatric recovery issues 1
- children recover from brain injury differently
- some may “seem” to recover back to premorbid levels of functioning, however higher level cognition must be assessed
- difficulties may not be obvious right away
- think about executive functions: multitasking, attention, memory, learning
- on-going limitations w/learning and memory can make it difficult to maintain age/grade level progress in school; slowed processing can affect socialization w/age-matched peers
Pediatric recovery issues 2
- brain recovery takes much longer than other medical conditions
- most recovery takes place during first 6-months post injury
- functional gains post 6-months can occur; will be much slower
- slow/steady becomes normal
- recovery due to plasticity
- Networks still forming
processes of recovery “positives”
- microscopically:
—cells in the brain may produce new dendrite branches for new connections w/other cells;
—previous cell connections may be strengthened or altered to change on how information is processed
—axon terminals may change amount of neurotransmitters that are released, making connections more effective
—axons may produce sprouts to re-establish synaptic connections
processes of recovery “negatives”
microscopically:
- recovery only involves the cells that were undamaged in the injury
- with a few exceptions, only the cells within an area of injury can help w/recovery
- cells from undamaged areas of the brain generally do not take over functions for other damaged areas
- cell growth involving axons and dendrites takes place at roughly 1/1000 or .001 meters per day; this accounts for the slow rate of brain recovery after an injury
predictors of recovery (3 predictors)
- in general, outcome from a brain injury is related to three main variables:
— physical aspects of the injury: type of injury, severity of injury, extent of injury (localized vs. diffuse)
— premorbid functioning: persons w/health brains and adequate intelligence prior to an injury will do better than those w/developmental disabilities
— support network and available resources: supportive families and resources that allow for more therapy or educational assistance after leaving the hospital generally recover better that those that do not
- What were they like?
- Family support is huge
patterns of recovery
- every case is different, however some similar patterns of recovery are:
— children w/more severe injuries are less likely to improve over the first two years following an injury than those w/less severe injuries
— children will progress through stages of recovery similarly, however, the progression may vary and then plateau.; recovery of skills can take days, weeks, months and years
— children may go through multiple periods of rapid gain followed by days or weeks of little recovery
- rates of recovery vary secondary to: medical complications, fatigue, pain, attention deficits, motor limitations, frontal lobe dysfunction
- Not just in hospital for TBI
yankauer suctioning
TRACH-NOSE-MOUTH
- Mucous may trap in Trach
- Mouth is full of bacteria so never start with the mouth, it’s the endpoint
LOC- Alert
- alert: fully awake and appropriately responsive to internal/external stimuli; still may have cognitive deficits
LOC- Lethargic
not fully awake; may drift in/out of awareness when not being stimulated; may appear sleepy or confused w/poor arousal or energy
LOC- apathetic
lacks motivation or initiation for goal-directed behaviors or volitional activities; shows diminished concern for things that were previous interests; loss of enthusiasm
LOC- aggressive
irritability and tendency for dis-inhibited verbal/nonverbal impulsivity; often temporary as pt recovers
LOC- fluctuating
variations in levels of awareness, energy, behavior
Traditional Test Tasks for cognition
- Stimuli
- Focus
- Units
- Setting
- Performance
- STIMULI-stimulus is presented in isolation; visual/auditory info presented (I)’ly
- FOCUS- specific processes are isolated; memory, attention, visual-perception
- Units- small amounts of info are used in tasks (e.g., words, shapes, pics, etc)
- SETTING- structured clinical setting w/reduced environmental distractions
- PERFORMANCE- responses are often judged quantitatively
Functional tasks (daily life) therapy for cognition
- Stimuli
- Focus
- Units
- Setting
- Performance
- STIMULI- multiple stimuli are presented w/integration of visual/auditory info
- FOCUS- ADL’s, etc involve simultaneous use of many processes
- Units- info = large amounts; stories, newscasts, conversations, directions
- SETTING- natural context is uncontrolled and unpredictable; multi-distractible
- PERFORMANCE- judged qualitatively per accuracy, adequacy, competence (perceived)
