TBI Revision Flashcards
What is the definition of a TBI?
trauma to the head other than superficial injuries to the face (NICE, 2014)
Massive range in the injury and impact of the TBI
What are some possible causes of TBI?
RTCs
Falls
Sports/Recreation
Assaults
What are the 3 injuries of a TBI?
- Primary injury - the cause of the TBI
- Secondary injury - oxygen shortage
- Tertiary injury - bleeding, bruising and swelling
Describe the first injury in a closed, non-penetrating TBI.
- Caused by rapid acceleration, deceleration or rotation
- Usually through collision
- Most common
- Usually causes diffuse damage
Describe the first injury in an open, penetrating TBI.
- Skull opened with brain tissue exposed and damaged
- Comparatively rare
- Damage typically localised
- could be caused by bullets, shrapnel, knives
Describe the first injury in a crush TBI.
- Least common
- Head is trapped between 2 objects, causing damage to the brainstem and the base of the skull
Describe the second injury in a TBI.
- Hypoxia (lack of oxygen to brain) increases the damage of the first injury
- Occurs minutes after the first injury
- Caused by airway obstruction, cardiac arrest or positioning
Describe coup/contrecoup.
- Coup is the primary impact
Contrecoup is the secondary impact, as the brain rebounds within the skull to the opposite side of the initial impact
Describe the tertiary injury in a TBI.
- Caused by bleeding, bruising, swelling and clotting
- Can increase intracranial pressure and reduce blood flow
- Occurs in days and weeks following initial/secondary injury
- Ongoing damage to the brain caused - can be weeks after the first injury
Describe a hypoxic brain injury.
- HBI is a lack of oxygen to the brain
- Anoxia - complete interruption of oxygen supply to the brain
- Hypoxia - partial interruption of the oxygen supply to the brain
What are potential causes of hypoxic brain injury?
Variety of causes: Suffocation Substance abuse Drowning Poisoning Cardiac arrest
What areas of the brain are particularly susceptable to hypoxic brain injury?
Cerebral cortex
Hippocampus
Basal ganglia
Cerebellum
What is the key function of the cerebral cortex?
Attention Perception, Awareness, Thought, Memory, Language Consciousness
What is the key function of the hippocampus?
Memory
What is the key function of the basal ganglia?
Speech, posture and movement control
What is the key function of the cerebellum?
Balance and coordination
What are the 4 low arousal states?
Coma - unresponsive and unrousable
Vegetative state - unresponsive but some functions working independently - breathing, heart rate, limited sleep/wake cycle
Minimally conscious/responsive state
Emerging minimally conscious/responsive state
Definition of minor brain injury:
Less than 15 minutes loss of consciousness
Less than an hour of post traumatic amnesia
Definition of moderate brain injury:
15 minutes - 6 hours loss of consciousness
1 hour to 24 hours post traumatic amnesia
Definition of severe brain injury:
6 hours - 48 hours loss of consciousness
24 hours - 7 days post traumatic amnesia
Definition of very severe brain injury:
Over 48 hours loss of consciousness
Over 7 days post traumatic amnesia
What are the symptoms of post traumatic amnesia?
- Confusion
- Disorientation
- Memory loss
- Retrograde amnesia - loss of memory shortly before the injury
- Anteretrograde amnesia - difficulty creating new memories post injury
What are the emotional/behavioural effects of brain injury?
- Personality Changes
- Mood Swings/Emotional Lability
- Depression
- Anxiety
- Frustration/Anger
- Abusive/Obscene Language
- Disinhibition
- Impulsiveness
- Obsessive Behaviour
What are the cognitive communication difficulties?
- Difficulty processing and understanding information
- Taking longer/being slow to react
- Difficulty understanding multiple meanings in jokes, sarcasm and adages or figurative expressives such as “a rolling stone gathers no moss” or “take a flying leap”
- Often unaware of errors and can become frustrated or angry and place the blame on others
- Not using/reading non-verbal cues accurately
- Word finding difficulties
- Lengthy and often faulty descriptions or explanations that cover for a lack of understanding or inability to think of a word
- Reading and writing abilities are often worse than those for speaking and understanding spoken words
- Altered turn taking
- Altered ability to talk around a shared topic (topic maintenance)
- Perseverating (topic fixating)
- Altered ability to order information
What are dysexecutive syndrome symptoms (DES)?
- Motivation/Initiation
- Concentration/Attention
- Planning/Organisation
- Self-Monitoring
- Flexible Thinking
- Multi-tasking
- Problem-solving/Making decisions
- Reasoning skills
- Delayed Information Processing
- Memory
- Repetitions
- Visual-perceptual Skills
- Insight/Empathy
- Behaviour/Emotions/Mood
- Social Skills
What is rehabilitation?
Royal College of Physician - 1986:
“The Restoration of patients to their fullest physical, mental and social capability”
Headway:
A period of change through which the head injured person goes in attempting to regain former abilities and to compensate for lost skills
Explain the continuum of care.
Gravell & Johnson - 2002:
Goes through stages of care: paramedics, A&E staff, ICU/Ward staff, inpatient rehab, community/specialist rehab, support and maintenance
What are 4 predictors of recovery?
- Months since injury
- Age
- GCS
- Months of treatment
What is the role of SLT in the acute stage?
- Identifying and promoting arousal/consciousness
- Likely focus on dysphagia management
- Identification/establishing of communication, often through low-tech AAC
- Support and advice to family
- There is a focus on medical stability, consciousness and out of post-traumatic amnesia
What are some assessments of low-arousal states?
SMART - Sensory Modality Assessment and Rehabilitation Technique
WHIM - Wessex Head Injury Matrix
FIM/FAM - Not an assessment technically but can measure the baseline before therapy. Functional independence measure/functional awareness measure
Observation scales can monitor responses/behaviours over time, ascertaining consistency, purposeful actions
What is the SMART assessment?
Sensory Modality Assessment and Rehabilitation Technique
- Used by the MDT
- Used at low-arousal stage
- Assesses the clients responses at rest and to a range of stimuli - olfactory, auditory, visual, tactile and gustatory
- Aims to assess/gather information about the clients functional ability, communication ability and level of wakefulness
What is the WHIM assessment?
Wessex Head Injury Matrix
- Measures the recovery in the acute/sub-acute phase
- Assesses and gathers information about communication skills, cognitive skills and social interactions.
What can SLT intervention involve?
- Establish whether behaviours are reflexes or purposeful
- Establish if there is communicative intent
- Establish AAC if appropriate
- Educate and support relatives and the MDT to support and communicate with the patient
- Manage dysphagia
AAC Ideas for Severe Difficulties:
- Yes/No methods - nods, pointing to y/n cards, eye movements, eye blinks
- Object choices - intervention tasks, clothing, food items
- Simple communication boards - 2/3 pictures of family, activity choices, treatment tasks
- Single message voice output devices - y/n, request an item or activity
- Writing or using an alphabet board to support speech
- Consider writing first because it is a more familiar ability than pointing/eye gazing with letters
- Low tech alphabet or communication boards - accessed by looking at/gazing with eyes or laser pointers for those with motor-impairment
- Digitised text-to-speech programs
- Most people will need cues to initiate use of the systems.
Who might be in the MDT for TBI?
Client Carers/Advocate SLT OT Physio Dietician Consultant Nursing Staff Rehab Support Workers Social Worker Clinical Psychologist Counselling Case Manager Pastoral Care Voluntary Organisations
Explain the AMORE pneumonic.
By MacDonald, describes common deficits in cognition following TBI
Attention and concentration Memory Organisation, planning, initiating Reasoning and problem-solving Executive functions
Symptoms range mild to severe, subtle to obvious
Massive variability in presentation of clients
Potential long term impact of TBI?
Ongoing cognition difficulties
Ongoing language issues
TBI associated with increased incidence of neuro disorders, e.g. seizures
Links to neuro-degenerative disorders like Alzheimers or Parkinsonism
Social impact - reduced participation, depression, anxiety, loss of role/identity, job, relationships, insight
What are the 4 main categories of effects of TBI that can affect communication?
Physical - how the body works
Cognitive - how the person thinks, learns and remembers
Emotional - how the person feels
Behavioural - how the person acts
Essential to consider the individual, their presentation and how the injury has directly affected them
Impact of cognitive impairments likely to impact how communication impairment is carried out
Explain the links between communicative and cognitive impairment.
Attention/concentration difficulties - can impact - difficulty resisting distractions during conversations, following line of conversations, topic maintenance
Memory problems - can impact - repeating self during conversation, topic maintenance, retaining instructions or messages,
Social impairment - can impact - not understanding sarcasm, missing jokes, poor conversational turn taking, interrupting others, excessive talking, missing/misreading cues or non verbals
What are some language symptoms of TBI-impacted communication?
WFDs
Poor sentence formation
Lengthy, often incorrect, descriptions or explanations - often cover lack of understanding or WFD
Slower or difficulty processing and understanding information
Difficulty understanding jokes, sarcasm, figurative language
Reading and writing often worse than receptive or expressive language
Altered turn taking
Altered ability to talk around a topic
Fixated on a topic
Perseverating
Altered ability to order information/give narratives/instructions
Not using/recognising/correctly interpreting non verbal cues
Often unaware of errors, often blame conversation partner, can cause frustration, upset and anger
Likely reduced insight into analysing situation/correcting behaviour
List assessments of TBI CCD
- LaTrobe Communication Questionnaire
- FAVRES functional ax of verbal reasoning and executive strategies
- Multi Factorial Memory Questionnaire
- QOLIBRI - Quality of Life after Brain Injury Questionnaire
Key points for goal setting?
Client centred
Focus on what the client wants so they’ll be more motivated and feel listened to
Work with client, or if not possible, those closest to them
Motivation is highest when a need exists
Ensure goals are relevant IRL - e.g. can order their own drink, can accurately communicate yes or no - NOT ‘understand 20 common phrases’
What are different goal types for PwTBI?
GAS Goals DRS - Disability Rating Scale QOLIBRI - Quality of Life after Brain Injury FIM/FAM EKOS
What is FIM/FAM?
Functional independence measure/functional assessment measure - assess disability resulting from physical and cognitive impairments
What is the MMQ?
Multifactorial Memory Questionnaire
Assesses functional memory, applicable to everyday life, Ω
Good for monitoring changes to memory overtime.
As well as ability, it assesses what self-help strategies people use to facilitate any memory difficulties, as well as how people feel about their memory. This is important, as care needs to be person centred - ?what use are raw scores, surely it matters what the persons perception of their difficulties are.
List 6 broad approaches you can implement for PwTBI
Client and family/friend/carer education Modifying their environment Compensatory devices and strategies Restorative approaches Managing emotions Increasing meta-cognitive awareness
What are the principles of experience-dependent plasticity?
Use It or Lose It - failing to use specific functions can lead to functional degradation
Use It and Improve It - training drives a specific brain function to enhance the function
Specificity - the nature of the training dictates the nature of the plasticity
Repetition Matters - plasticity requires sufficient repetition
Intensity Matters - sufficient training intensity needed
Time matters - plasticity differs at different times during training
Salience Matters - The training must be salient enough to induce plasticity
Age Matters - training-induced plasticity occurs more readily in young brains
Transference plasticity - training in one area can enhance the acquisition of similar behaviours
Interference - Plasticity in one experience can interfere with acquiring other behaviours
What are some intervention examples for environmental modifications?
Making changes to reduce risks specific to that client E.g. controlled door access Reducing stimulation or distractions Temperature controlled taps Controlled sharps access
What are some intervention examples for devices and strategies?
e.g: AAC Calendars Alarms Watches Organisers Pagers Schedules Language related strategies
What are some intervention examples for restorative approaches?
Important to make tasks tailored to the individual (or group as appropriate)
Aims to restore previous ability/function
Increase the complexity and demands of tasks gradually
- The amount of information presented
- The attention required
- The memory required
What are some intervention examples for managing emotions?
Consider both the client and their family/carer
Getting to know a person and building a rapport
Empathy
Couple and/or family therapy
Biomusic - for those with profound/multiple disabilities, changes physiological signals such as respiration and skin temperature create music specific to that person and their current physiology.
What are some intervention examples for client and family education?
Interdisciplinary approach - the team need to work together to provide consistent information an education.
The information provided needs to be suitable for the stage the person is at in their ‘journey’
Don’t overwhelm
Information as requested
Sign post to resources - support groups, etc.
What are some intervention examples for training in meta-cognitive skills?
Meta-cognition strategies target CCD - cognitive communication difficulties
Problem-solving training
CBT
Goal management framework:
Self instruction - strategies e.g. stop and think, zoom in/out
What are the 6 steps of the MMT framework?
1) Set main goal
2) Identify possible solutions
3) Identify and assess pros and cons for each
4) Choose the best solution for you, and plan the steps
5) Carry out the plan
6) Evaluate the process
Describe: Conversation/Communication Skills Work
Consider direct v indirect
Consider group v individual
Needs to be realistic, replicating IRL situations as much as possible
Pros: Conversation/Communication Skills Work
Group conversation work often beneficial
Groups can provide peer support within a naturalistic, social setting
Groups can role play specific social situations
Groups can replay videos of communication practices to evaluate together
Groups can offer more effective generalisation and maintenance of communication skills
Cons: Conversation/Communication Skills Work
Generalisation of skills/practice can be difficult
Group members may be critical
What are the stages of intervention proposed by Winson et al (2017)?
Building client and carer awareness of strengths and needs
Identifying areas for intervention
Develop skills and strategies
How can clients better understand communication breakdowns?
This may be difficult due to cognitive deficits.
Video feedback in a naturalistic setting
Role play pre planned scenarios (like shops, cafes, phonecalls)
Observation of self, aided by a communication checklist
This can prompt changes in behaviour and help with goal setting
What is TBI Express?
“social communication training” for PwTBI & their CPs
Includes modules on: education and understanding the effects of TBI on communication Effective communication Collaboration Elaboration Putting acquired skills together
Typically group training
Conversation Skills Training - Individual
What does IIPR stand for?
Individual Interpersonal Process Recall
Conversation Skills Training - Individual
What is the process of IIPR?
Videotape 10-15 minute interaction
Play video back to client, CP & SLT
Identify skills and barriers/deficiencies
20 sessions of treatment
Discuss adapting current, and more appropriate means of interaction
Rehearse new skills with the participant
Benefits of IIPR?
Noted reduced anxiety
Improved social self-concept, interpersonal and communication skills
Skills were generalised to communication in non-clinical settings
What does GIST stand for?
Group Interactive Structured Treatment
What is the process of GIST?
Manualised treatment
Emphasis on family participation and regular practice at home and in the community
13x 0.5hr sessions in the workbook
Includes self-assessment and goal setting
Targets: initiating conversation, strategies for conversation maintenance and using feedback, being assertive, problem solving, positive self-talk, social boundaries
Videotapes feedback and conflict resolution
What are potential behavioural and emotional difficulties following TBI?
Agitation - temporary stage rather than a permanent change
Anger/irritability - seemingly excessive reaction to minor annoyances
Impulsivity and disinhibition - lack of awareness of consequences, touching people inappropriately, speaking your mind regardless of circumstances. Work with neuro-psychologist to develop a behavioural management system can stop unacceptable LT behaviours developing through habit.
Demanding behaviour - self-centredness - concerned only with self, not considerate of the wider family. Can damage wider relationships.
Low motivation and apathy - breaking activities down can help avoid overwhelm.
Sexual problems - damaged hypothalamus can increase sex drive, promiscuity or misinterpreting the behaviour of others
What are some behavioural intervention approaches?
Break down activites into smaller steps
Use a consistent approach across the MDT/family
Routine
Reducing distractions
Avoiding overloading
Change confusing or distressing topics of conversation
Check the client is understanding throughout conversation
Do/discuss things the client enjoys
Reminders/rewards for what is socially acceptable
MDT approach - team must have a consistent approach that involves the family.
Set goals, remind of goals/revisit frequently
Potential emotional difficulties following TBI?
Emotional lability - very quickly move from one state to another
Depression - ‘healthy depression’ can be good as it can be worked through with support, with appropriate adjustments being made. It gives a sign the client is aware of the situation and how things have changed.
Anxiety - e.g. panic attacks, nightmares, feeling insecure. Talking about worries and adopting strategies to manage anxiety.
Obsessional/Inflexible - e.g. unreasonable stubborness, obsessive patterns of behaviour, fear of possessions being stolen. Helpful to reassure client, and to redirect attention to more constructive ideas and behaviours. This can be hard for family and friends to deal with.
Emotional Intervention Approaches
Adjustment and Acceptance
Education
Working with the family
Remaining calm if the client talks about depression/anxiety/suicide etc and working appropriately with the MDT
What are GAS goals?
Goal Attainment Scaling
Not pass/fail - rates a goal from -3 to 2 to quantity the success.
Overall aim is to increase engagement in activities that are meaningful to the individual.
The goals set should guide the interventions chosen by the therapists
Why are GAS goals appropriate for use in TBI?
The hugely diverse population means that GAS goals words for patients identifying, planning and managing their own behaviour
What are some advantages of GAS goals as an outcome measure?
Ertzgaard et al, 2011
- Completely personal to the individual
- Promotes collaborative working between client & SLT (and family)
- Allows SLT insight into the priorities of the client
- A study in the Mayo Brain Injury Outpatient Programme showed strong correlations between GAS score and independence measures
- Can be applied across the popn bc its specific to the client
- Goals selected by the client their self are more likely to be motivating and therefore achieve success.
- Allows for 1 or many goals to be set
- Goals can facilitate future planning - e.g. in regards to appropriate rehabilitation or support in community
What are some disadvantages of GAS goals as an outcome measure?
Ertzgaard et al, 2011
- Pw severe cognitive or behavioural impairments likely unable to set goals independently
- A lack of insight can mean goals chosen by the client are unrealistic
- clients with dysexecutive syndrome symptoms (DES) can make achieving goals harder - e.g. difficulties with attention, concentration and memory.
- using a scale with ‘- minus’ scoring can be demotivating (like in paeds)
- Can be time-consuming, and requires training so could be service constraints.
- Scale needs to be “clinically meaningful” - not totally subjective. How relevant is standardisation when we’re looking at PCC and helping that individual?
