TBI Flashcards
Definition of TBI
An acquired brain injury that disrupts the normal function of the brain that can be caused by a bump, blow, or jolt (or blast) to the head or a penetrating head injury
Incidence of TBI
number of new TBIs over a particular time period
Prevalence of TBI
number of people living with impact of TBI currently
Estimated prevalence of TBI-related disability in US
3.2 mill - 5.3 mill
Most likely to have TBI-related ED visit
0-4
15-19
> or equal to 75 yrs
TBI etiologies
bicylining, football, playground activites, basketball, soccer, falls struck by object, MVA, assualt, self-inflicted
TBI pathophysiology - primary injury
caused by initial blow or insult to the brain
TBI pathophysiology - secondary injury
disruption of the blood brain barrier
production of reactive oxygen species and resultant oxidative stress
metabolic dysfunction
inflammation and excitotoxicity
what is included in direct mechanical injury caused by trauma
fractures, intracranial hemorrhage, contusion and traumatic axonal injury
coup-coutracoup - primary injury
Injury at the site of impact and on the opposite side from the movement of the brain against the skull
(either front to back or side to side)- causes a contusion
diffuse axonal injuries - primary injury
Delicate nerve tissues rip, tear, and stretch
Secondary injury
deterioration that follows initial trauma, during first 24 to 72 hours, brain and body responding to insult
infection, hypotension, brain swelling, raised intracranial pressure
factors influencing outcomes after TBI
age - younger than 7 or older adults have worse outcomes
social-enviornmental factors - SES, caregiver and family function, social support, return to social functioning
access to care - insurance as a factor
comorbidities
factors associated with poor prognosis for tbi
defined as mortality at 14 days
death/severe disability at 6 months after injury
how to measure global outcomes after tbi
GOS-E (glasgow outcome scale) (most common for tracking overall recovery)
DRS - disability rating scale, measures impairment, disability, and handicap
SRS - supervision rating scale, 13 pt scale to rank levels of supervision
considerations for tbi assessment
level or consiousness/arousal
neurobehavioral deficits that may impact participation
motor deficits
sensory deficits
consider how task translate to real world
formal vs informal assessment
an assessment for tbi should
eval strength and weaknesses
guide development and implementation
guide devleopment of remedial and compensatory strategies
steer discussion w pateints and family regarding recovery
serve as an anchor for future challenges resulting from recovery and treatment
what kind of info do you need in case history - tbi
nature and onset of tbi
hospitalizations
medical status current and prior to injury
current medications
review of auditory, visual, motor, and cognitive status
review of emotional and mental status
education and occupational
areas of concern
languages used
impact of condition on individual and their family/caregivers
goals and priorities of individual and their family/caregivers
Pros and cons to standardized assessment
pros to standardized test - tbi
compares you to peers and gives a baseline
cons to standardized test - tbi
less patient feedback, stressful, other preexisting factors can complicate interpretation
things to be aware of in tbi formal and informal assessment
fatigue, emotional response, motivation, strategies used
Early assessments - tbi
GOAT - Galveston orientation and amnesia test
GCS
PTA - post-tramatic amnesia
often in acute care
TBI assements used in rehab
Rancho
DRS - disability rating scale
FIM - functional independent measurement
tbi assessment used further out of onset of injury
BREIF - A
QOLIBRI - quality of life after brain injury scale
hypothesis testing in tbi
figuring out why they cant do something
dynamic assessment in tbi
purpose is to make sure you are getting their best
you might test-teach-retest
accommodating
seeing what they respond to best
what is the goal of cognitive rehabilitation
minimize the functional impact of injury-related cognitive and behavioral impairment in order to maximize safety, independence, and quality of life
can use remediation, compensation, or environmental management
4 steps in cognitive rehabilitation
1 - problem orientation, awareness, goal setting
2 - compensation
3 - internalization
4 - generalization
long term goals for tbi
evaluated on longer time frames (often dictated by setting or mechanism)
Ex - patient will improve ability to compensate independently for memory deficits using external aids
short term goals for tbi
type of task, complexity, level of cueing or assistance, strategy employed, measure of success (speed, number, %)
ex- patient will initiate 10/10 simple household tasks in the morning for 5 consecutive days, with minimal assistance to use memory notebook
general approach for treatment for mild to moderate tbi
•Treatment of executive function is based in metacognitive strategy training
•Goal of re-establishing internal task-approach structures and improve ability to monitor and regulate behavior
•Focus on self-monitoring and self-regulating behavior
•May include problem solving and goal management training, especially as they relate to functional activities
•If self-awareness exists, need explicit performance feedback
general approach for treatment for severe tbi
•Skill-specific training (with focus on tasks), with errorless learning
•No expectation of generalization/transfer
tbi treatment framework
awareness - understanding and incorporating patient awareness and impairment levels into discussion
plan - help patient in anticipation and planning of step-by-step procedures to meet task demands, including patient’s proposed strategy use
execute and self-monitor - Observing the patient’s execution and self-monitoring of selected responses and helping the patient to internalize self-guided and self-monitoring techniques, as nee
evaluate - •Helping pt to evaluate task outcome, compare actual outcome to predicted outcome, change task and strategy approach if necessary, and the resets for next practice
what are the fundamental elements of supporting problem solving? tbi
•Identifying a problem and goals
•Picking a solution from alternatives and making a plan
•Executing the plan with self-monitoring
goal plan do review - tbi
build awareness of the goal
anticipate and plan how to accomplish goal
execute and self-monitor (do goal)
self-evaluate and review the goal and how the outcome was and what can be done next time and what worked and did not
why might people with tbi have issues identifying a problem
difficulty with initiation, impulsivity, task persistence, disorganization
goal management training - tbi
standardized approach (7 sessions, 2 hours each), group based, big focus on mindfulness-based attention regulation, often partnered with PST
content free cueing - tbi treatment
STOP
stop
think
organize
plan
pause current activity and review specific goals
treatment of attention impairments general approach
direct attention training
metacognitive strategy instruction
principles of treatment of attention impairments
task training should be hierarchical
lots of repetition
do not do direct attention training without MSI
What are general strategies for metacognition
•Self-pacing
•Verbal mediation
•Rehearsal
•Anticipate task demands
•Self-monitoring (following goal setting)
•Emotional regulation
•Modify the environment
•”What are your absolutes that you have to have to even start working on things?”
