WEEK 4 FEDERAL STATE REHABILITATION LAWS RULES REGULATIONS

WEEK 4: FEDERAL & STATE REHABILITATION LAWS, RULES, REGULATIONS & GUIDELINES AS THEY APPLY TO WORKING AS A VRC IN THE VA SYSTEM. Special Topics in Rehabilitation: REH 6560

Assignment 4 has been posted to the Course Website Reading Assignment for Week 4 has been posted to the Course Website

Amputations Acquired condition that results in the loss of a limb 3

Amputations: Causes 4 Trauma: Severance of a body part due to sudden severe trauma Severe open fractures with arterial and nerve damage can be treated; however, treatment is at a high cost, and multiple surgeries are required The result is often a limb that is painful, nonfunctional, and less efficient than a prosthesis

Amputation: Location 5 Below-Knee Amputation (B/K): This is an amputation above the ankle, but below the knee Full knee use is retained, but it is hard for these amputees to put weight on the stump

Amputation: Location 6 Above Knee Amputation (A/K): This is an amputation in the thigh The whole body weight can't be held on the stump, but a person is able to sit with this amputation

Amputation: Location 7 Hip Disarticulation (H/D): This involves removing the entire leg bone, but surgeons like to leave the upper femur for stability and a place or a prosthetic device

Amputation: Location 8 Wrist Disarticulation (W/D): This is a removal of the hand, but at the wrist joint Plastic sockets are now made to serve as wrists

Amputation: Location 9 Elbow Disarticulation (E/D): This is the removal of the whole forearm at the elbow This amputation creates a bulb shaped stump that can hold weight

Amputation: Possible Functional Limitations 10 Upper Extremity: �Grasping �Pinching �Bimanual �Carrying �Lifting �Holding �Pushing activities

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Amputation: Possible Functional Limitations 12 Lower Extremity: � Balancing � Climbing � Walking � Stooping � Pushing � Lifting � Jumping / Pulling

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Prosthetics 14 Fit Training Comfort Stump Care

Things To Ask About… 15 Frontal Lobe Injury �Alterations in personality Occipital Lobe Injury �Visual disturbances

Things To Ask About… 16 Cortical Disruption �Reduce mental status or Amnesia Retrograde Unable to recall events before injury Antegrade Unable to recall events after trauma “Repetitive Questioning”

The Effects of a TBI Depend on: 17 Number of injuries Severity of injuries Time since injury(s) Areas of injury Age the injury(s) occurs

The Effects of a TBI Depend on: 18 Status of the person before injury What happens after the injury to reestablish previous abilities

Effects of Injury 19 The effects of the injury will not be uniform or necessarily stable. l Impaired skills in one area does not necessarily mean impaired skills in another area. l Strengths and weaknesses may change over time, especially with more recent injuries.

Simplified Brain Behavior Relationships Frontal Lobe • Initiation • Problem solving • Judgment • Inhibition of behavior • Planning/anticipation • Self-monitoring • Motor planning • Personality/emotions • Awareness of abilities/limitations • Organization • Attention/concentration • Mental flexibility • Speaking (expressive language) 20 Parietal Lobe Frontal Lobe Occipital Lobe Temporal Lobe Parietal Lobe • Sense of touch • Differentiation: size, shape, color • Spatial perception • Visual perception Occipital Lobe • Vision Cerebellum Brain Stem Temporal Lobe Brain Stem • Memory • Hearing • Understanding language (receptive language) • Organization and sequencing • Breathing • Heart rate • Arousal/consciousness • Sleep/wake functions • Attention/concentration Cerebellum • Balance • Coordination • Skilled motor activity

Types of TBI: Open 21 Skull compromised and brain exposed Head Trauma - 21

Types of TBI: Closed 22 Skull not compromised and brain not exposed Head Trauma - 22

Brain Injury 23 As defined by the National Head Injury Foundation �“a traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes. ”

Brain’s Response to Injury q Swelling of brain Vasodilatation with increased blood volume Increased 24 ICP Head Trauma - 24

Brain’s Response to Injury 25 q Decreased blood flow to brain Perfusion Cerebral decreases ischemia (hypoxia)

Signs & Symptoms of Brain Injury: Altered Mental Status 26 Altered orientation Alteration in personality Amnesia �Retrograde �Antegrade

Signs & Symptoms of Brain Injury 27 Cushing’s Reflex �Increased BP �Bradycardia �Erratic respirations

Signs & Symptoms of Brain Injury 28 Vomiting � Without nausea � Projectile Body temperature changes Changes in pupil reactivity

Direct VS. Indirect Brain Injuries 29 Direct �Primary injury caused by forces of trauma Indirect �Secondary injury caused by factors resulting from the primary injury

Brain Injury: Direct Brain Injury 30 o Immediate damage due to force o Coup and contracoup o Fixed at time of injury Head Trauma - 30

Direct Brain Injury Types 31 Coup � Injury at site of impact Contrecoup � Injury on opposite side from impact

32 Coup Contrecoup

Indirect Brain Injury 33 o o o Results from hypoxia or decreased perfusion Response to primary injury Develops over hours Head Trauma - 33

Blast Injuries 34 Secondary blast injury (caused by flying debris and fragments) Tertiary blast injury (caused by being thrown by blast wind) from penetrating and blunt trauma that is not unlike head injuries from causes other than explosions

Blast Injuries 35 There is some controversy whether the brain is vulnerable to primary blast injury (caused by the overpressurization wave), animal models suggest that it is. Shear and stress waves from the overpressurization could potentially cause TBI directly (e. g. , concussion, hemorrhage, edema, diffuse axonal injury).

PTSD 36 Post-traumatic stress disorder (PTSD) is a mental health condition that's triggered by a terrifying event Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event

Summary 37 The frontal lobe of the brain is most commonly injured. Therefore, deficits in executive functioning and self-regulation are frequently observed after TBI

Summary 38 Self-regulation is at the core of who we are, how we respond to different situations, and how well we are able to move toward the completion of our long-term goals.

Summary 39 Self-regulation deficits can interfere with the effective provision of treatment and other services Many individuals with TBI have additional disorders associated with impaired selfregulation. The effects of such cooccurring disorders are not yet wellunderstood

Secondary Effects of Impaired Executive Functioning/Self-Regulation 40 Decreased automatic responses Slowed processing More effort required to learn and respond

Self-Regulation 41 Using the cognitively-based executive functions to manage one’s own responses to different situations Being able to make decisions based on longterm goals rather than immediate desires

Impulsivity/Disinhibition 42 Performing a response without considering the long-term consequences of that action

Lack of Initiation 43 Problems with “starting”--cannot initiate behaviors consistent with the achievement of one’s goals How would this impact looking for a job?

Deficits in Self-Regulation are also Observed in Persons with: 44 Substance use disorders Attention deficit disorder Various psychiatric disorders And all are more prone to having a TBI.

TBI: POSSIBLE FUNCTIONAL LIMITATIONS 45 Balancing, lifting, walking Strength, coordination Vision, hearing, communication skills Pain and headaches

Possible Functional Limitations: TBI 46 Memory, organizational and planning ability, concrete thinking Attention span/distractibility Writing skills, reading skills, visual-spatial skills Lack of initiative, inflexibility, irritability

TBI: Psychosocial Considerations 47 Social judgment, maturity Social awkwardness Feelings of isolation, impulsiveness, aggressiveness Anger, depression, anxiety, low self-esteem

Noise-Induced Hearing Loss (NIHL) 48 Sound is measured in units called decibels. The humming of a refrigerator is 45 decibels, normal conversation is approximately 60 decibels, and the noise from heavy city traffic can reach 85 decibels.

Noise-Induced Hearing Loss (NIHL) 49 Long or repeated exposure to sounds at or above 85 decibels can cause hearing loss. People usually experience pain at about 130 d. B

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Stats 1. 6 million troops deployed to OEF/OIF to date Approximately 40% have accessed VA care Three most common presenting problems: Musculoskeletal Ailments Mental Disorders (PTSD, SA/D, Depressive) “Symptoms, Signs, and Ill Defined Cond. ”

PTSD and Mild Traumatic Brain Injury (TBI) Slightly more than half of combat injuries early in OIF came from explosions 29% evacuated from combat theater to WRAMC had evidence of TBI (Jan 2003 -Feb 2007) Approximately 15% of all wounded vets have suffered TBI (4, 471 cases diagnosed between October 2001 and September 2007)

TBI Physical damage by external blunt or penetrating trauma Acceleration-Deceleration Movement (whiplash) resulting in tearing or nerve fibers, bruising/contusion of brain Scraping of brain across bony base of skull leading to olfactory, oculomotor, acoustic nerve damage. � Loss of sense of smell and reduction of taste (anosmia), double and/or blurred vision, dizziness or vertigo � Usually remit after several days or weeks (nerves recover or regenerate)

Levels of TBI Mild � LOC for less then 30 minutes w/normal CT and/or MRI � Altered mental state: “dazed, ” “confused, ” “seeing stars” � PTA less then 24 hours (unable to store or retrieve new information) � Glasgow Coma Scale (GCS): 13 -15

Levels of TBI Moderate � LOC less than six hours w/abnormal CT and/or MRI � PTA less than seven days � GCS: 9 -12 Severe � LOC greater than six hours w/abnormal CT and/or MRI � PTA greater than seven days � GCS: 1 -8

Post-Concussion Syndrome (PCS) Symptoms immediately post-injury may include: � Memory, attention, concentration deficits � Fatigues, poor sleep, dizziness, headaches � Irritability, depression � Anxiety Most common: free-floating anxiety, fearfulness, intense worry, generalized uneasiness, social withdrawal, heightened sensitivity, related dreams Recovery (mild TBI) expected within 4 -12 weeks; however, some symptoms may linger for months to years

Assessment Post concussion Syndrome (PCS) � � � � � Insomnia Memory Deficits Poor Concentration Depressed Mood Anxiety Irritability Headache Dizziness Fatigue Noise/Light Intolerance PTSD � � � � � Insomnia Memory Deficits Poor Concentration Depressed Mood Anxiety Irritability Intrusive symptoms Emotional Numbing Hyperarousal Avoidance behavior

Mild TBI among OIF Returnees (Hoge et al. , 2008) 2, 525 soldiers included in study (assessed 3 -4 months post-deployment) � 5% (124) reported injury with LOC (up to several minutes) � 10% (260) reported injury with altered mental status w/out LOC � Four soldiers reported LOC longer than 30 minutes � 17% (435) reported other injuries

TBI Among OIF Returnees (Hoge et al. , 2008) Of those who reported LOC, 44% met criteria for PTSD, as compared to: -27% of those with altered mental state -16% of those with other injuries -9% of those with no injuries

Blast Injuries Over 50% of combat injuries result from bombs, grenades, land mines, missles, mortar/artillery shells Account for majority of brain injury in theater with GSWs, falls, and MVAs close behind TBI among service members as high as 22% � 2003 -2008: over 6, 600 TBI � Four major polytrauma centers (MN, CA, FL, VA): 923 OEF/OIF patients with TBI

Blast Injury Blast injuries results from pressure generated from an explosion which causes in overpressurization Air-filled organs (ears, lung, GI tract) and organs surrounded by fluid filled cavities (brain, spinal cord) susceptible

Hoge et al. (2006) 01 May 2003 – 30 April 2004: � OEF (Afghanistan) � OIF (Iraq, Kuwait, Qatar) � Other (Bosnia, Kosovo, etc. ) N = 303, 905 Marines and Soldiers � OEF: 11. 3% of 16, 318 � OIF: 19. 1% of 222, 620 � Other: 8. 5% of 64, 967

Hoge at al. (2006) Combat Experiences: OEF Any 46. 0% Witnessed 38. 1% Discharged 6. 2% Felt in Danger 24. 6% OIF 65. 1% 49. 5% 17. 8% 50. 3% OTHER 7. 4% 5. 3% 0. 4% 3. 2%