OVERVIEW INTRODUCTION THE NEUROPSYCHOLOGY OF TBI NEUROREHABILITATION OF TBI PTS. PRACTICAL/CLINICAL MANAGEMENT ISSUES IN TBI REHABILITATION AND CARE

TBI Epidemiology Incidence - ~200 per 100,000 in the U.S. a year General Demographics - peak at ages 15-24; 3- 4X greater frequency in males.

TBI - Major Causes Motor vehicle accidents Personal violence Falls

Why Neuropsychology? Brain-behavior relationships can be quite complex. Often, there is more than “what meets the eye.” The neuropsychologist, who is trained in observing, assessing, and understanding brain- behavior relationships, can assist other professionals in clarifying and organizing what they see clinically.

Pathology of Head Trauma focal injury diffuse axonal injury (DAI) superimposed hypoxia/ischemia diffuse microvascular damage

Medical Complications Include: edema contusion laceration vascular lesions (hemorrhages, hematomas) infections cranial nerve injury focal cerebral lesions

Blood Vessels of the Skull The brain requires a rich blood supply, and the space between the skull and cerebrum contains many blood vessels. These blood vessels can be ruptured during trauma, resulting in bleeding. Groove for middle meningeal artery

Coup/Contre-coup Injury A French phrase that describes bruises that occur at two sites in the brain. When the head is struck, the impact causes the brain to bump the opposite side of the skull. Damage occurs at the area of impact and on the opposite side of the brain.

Epidural Hematoma An epidural hematoma is a blood clot that forms between the skull and the top lining of the brain (dura). This blood clot can cause fast changes in the pressure inside the brain. When the brain tissue is compressed, it can quickly result in compromised blood flow and neuron damage.

Subdural Hematoma A subdural hematoma is a blood clot that forms between the dura and the brain tissue. The clot may cause increased pressure and may need to be removed surgically. When the brain tissue is compressed, it can quickly result in compromised blood flow and tissue damage.

Classifying CHI Concussion - a mild traumatic brain injury characterized by a brief loss or change in consciousness and/or a brief post-traumatic amnesia.

Classifying CHI (cont’d) Means of classification: admission GCS score length of coma length of PTA

The Importance of PTA Post-traumatic amnesia (PTA) - refers to a period of clouded consciousness which precedes the attainment of full orientation and continuous awareness in persons recovering from head injuries. It can be defined as beginning from the last clear memory before a head injury to the first clear memory after.

The Importance of PTA (cont’d)

Understanding Posttraumatic amnesia will help you know when the patient is still in a fairly acute stage of recovery, with accompanying cognitive/behavioral symptoms. Understanding PTA will also help you to estimate the severity of the head injury.

The Importance of PTA (cont’d) PTAGCS Mild0-1 hr13-15 Moderate1-24 hrs 9-12 Severe> 24 hrs < 8

Understanding Diffuse/Nonspecific Vs. Focal Neurocognitive Sequelae of TBI

Diffuse Axonal Injury Brain injury does not require a direct head impact. During rapid acceleration of the head, some parts of the brain can move separately from other parts. This type of motion creates shear forces that can destroy axons necessary for brain functioning. These shear forces can stretch the nerve bundles of the brain.

Diffuse Axonal Injury The brain is a complex network of interconnections. Critical nerve tracts can be sheared and stressed during an acceleration- type of injury. Diffuse axonal injury is a very serious injury, as it directly impacts the major pathways of the brain.

Diffuse or Nonspecific Sequelae of TBI -diminished arousal/alertness -impaired attention/concentration -slowed information processing -concrete thinking -poor insight -fatigability

Interior Skull Surface The base of the skull is rough, with many bony protuberances. These ridges can result in injury to the frontal and temporal lobes of the brain during rapid acceleration or deceleration. Bony ridges Injury from contact with skull

Temporal Lobe The temporal lobe plays a role in emotions, and is also responsible for smelling, tasting, perception, memory, understanding music, aggressiveness, and sexual behavior. The temporal lobe also contains the language area of the brain.

Temporal Lobe Injury The temporal lobe of the brain is vulnerable to injury from impacts of the front of the head. The temporal lobe lies upon the bony ridges of the inside of the skull, and rapid acceleration can cause the brain tissue to smash into the bone, causing tissue damage or bleeding.

NP Sequelae of Temporal Lobe Injuries -impaired language comprehension -dysphasia, dysnomia -impaired learning and memory -affective changes anxiety anger outbursts irritabiity depression

Frontal Lobe The frontal lobe is the area of the brain responsible for higher cognitive functions. These include: Problem solving Spontaneity Memory Language Motivation Judgment Impulse control Social and sexual behavior.

Frontal Lobe Injury The frontal lobe of the brain can be injured from direct impact on the front of the head. During impact, the brain tissue is accelerated forward into the bony skull. This can cause bruising of the brain tissue and tearing of blood vessels. Frontal lobe injuries can cause changes in personality, as well as many different kinds of disturbances in cognition and memory.

NP Sequelae of Frontal Lobe Injuries Orbitofrontal deficits: -emotional/personality disinhibition -irritability, hypersensitivity -poor self-monitoring -impulsivity, inappropriate social behavior -anosmia -may appear manic or antisocial

NP Sequelae of Frontal Injuries (cont’d) Dorsolateral prefrontal deficits: -“executive”impairments -cognitive inflexibility, perseveration -poor cognitive organization, planning -diminished judgment and insight -motor programming disturbances -may appear depressed, avoidant, passive

NP Sequelae of Frontal Injuries (cont’d) Anterior cingulate or fronto-mesial deficits: -abulia (lack of initiative/drive) -akinesia -indifference -diminished spontaneity, initiation -reduced verbal output -may appear depressed

Parietal Lobe The parietal lobe plays a role in our sensations of touch, smell, and taste. It also processes sensory and spatial awareness, and is a key component in eye-hand co-ordination and arm movement. The parietal lobe also contains a specialized area called Wernicke’s area that is responsible for matching written words with the sound of spoken speech.

Occipital Lobe Injury Occipital lobe injuries occur from blows to the back of the head. This can cause bruising of the brain tissue and tearing of blood vessels. These injuries can result in vision problems or even blindness.

III. Neurorehabilitation of TBI

Rehabilitation Terminology Impairment -a loss or abnormality of structure or function at the level of tissue or organ that can lead to disability. Disability -the restriction or inability to perform a skill or activity that results from pathology or impairment. Handicap -a disadvantage for an individual on account of a disability that prevents the fulfillment of expected social roles.

What is Rehabilitation? rehabilitare - to restore, from re-, again; habilis, suitable. Activities designed to facilitate and maximize recovery of function following injury. In hospitals, frequently multi- or inter-disciplinary in nature, and provided by a team consisting of a physiatrist, neuropsychologist, nurse, speech-language pathologist, occupational therapist, and physical therapist.

What is Rehabilitation? Restorative -designed to bring an impairment closer to its original, premorbid function. Maintenance -designed to keep functioning at a static level, despite increasing impairment. Remember, rehabilitation generally emphasizes function!

Goals of Rehabilitation Reduce disability or handicap Increase functional independence Facilitate adjustment

Approaches to Cognitive Rehabilitation Restorative - Focus: restoration of specific neuropsychological impairment(s). Goal:to exercise and ultimately improve underlying difficulties rather than symptoms. Method:isolate/assess impairments; repeated practice on psychometric, computerized, or paper and pencil tasks believed to exercise areas of deficit. Efficacy:questionable. Generalization has not been consistently demonstrated in studies.

Approaches to Cognitive Rehabilitation Compensatory - Focus: reducing disability. Goal:to teach the brain-injured patient to use strengths, strategies, and skills to reduce the impact of the impairment. Method:use of mnemonics and other mediation strategies to deal with memory impairment; use of memory aids and cueing devices such as alarms, diaries, timers, calendars, etc. Efficacy:generally better than restorative approaches. Demonstrated success with external aids, provided patient is motivated, aid is relatively easy to use, and are taught to be applied to specific real life memory difficulties.

Approaches to Cognitive Rehabilitation Environmental Manipulation - Focus: reducing or avoiding disability. Goal:to maximize the patient’s performance by modification of environmental factors. Method:alteration/manipulation of patient’s environment. For example, quieter environment to avoid distraction; alteration of work duties such that they minimize demands on memory or initiative; use of external aids or cues for memory problems (patient more passive relative to same methods used in compensatory strategies). Efficacy:lack of well-controlled research to demonstrate efficacy.

IV. Clinical Management Issues in TBI Rehabilitation

Rehabilitation of TBI Patients: Some Behavioral/Emotional Challenges -depression/anxiety -agitation, irritability, lability -impulsivity -impaired motivation -dependency

Rehabilitation of TBI Patients: Some Neurocognitive Challenges -poor insight -diminished attention/concentration -impaired learning and memory -poor planning and organization -cognitive inflexibility

Managing Neurobehavioral and Neurocognitive Issues -family and staff education -behavioral and pharmacologic intervention -compensatory strategies/mechanisms -environmental modifications -lots of patience