Exam 3 Flashcards
Major etiologies of closed head injuries (4)
- falls
- motor vehicle accidents
- sports-related
- struck by/against injuries
Primary effects-diffuse
closed head injury (2)
- edema
- diffuse axonal injury (DAI)
- complete absence of observable change in behavior when presented visual, auditory, tactile, proprioceptive, vestibular, or painful stimuli
Rancho Los Amigos
Level I
No response: Total assistance
- intervention must be individualized
- intervention will vary depending on deficits and participation/ activity restrictions that result
- goals should reflect strengths and weaknesses
- individual and significant others should actively participate in goal selection and evaluation of progress
Client-Centered Treatment
closed head injury
secondary effects (7)
- ischemia
- hypoperfusion
- hyperperfusion
- necrosis
- increased intracranial pressure
- excitotoxicity
- oxidative stress
a lack of blood
ischemia
Blast Induced brain injury treatment (3)
- removal of foreign bodies
- control of bleeding
- craniectomy
mild traumatic brain injury (mTBI)
concussion
- demonstrates generalized reflex response to painful stimuli
- responds to repeated auditory stimuli with increased or decreased activity
- responds to external stimuli with physiologic changes generalized, gross body movement and/or not purposeful vocalization
- responses noted above may be same regardless of type and location of stimulation
- responses may be significantly delayed
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Level II
Generalized Resonse: Total Assistance
Risk factors for CTE (3)
- age at which mTBIs begin
- number of years playing for athletes
- genetics (APOE e4)
ask client to remember for increasingly longer periods
spaced retrieval
monitoring of memory and learning while it is taking place
- can the individual predict what will be difficult?
- can the individual learn when, how, what, and how long to use a strategy?
metamemory
Categories of TBI (3)
- penetrating injury
- closed head injury
- blast induced injury
Which is more common, penetrating or closed head injuries?
closed head injuries
Closed head injury
Primary effects- focal due to: (3)
- impact of the brain on the inner skull
- acceleration, deceleration, rotation of the brain within the skull
- coup, counter- coup effects (acceleration-deceleration injuries)
reduced blood flow
hypoperfusion
excess release of glutamate, excites cells to death
excitotoxicity
capacity to attend to, recognize and interperet interpersonal cues taht enable us to:
- understand the behavior of others
- predict the behavior of others
- share experiences and communicate effectively
- also called theory of mind
Social cognition
Cognitive communication treatment principles (5)
- promote restoration of function when possible
- maximize residual functions
- provide compensatory strategies for long term/permanent deficits
- modify the environment in ways that help compensate for deficits
- readjust expectations for the individual’s performance
- reduce memory demands and foster successful completion of real world tasks
- may include data storage devices, cuing devices, and environmental manipulations
- may require intensive training
- may be low or high tech
external appraoches
object enters brain (e.g., knife, shrapnel, bullet)
penetrating injury
Deficits that may accompany blast injury (2)
- chronic pain
- post-traumatic stress disorder
True or false
many tests for cognitive dysfunction have poor validity
true
- assist with development of coping strategies, confidence, self-esteem
- assist with behavioral and emotional control
- assist with defining and adapting to new lifestyle post-injury
- maximize ability to return to independent activity and participation in work, school, and social interactions
Treatment principles Psychosocial adjustment/adaptation
True or false
If metamemory is impaired, will need to use implicit training
true
tissue death
necrosis
True or false
funding for TBI assessment/treatment is limited so clinical efficacy is critical
true
- 6 stages of recovery
- used less frequently than the Rancho
Shoredone Scale
- Alert and in heightened state of activity.
- Purposeful attempts to remove restraints or tubes or crawl out of bed.
- May perform motor activities such as sitting, reaching and walking but without any apparent purpose or upon another’s request.
- Very brief and usually non-purposeful moments of sustained alternatives and divided attention.
- Absent short-term memory.
- May cry out or scream out of proportion to stimulus even after its removal.
- May exhibit aggressive or flight behavior.
- Mood may swing from euphoric to hostile with no apparent relationship to environmental events.
- Unable to cooperate with treatment efforts.
- Verbalizations are frequently incoherent and/or inappropriate to activity or environment.
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Level IV Confused/Agitated: Maximal Assistance
- Inconsistently oriented to person, time and place.
- Able to attend to highly familiar tasks in non-distracting environment for 30 minutes with moderate redirection.
- Remote memory has more depth and detail than recent memory.
- Vague recognition of some staff.
- Able to use assistive memory aide with maximum assistance.
- Emerging awareness of appropriate response to self, family and basic needs.
- Moderate assist to problem solve barriers to task completion.
- Supervised for old learning (e.g. self care).
- Shows carry over for relearned familiar tasks (e.g. self care).
- Maximum assistance for new learning with little or nor carry over.
- Unaware of impairments, disabilities and safety risks.
- Consistently follows simple directions.
- Verbal expressions are appropriate in highly familiar and structured situations.
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Level VI- Confused, Appropriate: Moderate Assistance
true or false
many tests for cognitive dysfunction are excellent at predicting functional abilities in real life
False
many tests for cognitive dysfunction are poor at predicting functional abilities in real life
long term pathology of moderate to severe TBI (3)
- continued loss of brain volume, including hippocampus (memory)
- continued loss of axonal connections
- accumulation of beta amyloid
Deficits of TBI varies by what factors (2)
- extent of the brain damage
- area(s) of the brain affected
Areas to assess when assessing social cognition (2)
- emotion perception
- cognitive empathy
Leading causes of TBI (5)
- Falls (40.5%)
- Unknown (19%)
- Struck by/against (15.5%)
- Motor Vehicle, traffic (14.3%)
- Assaults (10.7%)
- describes 8 stages of recovery
- revised by one member of the team to 10 stages
- not all individuals will pass through all stages
- reaching level 8 does not mean full recovery
- to be used with persons 1 year post or less
Rancho Los Amigos Levels
- educate the individual
- effects of head injury
- promote adjustment to deficits and participation in goal setting
- educate significant others
- to help them understand deficits
to
* help minimize reactions to the individual that may be maladaptive * educate other stakeholders e.g., teachers, employers
Treatment principles- education
- Alert, not agitated but may wander randomly or with a vague intention of going home.
- May become agitated in response to external stimulation, and/or lack of environmental structure.
- Not oriented to person, place or time.
- Frequent brief periods, non-purposeful sustained attention.
- Severely impaired recent memory, with confusion of past and present in reaction to ongoing activity.
- Absent goal directed, problem solving, self-monitoring behavior.
- Often demonstrates inappropriate use of objects without external direction.
- May be able to perform previously learned tasks when structured and cues provided.
- Unable to learn new information.
- Able to respond appropriately to simple commands fairly consistently with external structures and cues.
- Responses to simple commands without external structure are random and non-purposeful in relation to command.
- Able to converse on a social, automatic level for brief periods of time when provided external structure and cues.
- Verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided.
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Level V- Confused, Inappropriate Non-agitated: Maximal Assistance
- progressive neurodegenerative disease
- build up of abnormal form of a protein in the brain (tau)
- found in the brains of athletes and others who sustained repeated mTBI
- first noted in 1928 in boxers
- person may or may not have had symptomatic concussions
Chronic Traumatic Encepalopathy
TBI assessment requires a team approach
True
True or False
Memory drill does not work
true
Primary effects-focal
Closed head injury (4)
- contusion
- laceration
- potential skull fracture
- hemorrhage- subdural, subarachnoid, intracerebral)
2 types of penetrating injury damage
- focal
- diffuse
people with cognitive communication disorders have difficulties in communication competence including: (6)
- attention
- memory
- organization
- information processing
- problem solving
- executive function
What is the most common etiology of cognitive communication disorders?
TBI
- most commonly used scale to describe level of consciousness following TBI
- evaluates eye opening, verbal response, motor response
Glasgow Coma Scale
numerous injuries (organ damage, vision and hearing loss, spinal cord injuries, and amputations)
Polytrauma
- mainly acceleration injuries
- movement of part of the brain relative to others causes axons to stretch and tear
- occurs mainly in deep white matter and brain stem
diffuse axonal injury (DAI)
Communication impairments resulting from underlying cognitive deficits due to neurological damage
cognitive communication disorders
True or False
It may be difficult to separate TBI symptoms from PTSD symptoms
True
Use errorless learning to…(2)
- teach new skills (e.g., to use a planner)
- teach new knowledge (e.g., new procedure at work)
- procedural memory often intact when episodic is not
- use intact procedural to train functional skills (work, household duties, etc.)
Domain specific learning
too much blood flow
hyperperfusion
which has the better prognosis, penetrating or closed head injuries?
closed head injuries
- “signature” injury of the wars in Iraq and Afghanistan
- due to explosion of IEDs
- helmets do not protect brain, neck, face from injury
- blast waves can propel fragments, bodies, vehicles, with great force, which can also cause brain injury
- often numerous other injuries
Blast-induced brain injury
- Demonstrates withdrawal or vocalization to painful stimuli.
- Turns toward or away from auditory stimuli.
- Blinks when strong light crosses visual field.
- Follows moving object passed within visual field.
- Responds to discomfort by pulling tubes or restraints.
- Responds inconsistently to simple commands.
- Responses directly related to type of stimulus.
- May respond to some persons (especially family and friends) but not to others.
Rancho Los Amigos
Level III
Localized Response: Total Assistance
- person w/ TBI may have problems knowing incorrect from correct response
- incorrect responses may become “primed” and what are remembered the next trial
- goal is to prevent errors with cues, prompts, or correct answer
Errorless Learning
- hierarchically arranged series of training modules
- modules organized by attentional domain e.g., sustained, selective etc.
Attention Processing Training (APT, Sohlberg, and Mateer)
Coma/TBI Severity (2)
- Glasgow coma scale
- trauma score
Effects of blasts (4)
- sudden increase in air pressure followed immediately by decreased pressure that creates wind
- rapid pressure shifts can injure the brain (contusion or concussion)
- air emboli can form in blood vessels, causing infarct
- axons throughout brain affected
- time pressure management
- other self-instruction strategies; tell yourself:
- not to get distracted by irrelevant sounds, visual stimuli, etc.
- to imagine what is being said
- subvocalize these strategies
- the evidence suggests
- select these techniques based on the client’s needs
- identify tasks where attention problem interferes and address those
- this approach works best for clients who are aware of their deficits
Metacognitive Training- Self-instructional strategies
- Consistently oriented to person and place, within highly familiar environments.
- Moderate assistance for orientation to time.
- Able to attend to highly familiar tasks in a non-distraction environment for at least 30 minutes with minimal assist to complete tasks.
- Minimal supervision for new learning.
- Demonstrates carry over of new learning.
- Initiates and carries out steps to complete familiar personal and household routine but has shallow recall of what he/she has been doing.
- Able to monitor accuracy and completeness of each step in routine personal and household ADLs and modify plan with minimal assistance.
- Superficial awareness of his/her condition but unaware of specific impairments and disabilities and the limits they place on his/her ability to safely, accurately and completely carry out his/her household, community, work and leisure ADLs.
- Minimal supervision for safety in routine home and community activities.
- Unrealistic planning for the future.
- Unable to think about consequences of a decision or action.
- Overestimates abilities.
- Unaware of others’ needs and feelings.
- Oppositional/uncooperative.
- Unable to recognize inappropriate social interaction behavior.
Rancho Los Amigos
Level VII- Automatic, Appropriate: Minimal Assistance for Daily Living Skills
the clinician supports “everyday people” to be coaches for the client
collaboration
- Consistently oriented to person, place and time.
- Independently attends to and completes familiar tasks for 1 hour in distracting environments.
- Able to recall and integrate past and recent events.
- Uses assistive memory devices to recall daily schedule, “to do” lists and record critical information for later use with stand-by assistance.
- Initiates and carries out steps to complete familiar personal, household, community, work and leisure routines with stand-by assistance and can modify the plan when needed with minimal assistance.
- Requires no assistance once new tasks/activities are learned.
- Aware of and acknowledges impairments and disabilities when they interfere with task completion but requires stand-by assistance to take appropriate corrective action.
- Thinks about consequences of a decision or action with minimal assistance.
- Overestimates or underestimates abilities.
- Acknowledges others’ needs and feelings and responds appropriately with minimal assistance.
- Depressed.
- Irritable.
- Low frustration tolerance/easily angered.
- Argumentative.
- Self-centered.
- Uncharacteristically dependent/independent.
- Able to recognize and acknowledge inappropriate social interaction behavior while it is occurring and takes corrective action with minimal assistance.
Rancho Los Amigos
Level VIII- Purposeful, Appropriate: Stand-By Assistance
