Discuss risk factors and characteristics of various levels of brain injury from mild to severe

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1 Understanding Brain Injury and Effective Strategies for Communication Kristin A. King, PhD, CCC-SLP University of Tennessee Objectives Participants will be able to: Discuss risk factors and characteristics of various levels of brain injury from mild to severe Gain an understanding of the effects of brain injury on communication Identify and list appropriate communication strategies for different areas of deficits following brain injury 1

2 Goals for today... Further the understanding of brain injury and the effect on communication Equip professionals with knowledge and functional/ practical strategies that can be applied in the school, home, community, and vocational settings CLINICAL DILEMMA Major health problem No proven acute treatment. Injury must run its course. Severity of the brain injury may not be known until it has resolved. The final outcome may take years. Uncertainty about when it is safe to return to home, community, work, and/or school. Multiple criteria and guidelines exist; but these are based primarily on subjective clinical factors and the duration of impairment. They do not, unfortunately, correlate with outcome. 2

3 The Problems in the Medical Field There is much variation in the knowledge of health care providers managing brain injury Physicians (MD/DO) Physician assistants Nurse practitioners Chiropractors Athletic trainers Nurses Service providers Therapists New and emerging research and technologies will lead to a continuing evolution of care 3

4 Causes of TBI CDC 2006 Who is at the Highest Risk of TBI? 2010 Males 1.8 times as likely as females to sustain a TBI Two age groups most at risk are 0-4 year olds and year olds Third - elderly, 75 and older from falls 4

5 The Scope of the Problem Distribution of Severity: Mild injuries = 80% (LOC < 30 min, PTA,1 hour) Moderate = 10-13% (LOC 30 min-24 hours, PTA 1-24 hours) Severe = 7-10% (LOC >24 hours, PTA >24 hours) First, an understanding of the brain 5

6 Skull Anatomy Blood Vessels of the Skull Rough Interior of Skull Interior Skull Surface Bony ridges The base of the skull is rough, with many bony protuberances. These ridges can result in injury to the temporal lobe of the brain during rapid acceleration. Injury from contact with skull 6

7 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. The human brain requires a constant supply of oxygen. A lack of oxygen for just a few minutes results in irreversible damage to the brain. ANOXIC The Meninges The meninges are layers of tissue that separate the skull and the brain. Skull Dura mater Arachnoid Layer Pia Mater Brain 7

8 The Neuron Dendrites: Collects information from other neurons. Cell Body Axon: Transmits information to other neurons. External Brain Structures 8

9 Lobes of the Cerebrum Limbic Lobe Frontal Lobe Parietal Lobe Temporal Lobe Occipital Lobe 9

10 Limbic Lobe The limbic lobe is located deep in the brain, and makes up the limbic system. The limbic system is the area of the brain that regulates emotion and memory. It directly connects the lower and higher brain functions. Cerebellum The cerebellum is connected to the brainstem, and is the center for body movement and balance. 10

11 The Brainstem The brainstem is the most primitive part of the brain and controls the basic functions of life: breathing, heart rate, swallowing, reflexes to sight or sound, sweating, blood pressure, sleep, and balance. The brainstem can be divided into three major sections: Midbrain Pons Medulla oblongta. Click image to play or pause video The Cranial Nerves I. Olfactory nerve II. Optic nerve III. Oculomotor nerve IV. Trochlear nerve V. Trigeminal nerve VI. Abducens nerve VII. Facial nerve VIII. Vestibulocochlear nerve IX. Glossopharyngeal nerve X. Vagus nerve XI. Accessory nerve XII. Hypoglossal nerve 11

12 Traumatic Brain Injury Define: Refers to neurological damage to the brain resulting from he impact of external forces. Epidemiology studies show that TBI is a leading cause of death and disability in the United States Currently 1.7 million people living with brain injury Given the frequent long-term medical, vocational, and social needs of affected individuals, TBI represents a substantial health care issue in the United States. Injury Mechanisms The brain is a complex and delicate organ, and one that is vulnerable to injury from a variety of different traumas. These include: Frontal Lobe Injury Occipital Lobe Injury Temporal Lobe Injury Side Impact Injury Coup/Contre-coup Injury Diffuse Axonal Injury Epidural Hematoma Subdural Hematoma 12

13 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. 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. 13

14 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. Side Impact Injury Injuries to the right or left side of the brain can occur from injuries to the side of the head. Injuries to this part of the brain can result in language or speech difficulties, and sensory or motor problems. 14

15 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. 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. More on diffuse axonal injury. 15

16 Epidural and Subdural Hematomas An epidural hematoma is a blood clot that forms between the skull and the top lining of the brain (dura). A subdural forms between the dura and brain tissue. 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. 16

17 Brain Functions Vision Taste Cognition Emotion Speech Language Hearing Motor Cortex Sensory Cortex Autonomic Functions Vision The visual cortex resides in the occipital lobe of the brain. Sensory impulses travel from the eyes via the optic nerve to the visual cortex. Damage to the visual cortex can result in blindness. 17

18 Taste The gustatory complex (green circle) is the part of the sensory cortex (purple area) that is responsible for taste. Cognition The prefrontal cortex is involved with intellect, complex learning, and personality. Injuries to the front lobe can cause mental and personality changes. 18

19 Emotion Emotions are an extremely complex brain function. The emotional core of the brain is the limbic system. This is where senses and awareness are first processed in the brain. Mood and personality are mediated through the prefrontal cortex. This part of the brain is the center of higher cognitive and emotional functions. Prefrontal cortex Limbic system Speech Broca s Area Broca s area is where we formulate speech and the area of the brain that sends motor instructions to the motor cortex. Injury to Broca s area can cause difficulty in speaking. The individual may know what words he or she wishes to speak, but will be unable to do so. 19

20 Language Auditory Association Area Wernicke s area is a specialized portion of the parietal lobe that recognizes and understands written and spoken language. Wernicke s area surrounds the auditory association area. Damage to this part of the brain can result in someone hearing speech, but not understanding it. Wernicke s Area Hearing There are two auditory areas of the brain: The primary auditory area (brown circle) is what detects sounds that are transmitted from the ear. It is located in the sensory cortex. The auditory association area (purple circle) is the part of the brain that is used to recognize the sounds as speech, music, or noise. 20

21 Motor Cortex The motor portion of the cerebrum is illustrated here. The light red area is the premotor cortex, which is responsible for repetitive motions of learned motor skills. The dark red area is the primary motor area, and is responsible for control of skeletal muscles. Different areas of the brain are associated with different parts of the body. Injury to the motor cortex can result in motor disturbance in the associated body part. Sensory Cortex The sensory portion of the cerebrum is illustrated here. Different areas of the brain are associated with different parts of the body, as can be seen below. Injury to the sensory cortex can result in sensory disturbance in the associated body part. 21

22 Four main categories of the effects of brain injury Any of these can cause communication problems Physical - affecting how the body works Cognitive - affecting how the person thinks, learns and remembers Emotional - affecting how the person feels Behavioural - affecting how a person acts All of which can affect communication Possible Changes after Brain Injury Cognitive Changes Cognitive Fatigue and Lack of Awareness Physical Changes Emotional Behavioral Changes 22

23 What s the problem (mild??)? Effective Communication Strategies: what s effected? Speech and language: Aphasia Spoken language Comprehension Reading Writing Other factors: physical Motor control Vision, hearing, sensory awareness 23

24 Components of Communication: Expression Successful communication involves an exchange by 2 or more individuals where a message or intent by 1 person is expressed clearly, and received and understood successfully by the communication partner(s) This involves speech (or other non-verbal alternative system) which is the motor act of forming sounds The content is the language This is augmented by the equally important non verbal communication behaviours such as body language, eye contact and tone of voice, known as pragmatics Cognition and Communication Underlying successful communication are a number of key cognitive abilities. These include: Attention to the speaker, working memory, long term memory, and information processing (this involves the speed, amount and complexity of the information being presented). 24

25 Speech and Language: Strategies Keep instructions and information simple Provide everything in writing Give the person time to get responses out Offer a choice of two or three items do not ask open ended questions 25

26 Communication Receptive Deficits: Slow your rate of speech Simplify sentence structure, be clear and concise Pause between sentences or topics to allow for processing Repeat key words or concepts Rephrase as needed Summarize information frequently Communication Expressive Deficits: Do not expect an immediate response to a question or statement. Pause to allow the individual time to prepare their response. Accept gestures and pantomime in addition to verbal speech. Ask yes/no questions, avoid questions that require lengthy or detailed answers. Provide extra time for consumers who are using augmentative communication devices. Accept written answers or drawings. 26

27 Vision/Reading Use enlarged print. Print on yellow instead of white paper or use a yellow acetate overlay on documents to increase contrast. A book mark or ruler can be used to help with staying on the line when reading or scanning for information. Change florescent lights to high intensity white lights, or increase natural light. Simplify forms; determine if extra spacing, grid lines, bold print or bold lines are helpful. Cognition Planning, organization, problem solving Memory Attention Processing speed Thinking 27

28 28

29 Some of these demos are from: Simons & Levin, 1997, TINS, 1, Cognitive Deficits Affecting Communication Executive Functions Attention Memory Processing Speed Decreased Awareness 29

30 Competencies Driving Money management Personal decisions life choices, medical consent Work Dealing with emergencies Family and other social relations Impulse control addictions, spending, gambling, eating, sexual behavior, aggression Criminal behavior A deficit in executive skills might look like the inability to plan and organize or it might look like... Uncooperativeness, stubbornness Lack of follow through Laziness Irresponsibility 30

31 An attention deficit might look like trouble paying attention or it might look like Keeps changing the subject Doesn t complete tasks Has a million things going on and none of them ever gets completed Tries to do two things at once gets confused and upset A memory deficit might look like trouble remembering or it might look like Frequently misses appointmentsavoidance, irresponsibility Says he ll do something but doesn t get around to it Talks about the same thing or asks the same question over and over Invents plausible sounding answers so you won t know he doesn t remember 31

32 Unawareness might look like Insensitivity, rudeness Overconfidence Lack of concern about the extent of her problems Doesn t think support is needed Covering up problems ( everything s fine ) Big difference in what he thinks and what everyone else thinks about his behavior Blaming others for problems making excuses Cognitive Accommodations Processing Delays Increased time to complete assignments Extra time to answer questions verbally Breakdown complex directions into steps Provide written instructions Repeat important information Use precise, concrete language 32

33 Cognitive Accommodations Attention Encourage eye contact Use an opening statement such as Are you ready to get started to gain the client s attention before explaining an activity or giving directions. Be specific and clear. Avoid lengthy or vague explanations. Slow down when you speak. It is very difficult to listen carefully to someone who is talking at a fast pace. Limit interruptions when possible. Redirect as needed Cognitive Accommodations Memory Deficits Written & verbal directions for tasks Check understanding of directions by having the person provide oral summary Frequent review of information Strategy for note-taking during appointments Set timelines Have person repeat instructions to check for comprehension Use planner and make sure needs, medications, appointments, etc are all written down Pocket Voice It to record reminders throughout the day 33

34 Social/Behavioral Accommodations Emotional Well-Being Counseling Quiet area for re-grouping Public praise and private reprimands when possible Behavior Functional behavioral assessment Positive behavioral management plan Time and place to re-group when upset Additional structure in daily routine Avoid criticism Provide frequent positive feedback When aggression occurs, act in neutral manner Redirection Decrease frustration Without Appropriate Services, Individuals with TBI are at Risk for... Long-Term Unemployment Alcohol and or Drug Use and Abuse Social Isolation Higher risk of subsequent brain injuries than individuals who have never incurred a brain injury 34

35 Emotional and Behavioral Consequences... Impulsivity Depression and mood swings Lack of self-awareness and judgment Agitation and aggression Difficulty exercising good social judgment Strategies: Cognitive Calendar/keep schedule predictable Planner vs. loose paper Laptop/computer Tape recorder Timer/timer watches Books on tape/film adaptation Strategic scheduling Break tasks/ assignments into steps 35

36 Emotional and Behavioral Issues Can have a negative impact on communication and interaction with persons with brain injury Know triggers and reduce them Decrease environmental stimuli Always speak in a calm, easy (soft) voice Position yourself in a safe way Know your client How to modify your communication to facilitate a successful interaction If you are having trouble understanding their speech, assure them you ARE interested in what they have to say, ask them to repeat, maybe use a pen and paper DON T misinterpret a slow response and or flat affect for lack of interest or disrespect Speak calmly and respectfully Whenever possible, have a conversation in a quieter environment (make sure there is no TV, radio playing etc.) 36

37 KEEP IN MIND Progress can be inconsistent and unpredictable What works today may not work tomorrow, but may work the following day Reduced stamina and fatigue may persist Impairment of memory may hinder new learning Transitions may be especially difficult Faces of Brain Injury essionals/biaf-courses/face-of-braininjury.html 37

38 Treatments Prevention is the only cure Medications Presently no medications approved for TBI Cognitive Rehabilitation Takes time Qualified providers? Lack of insurance approval Changes after Brain Injury Things to remember: A person with a brain injury is a person first The age at time of injury will impact development No two brain injuries are exactly the same Often symptoms of brain injury and psychiatric symptoms are similar The effects of a brain injury are complex and vary greatly from person to person The effects of a brain injury depend on such factors as cause, location and severity Pre-existing skills will impact and be impacted by the brain injury (e.g. cognitive reserve) 38

39 Resources - StepPad $29.00, Records up to 72 seconds for step by step directions -Digital and Microcassette hand help recorders - has alarm watches, pillbox organizers with timers, alarms -Watch that can keep appointment schedules, phone numbers, contacts $ Watch with reminder functions, 30 alarm settings with viewable messages, $ carries the Cadex Alarm watch (12 alarm settings) for $50.00, as well as low vision devices, key finders, and more -Radiopaging system to send reminders of things to do. Monthly fee, arranged in conjunction with treating physician if medication involved 39

40 An online resource catalogue that lists different types of assistive technology available to help individuals with all types of disabilities Catalog of assistive technology for people with cognitive impairments. The devices listed have been reviewed by experts in the field of brain injury. Product information, and information about manufacturers, and more offered in this catalogue Resources for staff training As of April 2004, the Defense and Veterans Brain Injury Center at Walter Reed Army Medical Center is offering an online learning course on traumatic brain injury through the Veterans Health Initiative. For more information contact: this is a site that can be used in staff training. It is a simulation of the effects of cognitive disabilities. You will be asked to complete simple tasks, but other tasks will get in the way. links to many online articles, written not for professionals in the field, but for people learning about brain injury. They cover all types of topics, from substance abuse and brain injury to cognition and brain injury. Written by various experts in the brain injury field. Certified Brain Injury Specialist (CBIS) Training offered through the American Academy for the Certification of Brain Injury Specialists, 40

41 The Michigan Department of Community Health Web-Based Brain Injury Training for Professionals This free training consists of 4 module that take an estimated 30 minutes each to complete. The purpose of the training is twofold, to ensure service providers understand the range of outcomes following brain injury and to improve the ability of service providers to identify and deliver appropriate services for persons with TBI Resources Center on Brain Injury Research & Training Centers for Disease Control and Prevention Brain Injury Association of Pennsylvania Free Brain Injury Resource Line 1 of 14 TBI Model Systems of Care at MossRehab in Philadelphia (Center of Excellence) with 3 Centers for BI Research U of PA, Drexel U, and U of Pitt Medical Center Brainline 41

42 School-Wide Concussion Management Oregon Center for Applied Science Bibliography The following are excellent resources and were the basis of the anatomical and functional components of this presentation: The Human Brain: An Introduction to Its Functional Anatomy, Fifth Edition. John Nolte, Mosby, ISBN: Purchase Here Coping with Mild Traumatic Brain Injury. Dr. Diane Stoler, Avery Penguin Putnam, ISBN: Purchase Here Human Anatomy and Physiology, Fifth Edition. Elaine N. Marieb, Benjamin/Cummings, ISBN: Purchase Here 42

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