Traumatic Brain Injury

Question 1

Define:

Anterograde amnesia:

Answer 1

Anterograde amnesia is the loss of the ability to create new memories, leading to a partial or complete inability to recall the recent past, even though long-term memories from before the event which caused the amnesia remain intact

Question 2

Define: Retrograde amnesia

Answer 2

Retrograde amnesia is a form of amnesia where someone is unable to recall events that occurred before the development of the amnesia, even though they may be able to encode and memorize new things that occur after the onset.

Question 3

Define: Working memory

Answer 3

Working Memory is the thinking skill that focuses on memory-in-action: the ability to remember and use relevant information while in the middle of an activity.

Question 4

Define: Declarative (or explicit) memory (“knowing what”)

Answer 4

a type of long-term memory that refers to memories of facts/events that can be consciously recalled (or declared); it is called explicit memory because it consists of information that is explicitly stored & retrieved…(FYI, declarative memory can be further sub-divided into episodic memory and semantic memory)

Question 5

What term?
a type of long-term memory that refers to the unconscious memory of skills and how to do things (e.g. the use of objects or movements of the body like tying a shoelace or riding a bike); memories acquired through repetition and practice and are composed of automatic sensorimotor behaviors that are deeply embedded (we are not aware of them); it is called implicit because previous experiences help in the performance of a task without explicit/conscious awareness of these previous experiences

Answer 5

Procedural (or implicit) memory (“knowing how”)

Question 6

What term?
Use of memory and attention to identify oneself and to place oneself in time, place, & situation. Ongoing awareness of oneself, the current situation, the passage of time, and the environment
Patient’s orientation to person, place, date, awareness of situation, and post-morbid anterograde memory

Answer 6

orientation

Question 7

What term?
the spontaneous production of false memories: either memories for events which never occurred, or memories of actual events which are displaced in space or time. These memories may be elaborate and detailed. Some may be obviously bizarre, as a memory of a ride in an alien spaceship; others are quite mundane, as a memory of having eggs for breakfast, so that only a close family member can confirm that the memory is in fact false.

Answer 7

Confabulation

Question 8

What Rancho level is someone that is displaying confabulation?

Answer 8

4 or 5

Question 9

What is important to remember if someone is displaying confabulation?

Answer 9

It is important to stress that confabulators are not lying: they are not deliberately trying to mislead. In fact, the patients are generally quite unaware that their memories are inaccurate, and they may argue strenuously that they have been telling the truth.

Question 10

What term?
difficulty with math calculations (e.g. poor comprehension of math symbols, may struggle with memorizing and organizing numbers, have difficulty telling time, or have trouble with counting)

Answer 10

Dyscalculia

Question 11

What term?

• A prototypical lesion caused by rapid deceleration (individual nerve cells throughout the brain are stretched and then break)
• Degree of injury may vary from primary axonotomy, with complete disruption of the nerve, to axonal dysfunction, wherein the structural integrity of the nerve remains but there is loss of ability to transmit normally along neuronal pathways (extensive injury throughout the breain)
• Clinical severity is measured by the depth and length of coma (i.e., the time from the onset of injury until the individual performs purposeful activity) and associated signs such as pupillary abnormalities

Answer 11

Diffuse axonal injury

Question 12

What term?

• When a coma resolves and a person becomes either partially aware of self and the environment (pg. 886, Pedretti)
• Transition from persistent vegetative state to MCS is defined by definite behavioral evidence of awareness of self, environment, or both (pg. 887, Pedretti)

Answer 12

Minimally conscious state (MCS)

Question 13

What state is someone in if they display these characteristics:

• Clearly discernible, reproducible behavior in one ore more of the following areas must be demonstrated (pg. 887, Pedretti):
• ability to follow commands
• gestural or verbal yes/no responses (regardless of accuracy)
• intelligible verbalizations
• purposeful movements or affective responses that are appropriate responses to environmental stimuli (e.g. reaching for objects; touching or holding objects that accommodate their size and shape; engaging in eye pursuit movements or sustained fixation in direct response to stimuli; and smiling, crying, vocalizing, or gesturing in response to relevant stimuli)

Answer 13

Minimally conscious state (MCS)

Question 14

What state is described?

*absence of awareness of self & the environment despite maximal external stimuli…wakefulness without awareness

Answer 14

Vegetative state

Question 15

What are some characteristics of a vegetative state?

Answer 15

• No awareness of self or the environment and an inability to interact with others
• No sustained, reproducible, or voluntary behavioral responses to sensory stimuli
• No language comprehension or expression
• Sleep-wake cycles of variable length
• Ability to regulate temperature, breathing, and circulation to permit survival with routine medical and nursing care
• Incontinence of bowel and bladder
• Variably preserved cranial-nerve and spinal reflexes

Question 16

What state is described?
*refers to a condition of past and continuing disability with an uncertain future; the typical onset is within 1 month of traumatic or nontraumatic brain injury or after a month-long metabolic or degenerative condition

Answer 16

Persistent vegetative state (PVS)

Question 17

What state is someone in if they display these characteristics?

• Eye-opening
• Reflexive response
• Autonomic function intact
• No purposive activity (medullary-mediated movement, but no sign of higher cognitive function)

Answer 17

Persistent vegetative state (PVS)

Question 18

T/F
*If the client does not improve, then the term permanent vegetative state is appropriate, signifying that the change of regaining consciousness before death is exceedingly small
FYI: recovery of consciousness is rare in a PVS 12 months after a TBI or 3 months after a non-TBI

Answer 18

TRUE

Question 19

What two factors are the best predictors for long-term outcome following brain injury?

Answer 19

post-traumatic amnesia (PTA), which is probably the single best measurable predictor of functional outcome in the research literature” (PTA: the length of time from the injury to the moment when the individual regains ongoing memory of daily events (e.g. evidence suggests that longer PTA is associated with poorer long-term cognitive & motor abilities & a decreased ability to return to work/school…PTA lasting longer than 4 weeks is correlated with significant long-term disability))

“Monitoring an individual’s personal rate of recovery is probably more predictive of future recovery than any other factor”

“After a brain injury, an individual’s progression along this continuum of consciousness depends on age, prior health status, severity of injury, and the methods of medical, therapeutic, and environmental management” (pg. 885-886, Pedretti)

Question 20

What six areas are typically addressed by OT for patients at Rancho I-III?

Answer 20

General aim of intervention for those at Rancho Levels I-III is to increase the individual’s level of response and overall awareness of self and environment:

Sensory stimulation (goal is to increase the client’s level of awareness by trying to increase arousal with controlled sensory input such as olfactory stimulation with variety of scents to elicit an eye opening or a head turn)

Bed positioning (goal is to prevent abnormal posture, prevent pressure sores, facilitate normal muscle tone, prevent loss of pelvis/trunk ROM)

Casting or splinting (goal is to maintain functional positions when at rest and reduce tone, as well as increase joint ROM)

Wheelchair positioning (goal is to allow patients to interact with immediate environment in upright, midline posture)

Dysphasia management

Emotional & behavioral management (goal is to track improvement in arousal/awareness & establish a way to communicate)

Always include: family and caregiver education (goal is to include family/caregiver in therapy interventions)

Question 21

What are the primary strategies used in ICUs for managing intracranial pressure?

Answer 21

Treatments include mannitol, high-dose barbiturate therapy, ventriculostomy for drainage of cerebrospinal fluid, and craniectomy (i.e.removal of portions of the skull to allow for external brain swelling - bone flap)

Levels must stay below 20 mm Hg

Emergency treatment: craniotomy

Chronic treatment: placement of a shunt

Question 22

How do OTs utilize procedural memory during inpatient treatment for brain injury?

Answer 22

ADL IS KEY!

• access procedural memory
• provides window into patient’s condition
• may reduce agitation
• “glimmer into old self”

Question 23

What is agitation? How does it differ from aggression?

Answer 23

Aggression:

• using violence to get what you want
• as the individual becomes acclimated, they put cause and effect together
• comprehensive behavioral management program established for those who exhibit behavior that interferes with active participation in therapy/achievement of goals (pgs. 896-897, Pedretti)
• medication used with violent/aggressive patients to calm them down

Agitation:

• Adaptive (confused) attempt to explore the environment
• Typical at Rancho Levels 4-5
• “An excess (any behavior that interferes with functional activities) of one or more behaviors that occurs during an altered state of consciousness (amnestic phase of recovery)”
• “Post-traumatic amnesia plus a behavioral excess of aggression, disinhibition, and/or emotional lability”

Characteristics captured by the Agitated Behavior Scale

• Physical aggression
• Explosive anger
• Increased psychomotor activity
• Impulsivity
• Verbal aggression
• Disorganized thinking
• Perceptual disturbances
• Reduced ability to maintain or appropriately shift attention

Question 24

Be able to describe strategies for managing agitation.

Answer 24

Low-stimulation room
Night-day simulation
Vail bed or mattress or Craig bed
Hand mit to prevent pulling at lines/leads
Out of bed therapies followed by rest breaks
Trained “sitters”
Wean off medications
Provide orientation supports (e.g. wall clock/calendar)
NO restraints, therapies outside of room, television, overmedication, overstimulation, being left alone

Treatment is based on developing a safe environment, consistent routine, focus on over-learned tasks, and gradual re-introduction of more complex parameters/tasks (with consistent team member participation)

Therapist

• cool, calm, collected, self-assured;
• speak slowly/concisely using 1-2 word commands
• redirections to de-escalate
• be aware of your own safety

Question 25

List three early assessment tools that are typically used with people who have emerged from coma (from lecture or text). What do they measure?

Answer 25

1. Glasgow Coma Scale: assesses LOC after a TBI (pg. 886, Pedretti)
   - eye opening response
   - motor response to painful stimuli
   - verbal response
   * *FYI, the motor response is best indicator to signify no longer in a coma (score of 5 signifies purposeful response to pain and a score of 6 represents an ability to follow simple commands)
2. Rancho Los Amigos Scale of Cognitive Functioning: descriptive measurement of levels of awareness and cognitive function (Levels 1-8 (2 additional levels used at some outpatient facilities) described on pgs. 888-889, Pedretti)
3. Galveston Orientation & Amnesia Test (GOAT) OR the Orientation Log (O-Log): measurement to track levels of post-traumatic amnesia (PTA)

Question 26

Describe Rancho Level 4

Answer 26

Confused and Agitated

• be very confused and frightened
• not understand what he feels or what is happening around him
• overreacts to what he sees, hears, or feels by hitting, screaming, using abuse language, or thrashing about (due to confusion)
• be restrained so he doesn’t hurt himself
• be highly focused on his basic needs (e.g. eating, relieving pain, going back to bed, going to the bathroom, or going home)
• may not understand that people are trying to help him
• not pay attention or be able to concentrate for a few seconds
• have difficulty following directions
• recognize family/friends some of the time
• with help, be able to do simple routine activities such as feeding himself, dressing, or talking

Question 27

Describe Rancho Level 5

Answer 27

Confused and Inappropriate

• be able to pay attention for only a few minutes
• be confused and have difficulty making sense of things outside himself
• not know the date, where he is, or why he is in the hospital
• not be able to start or complete everyday activities, such as brushing his teeth, even when physically able ( may need step-by-step instructions)
• become overloaded and restless when tired or when there are too many people around
• have a very poor memory (will remember past events from before the accident better than his daily routine or information he has been told since the injury)
• confabulation
• may get stuck on an idea or activity (perseveration) and need help switching to the next part of the activity
• focus on basic needs such as eating, relieving pain, going back to bed, going to the bathroom, or going home

Question 28

Describe Rancho Level 6

Answer 28

Confused and Appropriate

• be somewhat confused because of memory and thinking problems (e.g. he will remember the main points from a conversation, but forget and confuse the details, like remembering that he had visitors in the morning, but forget what they talked about)
• follow a schedule with some assistance, but becomes confused by changes in the routine
• know the month and year, unless there is a severe memory problem
• pay attention for about 30 minutes, but has trouble concentrating when it is noisy or when the activity involves many steps (for example, at an intersection, he may be unable to step off the cub, watch for cars, watch the traffic light, walk, and talk at the same time)
• brush his teeth, get dressed, feed himself etc. (with assistance)
• know when he needs to use the bathroom
• do or say things too fast, without thinking first
• know that he is hospitalized because of an injury, but will not understand all of the problems he is having
• be more aware of physical problems than thinking problems
• associate his problems with being in the hospital and think that he will be fine as soon as he goes home

Question 29

Be able to explain why consistency in treatment is important during inpatient brain injury rehabilitation.

Answer 29

1. Important to build a therapeutic milieu by:
   - working everyday to structure a non-intrusive, comfortable, normalized environment
   - maintaining a strict adherence to same daily schedule & same therapists
   - upgrading amount, rate, complexity, and duration of tasks as patient recovers
   - involving all team members & family
2. Even the slightest change in treatment parameters can ruin a treatment session, sparking agitation and frustration by the patient (without consistency, agitation can increase and can quickly turn into recalcitrant negative behavior)
3. Also, patients have memory difficulties, so predictable routines will assist with memory making/re-learning tasks
4. Chris Gentry also told us that any change can lead to a breakdown in the transfer of skills

Question 30

Be able to explain the role of the 4 “S’s” in inpatient rehab.

Answer 30

1. Safety (for yourself and patient…Tony suggested taking self defense classes for future safety knowledge as a practitioner)
2. Stability (posture/movement…Tony talked about ensuring your patient feels safe and secure - “is the person feeling comfortable in the chair or would he/she rather complete ADLs on the floor?”)
3. Stimulus (environmental focus)
4. Sequencing (organized step-by-step routine)

Question 31

List several treatment parameters that should be considered when writing TBI treatment goals

Answer 31

1. Upgrading task goals (“changing the challenge”):
   - Vary extraneous environmental stimuli
   - Introduce a choice of self-care items
   - Diminish manual assistance
   - Diminish verbal cues
   - Perform task in a different setting
   - Offer tasks in a different sequence
   - Trial self-initiation of tasks

• *Example of initial goal: Patient will complete all steps of tooth-brushing task in low-stim environment with sequential set-up, verbal cues, and hand-over-hand guidance.
• *Upgrade: Patient will complete all steps of tooth-brushing task in low-stim environment with sequential set-up and occasional verbal cues.

Question 32

What are the components of a memory book? What is its purpose?

Answer 32

Purpose: used as both a day planner & a memory review log

Cover of memory book:
in large print, type patient’s name, hospital room number, name & location of hospital

First page of memory book:
a brief biography of the patient, including name, age, family members, home address, job or school, date and description of brain injury event, and current situation and location; ideally, this page can be written in collaboration with patient and family members; a good SLP treatment

Clinician I.D. page:
lists members of primary treatment team

Photo album:
family may bring in key photos of patient and family, home, car, office, pets, etc.
pasting these photos into memory book and adding captions can be a good collaborative treatment session for therapist, patient, and family

Day planning log:
facing pages set up (one for a.m. events, the other for p.m. events) so the patient can review the whole day at a glance

Question 33

What is sun-downing? What are some strategies for managing it?

Answer 33

Increasing restlessness, anxiety, or agitation as evening approaches; a primitive fight or flight response to evening coming on

Goal: decrease confusion and increase orientation cues during this difficult time, in order to ease the client toward bedtime and a good night’s sleep (a disturbed sleep-wake cycle is often seen in sun-downing clients, perhaps because they are so often mismanaged during their sun-downing episodes and go to bed frantic)

Multi-disciplinary approach requiring input from all team members:

• Doctors can prescribe a trial of Lorazepam
• Nurses can keep the lights turned on until bedtime; limit noise and confusing stimuli; avoid quizzing patient with orientation questions; if at all possible, avoid use of physical restraints as this only increases fears, confusion, and agitation
• Therapists can organize and run after-dinner group activities (e.g. typically low-key social activities such as a sing-a-long, flower arranging, crafts building that help people through this difficult hour or two before bedtime
• Family can be available during the sun-downing period; sit quiety and hold hands with person; only 1-2 family members at at time

Question 34

What is the role of “antecedent management” in brain injury rehabilitation?

Answer 34

The best way to manage difficult behaviors is to arrange situations and organize activates so that triggers for troublesome behaviors are minimized, thus stopping the behaviors before they occur

Environmental modifications to reduce external stimuli (if not, it could lead to agitated behavior by an amnestic patient who is not yet able to filter out extraneous information or cope with sensory overload)

In treatment: work to build a nurturing but not over stimulating milieu, in order to optimize the patient’s impaired information processing and reduce confusion

Question 35

Describe a Day Rehab Program.

Answer 35

A.M. planning meeting
Project-based interventions 
Individualized therapies 
Success in everyday routines 
Group lunch 
Group cognitive-behavioral modules 
Skills-based recreation 
P.M. review meeting 
Home visits 
Family counseling

Question 36

Describe a Brain Injury Clubhouse

Answer 36

Mill House (Richmond), ADAPT (Fairfax), Westwood Clubhouse (Fredricksburg), Denbigh House (Newport News), Beacon House (Virginia Beach)
No OT on staff
Social programs 1x per month
Daily lunch prepared by members
Morning Meetings; A.M. and P.M. unit meetings
Driven by clients themselves (e.g. members work on tasks throughout the day to keep the clubhouse running)
Vocational component

Question 37

Describe an outpatient clinic therapy

Answer 37

Neuromotor retraining
Visual-perceptual training
Vestibular rehabilitation
Dysphagia/aphasia
Psychological counseling/family counseling
O.T. life skills training
Cognitive-behavioral treatment
Pharmacological coordination

Question 38

What home management recommendations would you make to family caregivers as they prepare for a loved one with a brain injury to return home from hospital?

Answer 38

1. Avoid unnecessary trips to unfamiliar surroundings, which may provoke anxiety
2. Avoid ambiguity and do not present too many choices or decision- use statements such as “Now we must go to the store”, “Now it is time to take a shower” and “Brian is coming to visit after supper”
3. Keep grooming and bedside materials in the same place when not in use (for instance, put glasses in the same drawer, place toothpaste beside toothbrush in the bathroom)
4. Avoid confronting the individual with tasks that stress areas of weakness
5. Therapies should be delivered routinely by the same person
6. Try to maintain a daily routine that features well-established landmarks, such as regular mealtimes; make life predictable; avoid breaks in routine whenever possible; extend necessary changes in routine over time instead of changing things all at once
7. Allow extra rest time for the injured individual- schedule doctor appointments after nap times; encourage frequent rest breaks; do not schedule several hours of unbroken activities
8. Limit coffee and tea since their stimulant effects may be amplified
9. Be alert for adverse effects of medications
10. Provide adequate lighting, especially in hallways, stairs, and bathrooms
11. Limit confusing stimulation- family gatherings, for instance, may prove overwhelming; recreational activities are sometimes poorly tolerated, even if they involve previously enjoyed places or activities
12. Be alert for changes in physical or mental status (prolonged agitation, combativeness, changes in sleep or eating patterns)
13. It may be useful to have a radio tuned to a station playing familiar tunes; however, television may contribute to the confusion of the environment
14. Anticipate the possibility that the individual may wander off and get lost- sew labels into clothing to identify the person and who to call
15. Schedule respite periods for yourself and other primary caregivers

Question 39

Be able to describe some strategies for addressing psychosocial deficits after brain injury

Answer 39

“Individuals with TBI commonly report 1 or more years after the injury that psychosocial impairment is the greatest obstacle to rebuilding a meaningful lifestyle”

alteration of self-concept/identity

Goal of the OT is to help rebuild desired occupational and social roles with a 3 step process: 1) identify desired roles that were lost secondary to TBI; 2) identify the activities that would support desired roles; 3) identify rites of passage that were lost or never transitioned through as a result of TBI

Strategies once occupational/social roles, activities and rites of passage have been identified

Facilitate client’s use of adaptation, compensatory strategies, and integration of new learning

Enhance or regain interpersonal skills, self-expression, social appropriateness, time management, self-control

Group therapy/support groups

Find ways to re-engage in community

Question 40

Be able to list and describe at least 3 ecologically valid community-based cognitive-behavioral assessment tools:

Answer 40

Rivermead Behavioral Memory Test - This test is designed to: assess memory abilities of adults, detect and identify moderate to severe memory impairments that occur in everyday activity, and monitor change over time after acquired brain injury.

Test of Everyday Attention - This test is designed to: test attentional skills that influence everyday behavior. It uses familiar materials and tasks to identify attention-related problems in daily task performance.

Behavioral Assessment of Dysexecutive Syndrome: Designed to: assess executive function skills, including organization and planning, problem-solving, and decision-making, by using challenging real-life activities and time frames. It also evaluates the respondent’s awareness of behavioral problems caused by executive dysfunction in daily life situations.

Multiple Errands Test - Test assesses the impact of executive function impairments on the performance of the daily life task of shopping within an authentic real-world context.

Cambridge Prospective Memory Test - Designed to help predict problems arising from everyday prospective memory failures (time or event related) and to assist with treatment planning.

Question 41

What brain injury related deficits may have an impact on a driving evaluation?

Answer 41

TBI disrupts the motor control and attention needed to maintain constant lane position

• Diminished accuracy of visual perception and memory
• Decreased visual problem solving, eye-hand coordination, and reaction time

Executive functioning issues (e.g. lack of insight into physical and cognitive limitations; difficulty in learning new tasks/re-learning tasks; divided attention issues)

Seizure disorders

Clients with TBI frequently exhibit deficits (e.g., visual processing disorders, figure-ground discrimination dysfunction, and impulsivity) that significantly affect their ability to drive safely:

• Delayed visual processing: hesitate during driving maneuvers and stop in an unsafe manner (e.g., in the middle of the road or at a corner) to allow themselves adequate time to process visual information
• Figure-ground impairment: unable to identify stop signs and traffic signals at intersections or locate the gearshift near the dashboard
• Impulsivity: may respond aggressively rather than defensively when driving, increasing the risk of accidents; may use poor judgment when making driving decisions; unable to inhibit inappropriate responses

Question 42

What are mnemonics? How might you use them in outpatient therapy after BI?

Answer 42

Tool to help remember facts or a large amount of information. It can be a song, rhyme, acronym, image, or a phrase to help remember a list of facts in a certain order

3 fundamental principles underlying the use of mnemonics are association, imagination, location

Ways to make a mnemonic more memorable:

• Use positive, pleasant images
• Exaggerate size of important parts of image
• Use humor…rude or sexual rhymes also not easy to forget
• Incorporate symbols
• Vivid, colorful images vs. drab ones
• Use all of the senses to code information or dress up an image
• Bring in 3-D and movement to an image
• Locate similar mnemonics in different places with backgrounds of those places

Can use the above list with clients in outpatient brain injury and/or capitalize on the client’s learning style (visual, auditory, kinesthetic) to create mnemonics

Question 43

Describe a strategy for remembering names and faces:

Answer 43

“Link face and name.”

N: Notice the person’s special or unusual features
A: Ask the person to repeat his or her name
M: mention the name in conversation
E: exaggerate some special feature in building a link between name and face

Question 44

Your community-based client with a brain injury is impulsive and has impaired judgment related to frontal lobe injury. How might you help him improve insight into his condition?

Answer 44

Educating client about the effects of his/her injury (may help increase person’s insight/understanding as to what happened)

OT should structure client’s environment to reduce accidents and increase the client’s awareness of his/her limitations through repeated opportunities to practice and relearn safe and appropriate behavior (pg. 893, Pedretti)

Employ the Principle of Antecedent Management (“once the antecedents are known, the events that can lead up to an unwanted behavior can sometimes be eliminated or modified, thus, preventing the unwanted behavior from occurring in the first place. Trying to manage behaviors consequentially after the ‘water is over the dam’ or ‘the horse is out of the barn’ may be less effective for some individuals with prefrontal lobe injuries” - The Essential Brain Injury Guide)

Incidental teaching opportunities (“when unprogrammed situations arise, they present opportunities for teaching and sometimes provide the best opportunity to teach carryover or generalization of skills to other settings” - The Essential Brain Injury Guide)

Question 45

List at least five concussion symptoms.

Answer 45

Immediate Symptoms of Concussion:

• Attention difficulties
• Memory impairment
• Irritability
• Anxiety
• Dizziness
• Diplopia
• Insomnia or hypersomnia

Symptoms Secondary to Concussion (symptoms fluctuate with situation):

• Headache
• Fatigue
• Depression
• Slowed cognitive processing, especially in multi-stimuli environments

Question 46

Know basic return-to-play guidelines for the management of youth sports concussions.

Answer 46

1) NO ACTIVITY (RECOVERY): complete physical and cognitive rest until medical clearance (continue resting if not symptom-free)
2) LIGHT AEROBIC EXERCISE (INCREASE HEART RATE): walking, swimming, stationary cycling (continue resting if not symptom free)
3) SPORT SPECIFIC EXERCISE (ADD MOVEMENT): skating drills, running drills etc., but no head impact activities (return to step 2 until symptom free if you have symptoms)
4) NON-CONTACT TRAINING DRILLS (INCREASED EXERCISE, COORDINATION, ATTENTION): progress to complex training drills, such as passing activities (return to step 3 until symptom free if you have symptoms)
5) FULL CONTACT PRACTICE (RESTORE CONFIDENCE & ASSESS FUNCTIONAL SKILLS): if symptom free, return to play (return to step 4 until symptom free if you have symptoms)

If symptomless at each step for 24 hours, move to the next step

Question 47

Following concussion, when should an athlete return to the playing field?

Answer 47

Grade 1: 15 minutes (if all symptoms have cleared)

Multiple Grade 1: 1 week (if all symptoms have cleared)

Grade 2: 1 week

Multiple Grade 2: 2 weeks

Grade 3 (brief LOC - seconds): 1 week

Grade 3 (prolonged LOC - minutes): 2 weeks

Multiple Grade 3: 1 month or longer, based on decision of evaluating doctor

Question 48

What is the one common cognitive factor among people who have brain injuries?

Answer 48

Slowed cognitive processing

Question 49

Describe in lay terms what happens to body fluids and the brain in a blast-related concussion.

Answer 49

Blast related injuries: rocket-propelled grenades, improvised explosive devices, land mines

First there’s a direct blow to the head

Then there’s a penetrating head injury, in which the air spaces and fluids in entire body are compressed by shock wave

This is followed instantly by a vacuum wave (underpressure)

Impacts stomach, heart, blood vessels, brain (most fragile), etc.

Question 50

List at least 5 symptoms of PTSD

Answer 50

• Repeated, disturbing memories, thoughts, or images of a stressful military experience
• Repeated, disturbing dreams of a stressful military experience
• Suddenly acting or feeling as if a stressful military experience were happening again (as if you were reliving it)
• Feeling very upset when something reminded you of a stressful military experience
• Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful military experience
• Avoid thinking about or talking about a stressful military experience or avoid having feelings related to it
• Avoid activities or talking about a stressful military experience
• Trouble remembering important parts of a stressful military experience
• Loss of interest in activities which you used to enjoy
• Feeling distant or cut off from other people
• Feeling emotionally numb or being unable to have loving feelings for those close to you
• Feeling as if your future somehow will be cut short
• Trouble falling or staying asleep
• Feeling irritable or having angry outbursts
• Having difficulty concentrating
• Being “super alert” or watchful or on guard
• Feeling jumpy or easily startled

Question 51

Be able to describe how “graduated exposure” therapy is conducted.

Answer 51

A procedure designed to increase comfort and thus confidence in situations that evoke anxiety and/or physiological distress; desensitization-based therapy

A person is exposed to distressful emotional, physiological, and sensory reaction situations; there are incremental increases in tolerance (and incremental compensatory learning, anxiety extinction, sensory interpretation) without experiencing significant anxiety or sensory stress

In a nutshell, a person works with his/her OT to identify personal tolerance for self-selected activities; he/she will create a schedule of gradually increased engagement in assigned activities, incremented in time and/or distance and/or intensity, which are followed exactly by the person; person will self-assess exposure experience using the SUDS (subjective units of disturbance scale)

• Identify functional goals for social interaction and community reentry
• Identify “trigger” stimuli for anxiety
• Identify and rehearse “safe first step”
• Review successes of trials
• Grade up to next step
• Review and collaborate on supports needed