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Neuroanatomy term 2 > Brain Injury > Flashcards

Brain Injury Flashcards

1
Q

What are the main causes of brain injury

A

car accident, motorcycle accident, gun shot

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2
Q

2 types of brain injury

A

Focal brain injury

Multifocal brain injury

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3
Q

Progressive stages

A

Primary brain damage, secondary brain damage, complications

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4
Q

Focal Brain damage

A
  • direct blow to the head after collision with an external object or fall
  • a penetrating injury
  • collision of the brain with the inner tables of the skull
  • Bones of the face or skull may or may not be fractured
  • injuries to the coverings of the brain
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5
Q

Focal brain damage: Injuries to the coverings of the brain- epidural hematomas and subdural hematomas

A
  1. Epidural hematomas (EDH)
    - between dura matters
    - disruption of the integrity of the meningeal arteries
    - pressure builds up rapidly between the skull and the dura- quick mental and physical deteriorations
  2. Subdural hematomas
    - between the dura and arachnoid through tearing of bridging veins
    - deterioration is slower because venous bleeding is more gradual than arterial
    - may take hours or days to notice changes
    - usually traumatic
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6
Q

Multifocal or diffused brain injury- many different types

A
  • sudden deceleration of the body and head with variable forces transmitted to the surface and deeper portions of the brain
  • usually due to MVA, bicycle or skate board crashes, falls from high surfaces or off a horse
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7
Q

Different types (4)

A
  1. Intracerebral Hemorrhage- multiple small, deep hemorrhages
    - Typically between the grey and white matter, basal ganglia, corpus callosum, mid-brain, cerebellum
  2. Subarachnoid hemorrhage & intraventricular hemorrhage- when pia or arachnoid are torn
    - gives a bad head
    - can block CSF
  3. Diffused axonal injuries
    - due to rapid deceleration of the brain causing complete or partial rupture of nerves and axonal dysfunction
    -Lose ability to transmit normally along neuronal pathways
    clinical severity is determined by the length of the coma
    -shaken baby syndrome
    - associated with poor outcomes
  4. Ateriovenous malformation
    - congenital
    - defects on the capillary system
    - veins exposed to high flow
    - vessels enlarge at risk for hemorrhage
    - Leading cause of SAH in young
    - surgery, embolization, radiation
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8
Q

Progressive stages: Primary

A 
can be focal or diffucsed
- cognitive and behavioural deficits are among the most common, difficult and long lasting consequence of TBI
- common cognitive deficits include:
difficulty with memory for new info
visual and perceptual problems
decreased ability to process new info
limited executive function
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9
Q

Progressive Stages: secondary

A

Mainly result from limited oxygen in the brain

can be caused by increased intracranial pressure, ischemia,etc

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10
Q

Complications

A

Frequent:

  1. single or multiple seizures
  2. hydrocephalus
  3. extremity injuries
  4. cardiovascular complications
  5. deep comatose patients must be repositioned routinely to avoid bedsore and pressure ulcers
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11
Q

Severity ratings: (4)

Glasgow Coma Scale

A

Normal score is 15
used to determine the level of severity
1. identify within 48 hours of medical evaluation, based on the length of the coma and based on the score

Mild TBI
- loss of consciousness less than 10 minutes
GCS rating= 13-15
No skull fracture

Moderate TBI

  • hospitalization greater than 48 hours
  • GCS= 9-12

Severe TBI

  • Loss of consciousness greater than 24 hours
  • GCS= 1-8
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12
Q

Severity rating: Disability Rating Scale

A

Expanded on the GCS to provide a quantitative assessment of the disability of patients with severe brain injury

4 categories:

  1. Arousability, awareness and responsiveness
  2. Cognitive ability for self-care activities
  3. Dependence on others
  4. Psychosocial adaptability
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13
Q

Severity Rating: Rancho Los Amigos Level of Cognitive Functioning Scale (LCFS)

A

8 levels
corresponding cognitive function
descriptive measure of the level of awareness and cognitive function
for general classification

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14
Q

Galveston Orientation and Amnesia Test (GOAT)

A

no info- see slide for picture

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15
Q

Areas of OT assessment: Spasticity

A
  • flaccidity or hypotonic- decreased muscle tone- usually due to peripheral nerve injury
  • Spasticity or hypertonic- involuntary increase of muscle resistance- can be seen as early as a few days after Brain injury or take 3-6 months to develop- can lead to muscle shortening and contractures
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16
Q

Areas of OT assessment: Primitive reflex

A

occurs if midbrain is damaged- impaired righting reactions- ability to maintain the head in upright with changing body positions)
If basal ganglia is damaged- impairment in equilibrium reactions- maintain body alignment in response to change in position or surface support
** increased risk of falls during activities ex. transfers, toileting, bathing and lower limb dressing

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17
Q

Areas of OT assessment: Ataxia

A

damage to the cerebellum or motor pathways
- lose the ability to perform small adjustments in the distal and proximal extremities that are necessary for smooth and coordinated movement
- can occur in the entire body, trunk, UE, LE
- UE- difficult to bring glass of water to mouth
LE- difficulty maintaining balance
- muscle strength and ROM
-functional endurance
-sensation

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18
Q

Areas of OT assessment: cognitive abilities

A

memory, executive functioning, attention, concentration, visual status, perceptual skills
***remember cognitive and behavioural problems are among the most common difficult and long lasting consequences of TBI

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19
Q

Areas of OT assessment: Psychosocial

A

self-concept
social roles
affective changes
independent living status

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20
Q

Rancho Los Amigo level 1-3

Level 1- no response- total assistance
Level 2- Generalized response- total assistance
Level 3- Localized response- total assistance

A

Assessment Areas:
1- Level of arousal and cognition- ability to follow commands, purposeful movement, ability to verbalize, duration of staying awake

  1. Vision- maintain eye contact and scan environment
  2. Sensation- response to stimuli such as pain and cold
  3. Joint ROM
  4. Motor Control
  5. Dysphagia- ability to swallow
  6. Emotion- ability to express affect, flat or expressive
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21
Q

OT Treatment for level 1-3

A

Sensory stimulation- use a variety of different stimuli- visual, auditory, smell

Wheelchair positioning
Bed positioning
Splinting
Family and caregiver education

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22
Q

levels 4-8

4- Confused/agitated: maximal assistance
5.Confused, inappropriate non-agitated- max. assistance
6- confused, appropriate, moderate assistance
7. automatic, appropriate- min. assistance
8. purposeful, appropriate- by assistance

A

Assessment:
cognition: look for errors, frequency of cueing required, speed
formation assessment tools such as allen cognitive test, kohlman evaluation of living skills

Vision- visual attention, near and distant, depth perception

Perception

ADL and IADLS
Vocational rehab
Psychosocial skills

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23
Q

OT Intervention for 4-8

A

ADLS including transfers, self-feeding for patients with dysphagia

  • IADLS
  • behavioural management
  • cognitive remediation or compensation
  • organization strategies
  • re-teaching skills
  • social skills training
  • wheelchair management
  • energy conservation
  • environment modifications
  • community reintegration- home and safety adaptations and eduction, assistive devices, driving, family education, work skills training
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24
Q

COGNITIVE DEFICITS AND OT INTERVENTION

A

NOTHING

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25
Q

Memory deficits

A
  1. temporal extent
  2. Anterograde amnesia- any memory that extends forward in time from the onset of amnesia- prevents the formation of new and enduring memories
  3. retrograde amnesia- any memory that stretches backward in time from the onset of amnesia - prevents retrieval of info acquired prior to the onset of the amnesia
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26
Q

Brain structures related to amnesia

A
  1. Medial temporal lobe
  2. Hippocampal system- particularly critical for the formation of new long term memories- affects only new learning and memory for the recent past not remote past

Damage can occur from:

  • herpes simplex encephalitis
  • vascular accident
  • closed head injury
  • ECT
  • Alzheimer’s disease
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27
Q

Types of memory- contend description

A
  1. Episodic memory- autobiographical memory for contextually specific events= ex. remembering what one had for dinner, the content of therapy session
  2. Semantic memory- knowledge of the general world and vocabulary- remember names and holidats
  3. Declarative/explicit memory- knowing that something was learnt, having specific content
  4. Non-declarative memory/implicit memory- knowing how to perform a skill, procedure of tasks, habits, subconscious processes
28
Q

Types of memory- time factor

A
  1. Short-term- temporary stage of information with limited capacity; difficult remembering instruction about the use of adaptive equipment, not able to remember names introduced at a party
  2. Long-term memory- permanent storage of information, affect both declarative and non-declarative memory
  3. Working memory- actively manipulate info in short-term storage via rehearsal ex. while playing cards, unable to remember the rules of the game
  4. Prospective memory- remember to carry out future intentions- ex. remember to take medications, return phone calls, mail bills
29
Q

Types of memory- meta-cognitive

A

metamemory- awareness of your own memory abilities, ex. knowing when to compensate for memory capacity, recognizing errors

30
Q

Neural systems

A

declarative- facts and events: medial temporal lobe, hippocampus, frontal lobe, parietal lobe

  1. Non-declarative memory
    - procedural: skills and habits- striatum
    - simple classical conditioning: emotional- amygdala and skeletal responses in the cerebellum
    - non-associated learning- reflex pathways
31
Q

Assessment-

Rivermead Behavioural Memory Test (RBMT)

A
  • assesses memory skills related to every-day situations
  • items related to prospective memory, memory facts, immediate learning and delayed recall of new information
    subtests include:
    remembering an appointment, new short routine, deliver a message, remembering a name
32
Q

Assessment- Self-report; items describing a memory failure and patients rate the frequency of the memory failure

A

everyday memory questionaire etc

33
Q

Intervention

A

Compensatory techniques- memory notesbooks and assistive technology

Remediation- repetitive task practice to induce neural plasticity, gradually fade out the cue, provide immediate feedback on task performance

Task-specific training- errorless learning, chunking (grouping telephone numbers), developing a story, visual imagery

34
Q

Executive dysfunction

A

E.F acts as a manager of other cognitive processes such attention, memory and language

  • cognitive impairment following follwing TBI is often caused by impairment of central executive functioning
  • patients may be able to perform individual tasks eg. sustained attention, or recalling a persons name, but extremely poor in complex IADL tasks which require preparation, organization and planning
35
Q

Neural systems for executive function- Lateral Orbitofrontal Cortex

A
  • anterior and middle cerebral artery
    damage results in:
  • disinhibited
  • impulsive , poor affect and emotional control, socially inappropriate and increase distractibility, necessary to do risk assessment and evaluate, euphoric
36
Q

Neural systems for executive function: Dorsolateral Prefrontal Cortex

A

impaired attention, working memory, decision making, and procedural sequence learning- impaired higher-order cogntive functions- goal selection, planning, sequencing, shifting, self-monitoring

37
Q

Neural systems for executive function: medial area of frontal lobe

A

decreased drive, initiation, motivation, and interest, apathetic, reduced affect

38
Q

Assessment questionnaires for executive functioning

A

2o items sampling everyday symptoms associated with executive function impairments

  1. Behaviour rating inventory of executive function- adult version
39
Q

Performance Tests for Executive Functioning

A
  1. Multiple errands Test- undertaken in a shopping context that is unfamiliar to the person being tested
40
Q

Intervention- summary

A
  1. Metacognition- apply metacognitive strategies in tasks, usually can incorporate into task-specific process-specific training
  2. Task-specific training- eg. improve meal preparation, household cleaning
  3. Process-specific training- remedial activities to improve attention and memory, eg. working memory
  4. Compensatory- environmental adaptations, cueing device
41
Q

METACOGNITION STRATEGIES

A

metacognition is cognition about your cognition
assumes that metacognition can be learnt- understand- recognize deficits- ex. not able to plan, poor awareness
practice- use strategies eg. set priorities, stop and check
transfer- apply strategies to real life situations

42
Q

METACOGNITION STRATEGIES- CO-OP

A

Cognitive orientation to occupational performance
- Goal- Plan- DO- Check

Goal management training- 5 steps
Stop- what am i doing
Define- the main tasks
List the steps
Learn the steps
DO it
Check- am i doing what i planned?
43
Q

METACOGNITION STRATEGIES: Time pressure management

A

severe head injury can result in deficits in speed of information processing- feeling information overload
- teach patient to give themselves enough time to deal with daily tasks

44
Q

METACOGNITION STRATEGIES: Environmental adaptation

A

-decrease distractibility- keep workspaces clear of clutter eg. decks, kitchen table, turn off background noise

organize environment - use labelling, colour codes, calendars, appointment books, avoid multitasking

45
Q

METACOGNITION STRATEGIES: External cueing devices

A

Using AT such as Ipad Iphone, alarms, organizers, cues and timers

46
Q

ATTENTION

A

NEW SECTION

47
Q

Attention

A
  • Frontal Lobe
  • Reticular Activating System (RAS)
  • Alertness
  • Arousal
  • Speed of information processing
48
Q

Types of Attention

A

Selective Attention- attending to a therapist’s instruction and cues in a noise therapy clinic

Sustained Attention- being able to attend to long conversations, complete long assessment or treatment sessions

Alternating attention- able to pay attention to the therapist’s greetings, stop the task, and chat with the therapist in the treatment session

Divided Attention- Talking on the phone while choosing vegetables in a grocery store

***Distractibility- unable to follow instructions in a noisy environment

49
Q

Assessments for Attention

A
  1. Test of Everyday Attention- TEA- performance test- based on simulated functional activities
  2. Moss Attention Rating Scale (MARS)- observation by therapists
  3. Cognitive Failure Questionnaire (CFQ)- self-report
50
Q

Interventions for attention (3)

A
  1. Attention Process Training (APT)
    - Exercises resemble neuropsychological tests ex. detect targets with distractor noises, switching attention between figures
    - training of specific cognitive skills
    - transfer to functional tasks is difficult
  2. Training specific functional skills
    - simulated driving skills: visuomotor tracking, perform dual tasks while driving
    - training on specific ADL or IADLS or vocational tasks
    - incorporate strategies- time pressure management, self-instruction
  3. Compensatory techniques
    - avoid over-stimulating/distracting environments
    - shop or go to restaurants not at peak times
    - reduce visual distractors
    - use labels on drawers
    - use checklists for work, adls iadls
51
Q

VISUAL DEFICITIS FOLLOWING TBI & OT INTERVENTION

A

SECTION

52
Q

Deficits in visual attention

A
  1. Hemi-inattention
    - only occurs in patients with right hemisphere damage
    - Lost the attentional mechanism in the CNS that drive the search for visual information on the left
    - Difference in the way the hemispheres are programmed to direct visual attention
  • avoidance to search the left half of the visual space after right hemisphere damage
  • does not initiate the normal left to right visual search pattern
  • confine search to the right side of the visual array

assessments can include cancellation task, copying, clock drawing and line bisection

53
Q

Intervention for hemi-inattention

A

Remediation:
teach patient to recognize the scanning pattern, begin visual search on the left and progress to the right, to avoid patients from initiating the search on the right side, increase symmetry of the search pattern, reinforce item-by-item search strategies, attend to detail in the impaired visual space
-Activities to reinforce systematic and organized visual search
eg. games such as crossword puzzles, large pieced puzzles, dynavision (the lights on the board are illuminated one at a time in random patterns- to reinforce efficient search patterns to compensate for deficits in visual field- also useful for treating visual field deficits

  1. Occlusion- occlude the right half of the visual field to increase patients’ attention to the left- patients wear occluding lenses during the therapy session
    - practice search strategies on ADLS and IADLS depending on the needs of the patient
  2. Compensation using environmental modification- reduce background pattern so that objects in the foreground can be seen more easily- increase contrast between background and foreground- use markers and sharp labels on left side of drawers- eliminate visual distractors in the environment where the patient carries out daily activities
54
Q

Visual Field Deficits

A

-damage occurs on the visual tracks
- commonly occurs in brain injury- homonymous hemianopsia
-hemi = half
-anopsia= blindness
Homonymous- deficit is the same for both eyes

54
Q

Visual Field Deficits

A

-damage occurs on the visual tracks
- commonly occurs in brain injury- homonymous hemianopsia
-hemi = half
-anopsia= blindness
Homonymous- deficit is the same for both eyes

55
Q

Functional deficits following VFD

A

-narrow the scope of visual scanning
-typically turns the head very little and limits visual search because of the influence of perceptual completion
-the CNS is able to complete a visual scene based on expectation of limited visual information
- not immediately aware of the the loss of vision
- Basic ADLs- minor limitation
IADLS such as shopping and driving have more problems- may run into chairs on the blind side, not able to find items within the blind field, objects appear to be disappearing and reappearing esp. when walking
2 main areas of difficulty are mobility and reading

55
Q

Functional deficits following VFD

A

-narrow the scope of visual scanning
-typically turns the head very little and limits visual search because of the influence of perceptual completion
-the CNS is able to complete a visual scene based on expectation of limited visual information
- not immediately aware of the the loss of vision
- Basic ADLs- minor limitation
IADLS such as shopping and driving have more problems- may run into chairs on the blind side, not able to find items within the blind field, objects appear to be disappearing and reappearing esp. when walking
2 main areas of difficulty are mobility and reading

56
Q

Main differences between VFD and hemi-inattention

A

VFD= search pattern is abbreviated toward blind field HI= search pattern is asymmetrical and confined to the right side

VFD= attempts to direct search towards blind side vs. no attempt at all

VFD= search pattern is organized and efficient vs. search pattern is random and generally inefficient

VFD= client rescans to check accuracy of performance vs. not doing that

VFD= time spend on task is appropriate vs. completing activity fast and level of effort is not consistent with the difficulty of the task

56
Q

Main differences between VFD and hemi-inattention

A

VFD= search pattern is abbreviated toward blind field HI= search pattern is asymmetrical and confined to the right side

VFD= attempts to direct search towards blind side vs. no attempt at all

VFD= search pattern is organized and efficient vs. search pattern is random and generally inefficient

VFD= client rescans to check accuracy of performance vs. not doing that

VFD= time spend on task is appropriate vs. completing activity fast and level of effort is not consistent with the difficulty of the task

57
Q

Important**

A

Combination of hemi-inattention and left VFD = visual neglect

57
Q

Important**

A

Combination of hemi-inattention and left VFD = visual neglect

58
Q

Assessment for VFD

A

visual skills for reading test

58
Q

Assessment for VFD

A

visual skills for reading test

59
Q

Intervention for VFD

A

benefits from intensive rehabilitation is minimal
focus on compensatory strategies and reinforce safety in mobility
educate clients to develop insign, reinforce that visual input from the blind side can not be trusted

59
Q

Intervention for VFD

A

benefits from intensive rehabilitation is minimal
focus on compensatory strategies and reinforce safety in mobility
educate clients to develop insign, reinforce that visual input from the blind side can not be trusted

Neuroanatomy term 2 (8 decks)

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