Exam 1 Flashcards
Cognition (definition, areas included):
the act or process of knowing; includes every mental process that may be described as an experience of knowing;
includes attention memory reasoning problem solving
Rehabilitation (definition)
to restore or bring to a condition of health or useful and constructive ability
Cognitive Rehabilitation
a systematic applied set of medical and therapeutic services aimed to improve cognitive functioning and participation in activities; these activities may be affected by deficits in one of more cognitive domain. Its often part of a comprehensive interdisciplinary program (e.g. PTs, OTs, physicians, social workers, etc.)
Roles of Speech-Language Pathologist in cognitive-communication disorders
o Identification o Assessment o Intervention o Counseling o Collaboration o Case Management o Education o Prevention o Advocacy o Research
Criteria for Empirically Validated Treatment
What are some well-established treatment criteria?
(One sentence description)
Well-established treatments:
I. At least two good between-group design experiments, demonstrating efficacy in one or more of the following ways:
A. Superior (statistically significant differences) to pill or psychological placebo or to another treatment.
B. Equivalent to an already established treatment in experiments with adequate sample sizes.
Or
II. A large series of single-case design experiments (n> 9) demonstrating efficacy. These experiments must have:
A. Used good experimental designs and
B. Compared the intervention to another treatment as in IA.
Further criteria for both I and II:
III. Experiments must be conducted with treatment manuals or detailed descriptions.
IV. Characteristics of the client samples must be clearly specified.
V. Effects must have been demonstrated by at least two different investigators or investigating terms.
What are probably efficacious treatment criteria?
Probably efficacious treatments
I. Two experiments showing the treatment is superior (statistically significant so) to a waiting-list control group.
Or
II. One or more experiments meeting the Well-Established Treatment criteria IA or IB, III, and IV, but not V.
Or
III. A small, series of single-case design experiments (n>3) otherwise meeting the Well-established Treatment criteria.
Traumatic brain injury
a traumatically induced physiological disruption of brain function and/or structure resulting from the application of a biomedical force to the head, rapid acceleration/deceleration, or blast related forces. (Kay et al. 1993)
Focal lesions
occur precisely at a specific point
Result from cerebrovascular events such as: -hemorrhage
- neoplasms
- tumors
- brain abscesses
- focal trauma
- Effect of a focal lesion is directly related to the size, the location, and the depth
- Sudden onset lesion vs. tumor (gradual progression)
- Sudden onset lesions are more serious than tumors of the same size. There is more time to react to a tumor because the progression can be seen.
- Tumors typically create noticeable clinical effect
Multifocal lesions
o Multiple distributed occurrences of any of the pathologies described in focal lesions, multiple tumors, hemorrhages, focal trauma, or abscesses
Severe CVAs and TBI
• More likely to be severe when there are multiple lesions
Bilateral lesions vs. unilateral lesions
• Bilateral lesions lead to more functional impairments
Simultaneous lesions vs. staged lesions
• Simultaneous lesions more likely to be severe than staged lesions
o Stages lesions happen one instance at a time (e.g. several falls over the course of a year or two)
Diffuse brain injury
o Occur due to wide damage of brain tissue
o Examples:
• Injuries due to significant acceleration/deceleration forces
• Hypoxic-ischemic injuries where there is lack of oxygen to the brain
• Metabolic disorders
• Infectious disorders
• Inflammatory disorders
o Effect of these injuries depend on the nature and density of the damage to brain structures
Frontal lobe
Planning, organizing, problems solving, memory, impulse control, decision making, selective attention, controlling behavior and emotion.
Injury to the frontal lobe may effect
- emotions
- impulse control
- language
- memory
- social and sexual behavior.
The left frontal lobe plays a large role in speech and language.
Parietal lobe
Integrating sensory information from various parts of the body, contains primary sensory cortex, tells us which way is up, helps us keep from bumping into things when we walk.
Injury to the parietal lobe may effect:
-ability to locate and recognize parts of the body.
Occipital lobe
Receive and process visual information, perception of size, shape and color.
Injury to the occipital lobe may cause: -distortion of the visual field
-distorted perceptions of size, color, and shape
Cerebellum
Controls balance, movement, coordination. Allows us to stand upright, keep our balance and move around.
Damage may effect
- movement
- muscle tone
- gait
Temporal Lobe
Responsible for recognizing and processing sound, understanding and producing speech, and various aspects of memory.
Damage may effect
- hearing
- language
- ability to recognize familiar people’s faces, -processing sensory information.
Hippocampus
Important for memory creation and retention, helps with orientation in surroundings, facilitates our ability to navigate and find our way around the world.
Damage may effect
- new memory creation and retention
- mood
- confusion
- disorientation.
Brainstem
Regulates basic involuntary functions such as breathing, heart rate, blood pressure, swallowing. Also plays a role in alertness and sensation.
Damage may effect
- breathing
- heart rate
- swallowing.
Focal damage
Skull fractures and focal damage to the underlying brain tissue occur when the head is struck by or forceful contraction of a ridged surface (e.g. hit by something or fall and hit floor)
Acceleration-deceleration forces
occur when the head suddenly stops but the brain continues to move in the original direction of motion and then re-bounce in the opposite direction
o These forces can tear some blood vessels of meninges and brain surface.
o The bleeding can result in bleeding into space surrounding the brain surface (extradural and subdural hematomas).
o The blood accumulations can cause damage or create pressure on the brain itself.
o Deep cerebral damage may occur due to torn arteries resulting in intracerebral hematomas or due to infarcts where tissues are deprived of blood perfusion for some time.
o Acceleration-deceleration forces may also cause stretching, deformation, and shearing effects on the neurons.
o Long fiber tracts coursing throughout the brain are vulnerable to acceleration-deceleration injuries.
Cortical contusions
o They happen because of focal areas of bleeding and swelling
o They are very common in motor-vehicle accidents and falls
o Rubbing of the tissues together so there is a lot of tissue damage
Coup and contre-coup injuries (actual damage caused by acceleration/deceleration, fall forward and then fall backwards)
o Injuries in which the brain is thrust forward on impact and then rebounds to the opposite direction causing damage to opposite sides of the brain
o Very common in motor-vehicle accidents
o Front part (hits front of head) is coupe, then contre-coup when it bounces and damages the opposite side of the brain
Diffuse axonal injury (DAI)
• During rapid and powerful acceleration/deceleration forces the axons of the nerves cells may be damaged due to the widespread shearing and stretching action of the nerve tissues
o A significant destruction or damage of neuron involves the entire neuron including the cell body.
o It is also possible that neighboring neurons which receive inputs from the damaged neuron may also die.
o Large portions of cerebral hemispheres and brainstem may be damaged depending on the amount and location of DAI.
o DAI follows a gradient, there is a sequence in which the injuries happen. Least injury in the peripheral areas and most damage to the central and midbrain areas
o In addition to axonal damage, DAI may also lead to destructive processes including axonal transport and axonal swelling which may further result in separation of proximal and distal ends of axons. Affects communication between the neurons.
o The extent of DAI is directly related to the overall severity of the TBI and the functional outcomes (things they want to do for their basic needs and wants).
o Some commonly affected areas: the medial frontal lobe, corpus callosum, and superior cerebellar peduncles.
Coma
Period of unconsciousness or unawareness following brain damage
Depth of coma is an important early indicator of severity.
• Classification of level of coma during the first 24 hours after the injury and the duration of post-traumatic amnesia (PTA) help define whether it is mild, moderate, or severe
Tests to assess coma:
Glasgow Coma Scale (GCS)
• P. 34 Table 2.3: Classification of Severity of TBI
-has scores ranging from 3-15. Scores of 8 or less indicate severe injury.
Galveston Orientation and Amnesia Test: used to assess different levels of PTA
-used to assess different levels of post traumatic amnesia. Assesses major levels.
Post-traumatic Amnesia (PTA)-
PTA includes the period of coma and extends until the patients memory of ongoing events become reliable, consistent and accurate
Duration of PTA correlates with residual physical and cognitive impairments
Classification of level of coma during the first 24 hours after the injury and the duration of post-traumatic amnesia (PTA) help define whether it is mild, moderate, or severe
Patterns of Recovery (brief 1-2 sentence descriptions)
Initial Stage
First 4 weeks since the time of injury
• Unconsciousness and sleep/wake cycles and opening eyes
• May or may not have purposeful behavioral responses or understanding of what is going on around them
• If this stage continues for more than a year it is then called a vegetative state, and that can continue for weeks or years. Vegetative state: arousals but are not alert or aware.
First signs of recovery
• Tracking of visual stimuli or orientation to auditory stimuli
• May respond to automatic or reflexive responses (e.g. feed and opens mouth or wipe face closes eyes)
• Gradually come to have greater volitional control
Other features
• May also begin to respond to some commands
• Some restlessness and agitation
Patterns of Recovery (brief 1-2 sentence descriptions)
Next Phase
o Orientation and continuous memory may be restored.
o Deficits in memory and learning may persist.
o Length of this phase varies with severity of the injury.
o This stage involves emphasis on training and resumption/stabilization of self-care activities, and on ambulatory and other motor activities (rehabilitation)
o Cognitive deficits may still persist and efforts are made to: • Stabilize orientation • Facilitate effective communication • Improve attention • Use compensatory strategies
o Many individuals with TBI have no or limited awareness of the extent or implications of their deficits or functional impairments. Educate them and the family members.
Patterns of Recovery (brief 1-2 sentence descriptions)
Later Stages
o Following discharge from inpatient rehabilitation, majority of individuals with TBI return home.
o Based on severity of injury and degree of residual functional impairment, most individuals are able to redevelop some level of independence in self-care.
o Residual problems are seen in a wide range of cognitive abilities such as attention, memory, organization, and carrying out goal-directed behaviors.
Cerebral hemorrhage: definition
bursting of a blood vessel and release of blood into the brain
Cerebral infarction: definition
i. Thrombosis vs. Ischaemia
A type of ischemic stroke resulting from a blockage in the blood vessels supplying blood to the brain
o Thrombosis
• Blockage of a blood vessel by a blood clot
o Ischemia
• An atherosclerotic tissue where a tissue is deprived of blood because of a blockage
• Mortality is typically related to size of infarct. Big infarct the person may die
• Cognitive and behavior abnormalities may be seen even with smaller infarcts
• Causes of infarcts
o Complete or partial blockage of an artery due to arteriosclerosis
o Artery blockage due to an embolus
o Specific degeneration of small blood vessels resulting in lacunar infarcts
CVA involving middle cerebral artery: areas involved, symptoms
• Supplies to lateral surfaces of frontal, temporal, and parietal lobes
o It is most commonly involved artery.
o Origin of MCA and innervated areas
o Most common physical effects of stroke
• Deficits in ambulation
• Upper extremity paralysis
• Tactile sensory impairment in contralateral limb
• Visual effects involving the contralateral visual field
o Common cognitive impairments for left MCA
• Aphasia
• Oral and limb apraxia
• Verbal learning impairments
o Common cognitive impairments for right MCA
• Visual spatial impairments
• Non-verbal learning impairments
• Impair awareness of self-deficits
• Deficits in pragmatic aspects of communication
• Impaired attention
CVA involving posterior cerebral artery: areas involved, symptoms
o Relatively rare in occurrence compared to MCA lesions.
o Areas innervated by PCA include occipital lobes, medial and inferior parts of the temporal lobes, and the thalamus
o Bilateral thalamic strokes have devastating effects • Effects can include: • Severe deficits in attention and memory • Confabulations • Lack of spontaneity • Apathy • Flat affect • Trouble with eye movements
o In some cases thalamic pain syndrome may occur: there is initial contralateral feeling of numbness or tingling with compromised tactile sensation (not sure exactly where the pain is)
CVA involving anterior communicating artery: areas involved, symptoms
o Anterior communicating artery crosses the midline right at the base of the brain and it forms the anterior portion of the Circle of Willis.
o It communicates with anterior cerebral arteries.
o Common site for aneurysms which involve balloon-like structures developed from weak or abnormal vessel walls.
o Common risk factors for aneurysms are -age
- cerebrovascular disease
- increased blood pressure
o Symptoms
• Confabulations
• Disinhibition
• Amnesia (Severe anterograde amnesia: no memory after the injury )
• Severe retrograde amnesia: no memory before the injury
• Deficits in executive functions
• Limited awareness
Hypoxic-hypotensive brain injury: definition, areas involved
i. Mild injuries vs. severe injuries
o Cerebral hypoxia (AKA cerebral anoxia): lack of oxygen in brain areas
o Cerebral hypotension: Refers to inadequate cerebral perfusion due to insufficient blood pressure or flow to maintain oxygenation
o Cerebral hypoxia and hypotension may occur during abnormal cardiac or respiratory functions.
o Mild hypoxic-hypotensive injuries: They will have rapid recovery in most cases
o Severe hypoxic-hypotensive injuries: Poor prognosis in terms of functioning
o Areas vulnerable to hypoxic-hypotensive injuries include occipo-parietal cortex and cerebellum
Coma durations and effects on prognosis
o Anoxia is often followed by period of coma. Prognosis is better with coma durations of less than 24-48 hours. A coma lasting longer than 48 hours may lead to higher mortality incidence.
o Period of coma is followed by gradual recovery of orientation along with a persistent and often severe memory impairment.
o Memory deficits may be seen over a much longer period of time compared to other brain injury events.
Encephalitis: definition, areas affected, symptoms
Infection of the brain itself
o Meningoencephalitis: Infection affecting the brain and the meninges
o Herpes simplex virus is one of the most common infectious agents. It can affect individuals of all ages.
o Epidemic and seasonal viruses are often transmitted from infected vertebrate carriers to humans by mosquitoes.
o Effects of most viral infections are difficult to predict:
• Widespread destruction of neurons in many locations throughout the brain/
• Usually there is extensive damage to the inferior and medial temporal lobes, to the basal and orbital portions of the frontal lobe, and to insular cortex.
• Acute phase of viral encephalitis is characterized by fever and meningeal involvement.
• Depending on nature, severity, and course of the infection, the individual may present range of symptoms or more specific neurological signs
• A week or two after onset, patients who survive the infection begin to regain consciousness after which specific neurological impairments may become evident.
• It is also possible to see global cognitive, motor, and behavioral problems.
• Lesions affecting medial temporal lobe can cause anterograde episodic amnesia and can also cause problems with learning new information
• Lesions affecting anterior temporal association areas and insula can cause retrograde amnesia and semantic memory loss (won’t understand the meaning of words)
Meningitis:
infection of the meninges of the brain
Cerebral Tumors
o Brain tumors are abnormal growths of tissue found inside the skull.
o Tumors may be classified as benign (or noncancerous) or malignant (or cancerous).
• Benign tumors: look very similar to normal cells, they grow relatively slowly, and they are confined to one location (won’t spread)
• Malignant tumors: have a different kind of cells, grow quickly, and can spread to other locations
o Symptoms • Headaches • Seizures • Nausea • Vision problems • Motor problems • Balance problems • Hearing problems • Or a combination of behavioral and cognitive symptoms
o Commonly used treatments
• Surgery
• Radiation
• Chemotherapy
o Doctors may recommend additional treatments including radiation and/or chemotherapy for malignant tumors.
Angiogram
2-4 sentence descriptions
o Description: Primarily used to detect vessel abnormalities including occlusion, malformation, or aneurysms.
o Can also be used to determine position of vessels in relation to other intracranial structures.
o A contrast medium (dye) is injected into the major blood vessels and a series of x-rays are conducted following each injection.
o Can help in identifying occlusions, abnormalities, swellings within the vessels, as well as displacement of the vessels or ventricles indicative of tumors.
o Outdated in some cases today because of CT scans and fMRI
Computed tomography (CT) (2-4 sentence descriptions)
o One of the revolutionary diagnostic tools, which is noninvasive, fast, safe, and painless.
o Principle: the body tissues absorb x-rays differently based on their electron density (bones have different density than the muscles)
o Preferred method for diagnosing congenital brain abnormalities, abnormal calcifications, demyelinating diseases, brain edema, tumors hemorrhages, and CVAs
o Critical tool for individuals with TBI involving skull fractures, seizures, focal neurological deficit, and a Glasgow coma scale score (GCS) of less than 15 for 24 hours or more (range 3-15).
o A contrast media may be used to improve the spatial and density resolution of the images
o Allows direct visualization of intracranial soft tissues, bone, ventricles, cisterns and subarachnoid spaces, sinuses and vessels.
o Useful for imaging of major blood vessels
Magnetic Resonance Imaging (MRI)
2-4 sentence descriptions
o It involves computer processing of radiofrequency-induced excitations of protons aligned in a strong magnetic field.
o 3-D images of brain and surrounding skull can be created.
o Provides more in-depth imaging of anatomical structures than CT.
o Useful to identify:
• Small lesions within the brainstem and the sub-cortex.
• Intracranial tumors
• CVAs
• Multi-infarct disease
• Multiple sclerosis
• Brain degeneration and atrophy related to degenerative diseases (Alzheimer’s)
o Can identify small lesions within the brainstem and subcortical areas.
o Allows study of blood flow within medium-sized and larger arteries and veins without any contrasting agents.
o Limitations: no Pacemakers, no electronic devices, must be very still and patient (longer imaging time), incompatible with life-support systems, can be noisy and confining, exposure to magnetic field, very expensive (may not be available in some medical settings).
Functional Magnetic Resonance Imaging (fMRI)
2-4 sentence descriptions
o Some fMRI applications include magnetic resonance spectrography, diffusion-weighted MRI, and magnetic resonance angiography.
o Principle: the blood flow within the body varies with the level of metabolism and functional activity in those tissues. The areas that are really active need more blood supply and oxygen and that will show up on the fMRI. Higher activity is linked to greater oxygen supply.
o Brain functions are studied by monitoring the cerebral metabolism and blood flow.
o It involves much less risk than PET and SPECT and can be used repeatedly. Can be repeated safely.
o More functional because patient can do tasks while brain is examined (look at a picture)
Positron Emission Tomography(PET)
2-4 sentence descriptions
o Involve imaging of cerebral blood flow, brain metabolism, and other chemical processes of brain during tasks.
o These techniques are considered dynamic as they provide information while a participant is engaged in motor, sensory, cognitive, or behavioral tasks.
o PET utilizes positron emissions from radioactive isotopes of different elements.
o Patients inhale or are injected with a radioactivity-labeled form of glucose, and emissions from different compounds are measured. Radioactivity will be increased in active brain areas utilizing more glucose.
Infants and children:
• Neurons undergo massive changes in form and connections during normal development and aging.
• Sequence of development:
➢ 1 month (after birth): the nerve cells migrate to appropriate targets in the CNS. Once the neurons reach their destinations they develop axons and dendrites and form synapses.
➢ 8 months: the most intense dendritic growth happens.
➢ 1 year: the synaptic density activity reaches the maximum.
➢ Pruning: occurs with deletion of unwanted synapses. (Capability of babies to speak any language up to 8 months when synapses are pruned around 8 months to 1 year). Pruning can happen in terms of other development if that skill is not being used up to 8 months of age (hearing).
• Kennard principle: If someone gets a TBI early in life they will have a quicker recovery from the injury.
• In contrast to Kennard, Hebb (1949) postulated that brain injury results in more severe behavioral disruption than similar damage in later life.
• Although the “earlier is better” theory hold true for focal lesions, recovery from prenatal injuries, early diffuse injuries, or early injuries to particular brain regions may have serious implications and long-lasting effects (e.g. CP).
• Early injury can significantly affect the acquisition and development
• Although there is more potential for plasticity in younger children, critical lesions may result in permanent deficits.
Young adults:
- Better recovery levels than older individuals.
- Age has an effect on long-term adaptation to brain injuries
- According to Corkin et al. (1989), individuals with prior brain injuries show a greater decline in performance than individuals with no history of brain injury.
Old adults:
- Impact of an injury on an older individual may vary with age-related maintenance or decline of cognitive abilities.
- Age-related neuronal cell shrinkage in the frontal areas (most commonly happens in older individuals)
- With normal aging, the frontal lobes show greater volume reduction, neuronal loss, and reduced blood flow compared to the parietal, occipital, or temporal regions. As a result, cognitive processes supported by frontal lobes show earlier and greater decline than cognitive processes supported by other brain areas.
• From a rehab point of view, it can be easier to work with the older adults because they have a stable lifestyle, better coping skills, more support, and fewer life demands than young adults. All of these things can have positive impact on the rehab outcomes.
Brain reserve capacity:
hypothesis which states that there is a pool of available brain capacity that provides protection from clinical symptoms but is still vulnerable to depletion via intrinsic and extrinsic events.
Premorbid intelligence and educational level
i. Lower vs. higher education
o Varied cognitive requirements associated with educational activities may contribute to greater connectivity of neural networks.
University education vs. high school education.
• Brains of deceased people with university education tend to have more cortical neurons and dendrites then people with high school education
Role of innate ability and exposure
• Role and involvement in various experiences contributes to brain physiology and functional capacities
Educated individuals are more likely to have better or more practiced premorbid learning abilities and potentially more motivation for participation in rehab, more family support, and more access to rehab services
Gender
Limited research on possible gender effects on recovery of function.
o Evidence for brain differences are present between males and females in terms of the shape and size leading to both interhemispheric and intrahemispheric (differences in brain function between males and females in terms of right and left hemispheres and within the hemispheres)
o Potential recovery mechanisms including dendritic branching and synaptic contacts appear to be influenced by fluctuations in gonadal hormones.
o According to Kimura (1983), aphasia is more frequently in males.
o Sex hormones and hormonal cycling play a really important role in an individual’s response to injury.
Cultural background
o Includes: language disturbances, differences in group identity, beliefs and values.
o The literature indicates that multicultural clients are likely to end treatment prematurely due to misunderstandings, frustration, role ambiguities, difference in priorities of treatment.
o There is a need to develop culturally relevant and appropriate treatment materials and activities.
Premorbid functioning
o Individuals with TBI tend to have a higher rate of drug and alcohol abuse prior to injury. In many cases, the substance use may contribute to brain injury.
o Factors predictive of poor vocational outcomes in TBI
• Unstable work history
• Alcohol use following injury
Injury-related Variables
-Time since injury
o Early vs. later stages
• Rate of recovery is faster during the early stages of brain injury and usually decreases over time
• Spontaneous recovery: natural recovery within the first 6 months after the injury. Maximize that period with rehab.
o Most rapid recovery occurs during the first 6 months (spontaneous recovery) with slow but significant recovery occurring over the next 2 years.
o Some evidence suggests that underlying motor and cognitive skills including attention can improve with structured interventions even years following injury.
o For mild TBI injuries the recovery rates are faster with resolution of symptoms within 3-6 months in 70% of those injured and 85% asymptomatic by 12 months after injury.
o The differences in rates of recovery may occur as undamaged areas may get deprived of neuronal input from and to the damaged areas. As a result, the undamaged areas may have altered functioning and leading to a large area of functional lesion.
-Spontaneous recovery- definition, time range
Spontaneous recovery: natural recovery within the first 6 months after the injury. Maximize that period with rehab.
o Most rapid recovery occurs during the first 6 months (spontaneous recovery) with slow but significant recovery occurring over the next 2 years.
o The spontaneous recovery occurring during the first 6 months includes:
• The reconnection of undamaged areas with other areas
• Adjustments of functions to compensate for the lack of input from lesion areas.
Diaschisis:
refers to reduced activity in remote and undamaged areas that is functionally connected to a lesion area (could result in poorer outcomes and more problems).
Injury extent and severity
i. Focal vs. diffuse
o Mild TBI vs. severe TBI injuries.
• Severe- slower recovery
• Mild- faster recovery
o According to Dikmen et al. (1995), there is a close relationship between the TBI severity and expected recovery curve. Recovery tends to occur rapidly for focal pathologies compared to diffuse injuries, although recovery may also relate to overall size of injury. Focal lesions may still have a significant and long-term impact based on areas of damage.
o Some types or degrees of brain damage are irreversible.
o With focal lesions, it is possible to restitution of functions. However, with severe injuries the recovery involves greater amount of compensation and behavioral adaptation.
o Diaschisis plays an important role in recovery; however, some types or degrees of brain damage are irreversible such that no synaptic reorganization would allow reconnection of affected brain areas.
Recovery rate
i. Simple overlearned tasks vs. complex activities
Simple highly familiar tasks vs. complex tasks
• Highly familiar tasks typically occur faster than recovery of more complex or novel activities
• Writing your name vs. filling out a medical form
Complex activities tend to require multiple underlying and interconnected skills
• Require multiple skills and more conscious and flexible control
• The frontal lobe is important for a lot of complex functions
• It can be concluded: The frontal lobe functions including effortful attention, flexible planning, organization, and problem solving are often the most persistent impairments following diffuse brain injury.
Differential recovery may also relate to the extent of lesion. Some areas may have a higher chance of recovery sooner than other areas
• Broca’s and Wernicke’s demonstrate gradual and usually incomplete recovery
Psychological Factors
Depression and anxiety are very common.
Conditions posing serious challenges to progress.
o Anger
o Resistance
o Refusals to participate
- During early stages of rehabilitation, individuals with severe TBI may benefit from behavior-based interventions. As self-awareness and self-regulation of client improves, therapists may work toward creating a more effective context for rehabilitation.
- Management of depression and anxiety through pharmacotherapy and supportive psychotherapy may be helpful to rehabilitation efforts.
Neuroplasticity:
the brain’s capacity to change and alter its structure and function. It is very critical to rehabilitation following a brain injury.
Synaptic plasticity
o Learning and experience cause physical changes in the adult brain.
o All adults have an ongoing neural connectivity.
o A neuron that has lost input from a damaged neuron can develop new dendrites or dendritic spines to receive information from another neuron in the same circuit, or even from another, more distant circuits. This synaptic plasticity is important for both normal learning as well as recovery processes.
o “Cells that fire together wire together”
• The synaptic connections become stronger when pre- and post synaptic neurons are activated at the same time
Recommendations during early stages of recovery:
o Make sure the patient is rested.
o Make informed use of pharmacological interventions.
o Make use of natural windows of increased arousal and responsiveness.
o Monitor and control the attentional load of your clients. Watch out for overstimulation.
o Many behaviors may be elicited by an effective cue.
o Distributed practice over short periods is more effective than massed practice conducted in a single session.
Recommendations during later stages of recovery:
o Use shaping and behavioral chaining strategies.
o Emphasis on modification of antecedents and consequences in behaviorally oriented training.
o Teaching personalized attention and memory strategies.
o Work towards speed and efficiency of processing and responding while minimizing error rates.
Impairment: definition
loss or disorder of cognitive, emotional, or physiological function
Activity/functional limitations: definition
resulting from impairments and refer to effects or impairments on a person’s daily like functioning
Participation: definition
the nature and extent of a person’s involvement in life situations in relation to impairments, activity limitations, health conditions, and contextual factors.
o Represented by both the person’s degree of participation and society’s response
o Seven domains of participation that we might assess
- Personal maintenance (hygiene)
- Mobility
- Exchange of information
- Social relationships
- Areas of education, work, leisure, and spirituality
- Economic life
- Civic and community life
Validity- definition
Accuracy, how accurate the test is, whether it is giving you the right information
Reliability- definition
Consistency, Same consistent result over and over again
Generalizability- definition
the extension of research findings and conclusions from a study conducted on a sample population to the population at large.
Noncognitive factors influencing cognitive assessments:
Variety of nonspecific factors ➢ Hunger ➢ Fatigue ➢ Headache ➢ Other sources of pain
Some additional physical factors ➢ Visual field deficits ➢ Hemiparesis ➢ Poor visual acuity ➢ Hearing problems
Emotional problems ➢ Anxiety ➢ Worry ➢ Boredom ➢ Preoccupation with other thoughts and concerns
Functional Approaches
a. Structured observations
b. Rating Scales
Functionally oriented psychometric measures (ecologically valid measures)
• These tests have been developed by testing people at home or in more natural settings (more information is acquired than in a clinic environment)
Structured observations and functional rating scales
• Survey, rating form, have them talk with family member and observe their interactions
Direct observations can be extremely useful in functional setting.
• Observe them while they are talking or explaining their problem to you
Rating scale can be particularly effective to examine differences in ability across different settings.
• How bad is your memory in a noisy environment?
• Compare performance across settings
Limitation
• May not have adequate psychometric properties
Orientation and arousal: Tests used
The Agitated Behavior Scale (Corringan, 1989; Corrigan & Bogner, 1994):
a. It is useful for assessing individual’s recovering from severe injuries demonstrating slow emergence of cognition
b. It is helpful in monitoring time-related patterns of agitation and restlessness
c. It is useful for documenting aggression when it is a product of agitation and confusion
d. It can be used to get different scores: a Disinhibition score, and aggression score, and a lability score (inappropriate laughter or crying).
General cognitive/intellectual abilities: Test used
The Wechsler Adult Intelligence Scale- III (WAIS III) is the most widely used measure of general intellectual ability.
➢ Represents a composite of performance on variety of skills:
o Retrieval of general information
o Vocabulary knowledge
o Abstract reasoning
o Both verbal and non-verbal problem solving or reasoning tasks
o Memory recall
o Tests involving psychomotor speed
WAIS-III gives four factor scores o Verbal comprehension score o Perceptual organization score o Working memory score o Processing speed score
Verbal vs. nonverbal subtests
o Verbal subtests tend to be less sensitive to acquired brain damage
