Traumatic Brain Injury III Scott S Rubin Ph
Traumatic Brain Injury - III Scott S. Rubin, Ph. D. SPTHAUD 6464
Recovery • A multi-stage process • Continues for years • Differs for each person
Recovery
Recovery Ø Traumatic brain injury (TBI), stroke and other acquired brain injuries (ABI) have variable outcomes affecting many areas, each to a different degree. Ø Recovery from TBI or stroke takes years, often requiring extensive rehabilitation.
Recovery Ø Rehabilitation professionals need a way to find out which are the areas in greatest need of rehabilitation, to improve daily functioning and lessen the impact of the brain injury on family members.
Recovery Ø To discover where people are having problems, you should ask them. However, they may not be able to recall problems on their own and may need to be asked about specific areas.
Recovery Ø Rehabilitation should be able to demonstrate gains to clients, family and funders.
GLASGOW OUTCOME SCALE • Good recovery: the capacity to resume normal occupational & social activities, although there may be minor physical or mental deficits. • Moderate disability: (disabled but independent) able to look after himself at home, to get out and about to shops & travel by public transport. Some previous activities, at work or in social life, no longer possible by reason of either physical or mental deficit.
GLASGOW OUTCOME SCALE • Severe disability: (conscious but dependent) needs assistance of another person for some activities of daily living every day. Ranges from total care to assistance with only one activitydressing, going out to shop. • Vegetative State • Dead
The Prognosis • Interview with family (and patient? ) • Extensive chart review • Weigh the factors…
Mild injury 0 -20 minute loss of consciousness GCS = 13 -15 PTA < 24 hours Moderate injury 20 minutes to 6 hours LOC GCS = 9 -12 Severe injury > 6 hours LOC GCS = 3 -8
Prognostic Variables • Post-Injury Factors – – Early Medical Intervention Early Rehabilitation Long-term Supports Individual Resilience, Effort, and Adjustment
Factors influencing outcome • Nature of Brain Injury – unilateral vs. bilateral/ brainstem – extent of brain damage • Premorbid health(physical & mental) • Family support
The Prognosis • Pre-injury Factors – Social Adjustment – Neurological integrity – Knowledge Base
Post Head Injury Behaviour • Premorbid Factors – – – mental constitution personality antisocial behaviour alcohol/ substance abuse family dynamics “It is not only the kind of injury that matters, but the kind of head” Symonds 1937
Recovery • Duration of Coma. The shorter the coma, the better the prognosis. • Post-traumatic amnesia. The shorter the amnesia, the better the prognosis. • Age. Patients over 60 or under age 2 have the worst prognosis, even if they suffer the same injury as someone not in those age groups
Recovery • Knowledge of Disorder – needed to deal with treatment.
Recovery • Other Prognostic Indicators… – Standards you should know! – Class? ? ?
Prevent complications • PHYSICAL –Falls –Pressure Sores –Urinary infection –Chest Infection –Musculoskeletal –Epilepsy –DVT - deep vein thrombosis –Constipation • PSYCHOLOGICAL –Communication • dysphasia/intelligibility –Cognition • confusion/memory –Behaviour • agitation/apathy –Emotion • depression/lability
Delayed Consequences of TBI • Neurological Development • Increasing Failure • Restrictions
Permanence of change? • Physical recovery • Reeducation of the individual • Environmental modifications
Therapy Effectiveness? – Wilson (1997) provided direct evidence of the effect of compensatory cognitive devices (notebooks, wristwatch alarms, programmed reminder devices) on the reduction of EMF’s for persons with TBI
Therapy Effectiveness? – Helfenstein (1982) provides evidence that compensatory cognitive rehabilitation reduces anxiety, and improves self-concept and interpersonal relationships for persons with TBI
Review of Terminology: Memory • Short-term • Long-term and Active • Working memory Environment – Learning, comprehending, and reasoning Working LONG TERM Active
Memory • • • Autobiographical Episodic Procedural Topographical Sensory – Visual – Auditory • Etc • continued
Memory • Lexical • Semantic – – Concept • units – Proposition • relationships – Schmata • Large pictures
Memory
Schemas • Schemas have Variables – The variables include concepts and propositions. • Schemas can embed one within another • Schemas represent knowledge at all levels of abstraction • Schemas represent knowledge rather than definitions
Communication and Memory • Automatic or Effortful Retrieval – Automatic – Include priming – Effortful • • Slow interactions Socially distracting Repetition Social breakdowns • Inefficient encoding – Impacts return to school/work – Missed appointments, medicines, activities – Social withdrawal
Types of Activation • Serial – Serial Activation of Systems • Parallel – Parallel Activation of Systems
Types of Activation • Bottom-up
Types of Activation • Top-down
Types of Activation • Horizontal Activation
Assessment in Traumatic brain Injury
Assessment • Assessment crosses all areas of speech, language, and cognition. • TBI patients don’t have aphasia… see other causes. • Quote Audrey Holland: TBI usually “don’t look like aphasia, sound like aphasia, act like aphasia, feel or taste like aphasia”
Assessment • Quote from Wertz – “Aphasic patients usually communicate better than they talk, and TBI patients frequently talk better than they communicate”. – Think about what you are evaluating
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Evaluation • To Answer Consult – – Chart Review Interviews (pt and family? ) Screenings Coma Scale? – Next up - Screenings
Screenings • What should you have in your lab coat? As we discuss each area of screening – think about what materials you need with you… now – on to the areas!
Evaluation - Screening • Orientation (or Mental Status) – Oriented X 3 • Following is in reverse order of vulnerability of disruption. – 1. Person – 2. Place – 3. Time
Evaluation - Screening • Language Screening – – Particular tasks to screen language… think about the specific behaviors used in aphasia categorization.
Evaluation - Screening • Motor Screening – Structures to examine? – Tasks? – What are you screening for? • i. e. , the presence of what?
Evaluation - Screening • Right hemisphere Screening – Language aspects in right hemisphere? – Specific non-dominant hemisphere abilities • Attn? • Memory?
Evaluation - Screening • Derive Coma Level (if appropriate) Rancho? Glasgow?
Ross Information Processing Assessment • RIPA or RIPA-G – RIPA-2 (now standardized) – RIPA-G (geriatric) standardized – Materials needed: • Picture book • Test Form • See next slides for content
RIPA; RIPA-G – Areas of Assessment • • Immediate Memory Recent Memory Temporal Orientation Spatial Orientation to Environment Recall of General Info Problem solving and Abstract Reasoning • Organization of Info • Auditory Processing and Comprehension • Problem Solving and Concrete Reasoning – Supplemental Subtests • Naming Common Objects • Functional Oral Reading
RIPA • + fairly quick test • + gives rough profile of patient’s processing skills • + scaled scores strengths and weaknesses within subjects and percentiles among other TBI patients • + reliable and valid with older adults, easy to administer
Communication Activities of Daily Living • CADL-2 – Standardized – Materials Needed: • Picture Book • Patient Response Booklet • Test Form – Areas of Assessment • • Social Interaction Divergent Communication Contextual Communication Sequential Relationships Nonverbal Communication Reading, Writing, and Using Numbers Humor/Metaphor/Absurdity
CADL – Pros • + good complement to diagnostic batteries • + assess function in “real” situations • + allows credit for nonverbal communication
Scales of Cognitive Ability For Traumatic Brain Injury – SCATBI – Norms are based on head injured subjects – Materials needed: • Tape recorder & SCATBI Tape • Stimulus Manual • Stimulus Cards – Areas of Assessment • Perception and Discrimination • • Orientation Organization Recall Reasoning
SCATBI • Pros – • assess cognitive skills supporting communication function; assist in decisions regarding treatment plan • Good to assess communicativecognitive and verbal/working memory • for more specific or in-depth testing • covers a broad range of cognitive and Linguistic skills
SCATBI • Cons… • too high level for some patients • standard scores compare to patients with TBI not to normals • does not assess any area in depth • does not test memory beyond one second delay and less than one minute of distracting questions
Evaluation • American Speech Language Hearing Association Functional Assessment of Communication Skills for Adults • used to obtain self-reports of abilities in variety of communication situations, tasks having both client & family or friend fill it out, can compare clients perceptions of skills with other’s perceptions = awareness of abilities/disabilities
Evaluation • Brief Test of Head Injury (4) • good for patients with short attention span and who are ‘lower’ level. • cognitive-linguistic tool, for acute and rehabilitation patients • + screens areas • + fast • + brief • + has language and gestural scoring and can be used to track recovery • - if someone does well in an area, doesn’t mean that they are “functional”
Evaluation • Measure of Cognitive Linguistic Abilities – Positives • addresses language skills in more depth than the SCATBI – assesses more higher level language skills than most other language batteries – Cons • too long to use the whole test • annoying typos and graphic layout errors
Evaluation • Test of Nonverbal Intelligence – Third Edition (TONI) – Like the Raven’s Colour Progrssice Matrices (used in WAB) – but black and white.
Evaluation • Wechsler Memory Scale – Revised • Boston Naming Test • Revised Token Test • Reporter’s Test
Evaluation • Reading Comprehension Battery for Aphasia • MTDDA – Minnesota Test – – – 46 SUBTESTS IN 5 domains Auditory Disturbances Visual and Reading Disturbances Speech and language disturbances Visuomotor and writing disturbances Disturbances of numerical relations and arithmetic processes
Evaluation • When testing can not vary from test protocol – however assessing patients abilities – after formal tests complete, consider stimulus manipulation (informal probes) • Stimulus Manipulation may include… • Vocabulary Level – adjust FOA • Stimulus length – Short vs Long • continued
Evaluation • Grammatical construction – Simple vs Complex • Content abstractness – concrete vs abstract • External Structure – Ridged vs Relaxed • Temporal Presentation – slow vs rapid
Traumatic Brain Injury V Scott S. Rubin, Ph. D. SPTHAUD 6464
Awareness Questionnaire (AQ) • 3 forms; – one form completed by the patient – one by family member/significant other – one by a clinician familiar with the person with TBI – abilities of patient to perform various tasks after the injury as compared to before the injury are rated on a five point scale ranging from "much worse" to "much better. "
TBI – AQ examples • 1 = much worse, 2= little worse, 3= about the same, 4 little better, 5 = much better • Examples… • 14. How good are you at planning things now as compared to before your injury? • 15. How well organized are you now as compared to before your injury? • 16. How well can you keep your feelings in control now as compared tobefore your injury? • 17. How well adjusted emotionally are you now as compared to before your injury? *Compare scores from beginning of treatment – to later stages of Tx…
Agitated Behavior Scale (ABS) • Developed to assess the nature and extent of agitation during the acute phase of recovery. • Obtained through observation • 1 = absent: behavior not present. • 2 = present to a slight degree: behavior present but does not prevent the conduct of other, contextually appropriate behavior. • 3 = present to a moderate degree: individual needs to be redirected from an agitated to an appropriate behavior, but benefits from such cueing. • 4 = present to an extreme degree: individual not able to engage in appropriate behavior due to the interference of the agitated behavior, even when external cueing or redirection is provided.
TBI - (ABS) • 1. Short attention span, easy distractibility, inability to concentrate. • 2. Impulsive, impatient, low tolerance for pain or frustration. • 3. Uncooperative, resistant to care, demanding. • 4. Violent and or threatening violence toward people or property. • 5. Explosive and/or unpredictable anger. • 6. Rocking, rubbing, moaning or other self-stimulating behavior. • 7. Pulling at tubes, restraints, etc. • 8. Wandering from treatment areas. • 9. Restlessness, pacing, excessive movement. • 10. Repetitive behaviors, motor and/or verbal. • 11. Rapid, loud or excessive talking. • 12. Sudden changes of mood. • 13. Easily initiated or excessive crying and/or laughter. • 14. Self-abusiveness, physical and/or verbal. • _____ Total Score
TBI - ABS • The Total Score is calculated by adding the ratings (from one to four) on each of the fourteen items. • Can average to obtain overall level.
Satisfaction With Life Scale (SWLS) • 1 = strongly disagree , 2 = disagree, 3 = slightly disagree, 4 = neither agree nor disagree, 5 = slightly agree, 6 = agree, 7 = strongly agree • • 1. In most ways my life is close to my ideal. 2. The conditions of my life are excellent. 3. I am satisfied with my life. 4. So far I have gotten the important things I want in life. • 5. If I could live my life over, I would change almost nothing.
SWLS • mean of 19. 0 (middle of the road), standard deviation of 7. 6. sample of 98 patients with TBI six months to 5 years post-discharge from acute rehabilitation. • Time post-injury was significantly associated with higher SWLS total score. • Corrigan, Smith-Knapp & Granger (1998) • Track patient over time!
Scope of Intervention • Conventional (older way) • Functional – SLP: speech and – Each Profession: linguistic competence achievement of realworld goals in real– Behavioral Psych: world contexts management of problem behaviors – Behavior analysis, pragmatics, social – Cognitive Rehab: cognitive intervention targets separate cognitive components – Stresses importance in a hierarchy of executive or selfcontrol functions
Collaboration • Conventional • Functional – Cognition, – Overlap of services communication, and behavioral psychs, behavior are treated cognitive rehab separate and in specialists, SLPs isolation and others – Reports, goals, – Plans of objectives, and plans intervention are produced integrated across separately disciplines – The disabled individual and people in their lives are included in the planning
Deficits and Strengths • • Conventional – Cognitive Rehab Specialist treats and restores cognitive deficits – SLP treats and restores communication deficits – Behavioral psych eliminates undersirable behaviors Functional – Each professional: begins with strengths and builds on them by ensuring success in functional activities and compensatory strategies to use strengths to compensate for weaknesses – Success is the goal – Substituting undesirable behaviors with positive ones – Enhancement of selfesteem.
Settings and Activities • Functional • Conventional – Each profession: – SLP: Drill and practice focus is on real-world in isolated settings needs in real-world – Cognitive Rehab contexts Specialist: Drill and – Communication and practice in isolated behavioral services setting are delivered in meaningful social – Behavioral Psych: groups targets behavior – Goal is to pursue services in a behavior cognitive, executive unit or facility function, communication and behavior in the context of daily routines
Involvement of Everyday Communication Partners • Conventional – Professionals are the agents of change – Intervention is impairment oriented • Functional – Focus is on improvement of function within daily routines – Communication partners include: • family members • paraprofessional aides • supervisors • teachers • friends – Rehab Specialists train and provide ongoing support of everyday communication partners
Source Control • Conventional – Relies on external control of behavior. Professional assumes responsibility for executive dimensions – TBI Pt. Is not included as a member of the team for goal selection, evaluation, or monitoring for intervention • Functional – Ultimate goal is to ensure that the individual controls his or her behavior as much as possible – TBI Pt. Is included as a team member
Intervention Procedures • Conventional • Functional – Goal is acceptable range – Behavioral of behaviors objectives specify – Modification of behavior is isolated targets a result of manipulating – Modification of the consequences as well behavior is largely as the antecedents, the a result of the focus is on the manipulation of antecedents the consequences – Contingency management of behavior focuses on positive consequences for desirable behavior – Apprenticeship Relationship (mentoring)
Supporting Research • Morton and Wehman (1995) • Lezak and O’Brien (1988) • Hoofien, et. Al (2001)
Traumatic Brain Injury Scott S. Rubin, Ph. D. SPTHAUD 6464
Treatment – Tasks for Memory • Procedural memory – Following sequential directions – Listen to directions. How many steps are involved? Then carry it out with objects in front of you – objects needed - 3 index cards, pen (sharpie? ) – Write a different number on each card. Put the cards in order starting with smallest number • Other cognitive functions involved?
• Procedural memory - Continued • Identify steps for task in a sequence • Cashing a check • fill out check • • • take it to bank give it to teller Count money you receive – Other cognitive functions involved?
• Procedural memory - Continued • Describe how you --- • Drive a car • Order a pizza • Bake a lasagna – Other cognitive functions involved?
• Episodic memory • Word list recall • Story retell • Relate life events - “What did you do in college” • Other cognitive functions involved?
• Topographic memory • Describe the route you drive home. • Draw the layout of your bedroom • Order photographs by locations • (requires previous picture taking of areas) • Other cognitive functions involved?
• Semantic (conceptual) Memory • Name category to which these items belong: • necklace earrings watch • sister mother aunt cousin • Then – opposite – name within category – Remind you of direct language tasks? – Other cognitive functions involved?
Therapy in TBI – Compensatory Strategies • Compensatory Strategies should maximize strengths and make use of what the patient CAN do. (Based on Milton & Wertz, etc) • Example: If patient can’t use public transportation – but can read a list of directions… make cue cards for specific trips. Train patient to follow the directions in sequence.
Compensatory Strategies • Strategies are on a continuum. As patient progresses and learns – techniques may change. External cues may become internalized. • A strategy may be difficult at first – but – patient learns and it becomes easier.
Compensatory Strategies • The patient should be involved in developing the strategy. • The number of strategies used should be monitored. Too many strategies reduces effectiveness. Evaluate the effect of a new strategy on the performance of those already used. May decline!
Compensatory Strategies • It helps if a patient understands why a strategy is being used (but not essential) • Strategies prior to teaching the compensatory strategy – See next slides…
(pre)Compensatory Strategies • Again, these may be actual goals – for treatment – prior to implementing strategies! • Self awareness – Goals: • Be able to discriminate between effective and ineffective performance • Become aware of deficits • Recognize implications of deficits
(pre)Compensatory Strategies • Procedures (related to previous slide) – Show two video tapes (or role play) illustrating successful and unsuccessful performance of a task. Analyze tapes together. – Watch other TBI patients in Group Tx, they make note of deficits. They discuss these with you. – Videotape patient… Review tape first with no commentary. Comment on what was done well, and whats done poorly. May need several sessions of this. Tell pt to stop the tape when they see a problem. – Discuss long term goals. List skills needed to achieve those goals.
(pre)Compensatory Strategies • Teach value of strategies • Goal: Patient to agree that strategies are helpful in accomplishing their goals – Show video of someone failing without strategy and another of someone succeeding with strategy – Have advanced patients provide testimonial of value of strategies. – Do problem solving exercises – use strategies to solve – Have patient evaluate self – with and without strategies (video) – Discuss with patient – how non-tbi people use strategies – like day-timers, memos, etc)
Compensatory Strategies • Teaching the Strategies – – Subtitled: Ways to teach strategies. – Self Discovery • Construct task that causes failure then adjust the task for success (example – a paragraph reading task with too little time versus one with adequate time) – Modeling • SLP or Peer models use of the strategy (role play – use video, etc) • Verbalize the strategy as you do it.
Compensatory Strategies • Teaching continued. – Direct Instruction • Guide use with pictures, diagrams, written instruction, outline, flow chart, etc. • Make it concrete.
Compensatory Strategies • Attention and Concentration – External aids: use timers, alarm clock – Internal aids: self-instruction, selfmonitoring • Orientation – External: pictures, memory book – Internal: selecting “anchor points” to places or points in time.
Compensatory Strategies • Input control – If Auditory; Give speaker feedback… “please slow down”, “please write it down for me”. – If Visual; cover parts up and systematically look at parts. Index card with slit. • Verbal processing – comprehension – Use self questioning, “Do I understand? ” – Ask for clarification or repetitions.
Compensatory Strategies • Memory (encoding and retrieval) – Create basic scripts (external or internal) • Example, Script for going to a restaurant. – Memory book * • Appointments, people met, dates, tasks by day, biographical information, etc. – Pigeon-holing • Use spatial arrangement for remembering things by locations.
Compensatory Strategies • Word Retrieval – Search words by categories and subcategories (can be part of a memory book) – Free circumlocution
Compensatory Strategies • Learning Behaviors – Use tape recorder – Hook up recorder to timer – for self questioning
Compensatory Strategies • Organization – Task Organization – Lay out tasks in advance, include materials needed, steps, and time frame – Thought organization – construct timeline to maintain order of events
Functional Skills for Tx • Functional Memory – – Orientation Recalling schedules Recalling events Learning new tasks
Functional Skills for Tx • Functional Reading – – – – Signs Coupons Menus Advertisements Brochures Applications Newspapers Magazines
Functional Skills for Tx • Money Management – – – Coins and paper money Calculations Purchases Credit cards Investments
Functional Skills for Tx • Study and Testing Skills – for school or for education for new occupation – Following Schedules – Classroom behavior – Initiating asking for help – Concentration (attention) – Study habits (time management – completion of work)
Functional Skills for Tx • Telephone Skills – – Placing a call Recording the information Using telephone book Making emergency calls
Functional Skills for Tx • Transportation – Planning for use of public transportation – Organizes and executes trips – Obtaining a drivers license – Use of Maps – Problem solving breakdowns, etc
Functional Skills for Tx • In depth examples of “skills” – For banking – – – Complete checks Filling out deposit and withdrawal slips Balancing checkbook Managing savings record Using Cash card Recording transactions
Functional Skills for Tx • Easy Street
Functional Skills for Tx • Easy Street
Functional Skills for Tx • Easy Street
Life with TBI • After treatment ends… patients typically have a different life than before the injury • Life long alterations may include – – Long term use of strategies – some will even need reminders on what strategy to use in what situation. – Close self monitoring… what is said and how situations are handled. – Approach each situation (or task) step by step with monitoring.
Life with TBI • Long term adjustments continued – – Follow a less active life style. – Friends from before the injury tend to dissipate and new friendships are difficult to establish. – Some can not return to work – others have to make modifications in vocation.
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