Title: Chapter 1 Overview of Brain Injury by Cathy FickerTerill, M.S., Karen Flippo, M.R.A., Terri Antoinet
1Chapter 1Overview of Brain Injuryby Cathy
Ficker-Terill, M.S., Karen Flippo, M.R.A., Terri
Antoinette, N.G.S.A., R.N.C. and Debra
Braunling-McMorrow, Ph.D.
2Learning objectives
- Describe the incidence, prevalence and
epidemiology of brain injury - Distinguish between traumatic brain injury and
acquired brain injury - Describe the systems of care available in the
rehabilitation continuum - Demonstrate several of the funding issues for the
support of persons with brain injury - Explain the Traumatic Brain Injury Act of 1996
and its impact on services and funding for
persons with brain injury.
3Introduction
- Traumatic brain injury (TBI) has been called the
silent epidemic.
Chapter 1 Overview of Brain Injury
4Prevalence
- 18.8 million- Depressive disorders
- 6.2. - 7.5 million- Mental retardation
- 5.3 million - TBI
- 4.7 million Stroke
- 4 million - Alzheimers disease
- 2.3 million - Epilepsy
- 500,000 - Cerebral palsy
Chapter 1 Overview of Brain Injury
5TBI is a largely unrecognized major public health
problem!
- An estimated 10 million Americans are affected by
stroke and TBI . . . -
- which makes brain injury the second most
prevalent injury and disability in the United
States.
Chapter 1 Overview of Brain Injury
6Definition of TBI
- TBI is an insult to the brain, not of a
degenerative or congenital nature but caused by
an external physical force, that may produce a
diminished or altered state of consciousness,
which results in an impairment of cognitive
abilities or physical functioning. It can also
result in the disturbance of behavioral or
emotional functioning. These impairments may be
either temporary or permanent and cause partial
or total functional disability or psychosocial
maladjustment. - National Head Injury Foundation (1996)
Chapter 1 Overview of Brain Injury
7Causes of TBI
- Motor vehicle crashes (44-50)
- Falls (20-26)
- Gunshot wounds (1 cause of fatalities)
- Sports injuries
- Workplace injuries
- Shaken baby syndrome
- Child abuse
- Domestic violence
- Military actions
- Other
Chapter 1 Overview of Brain Injury
8TBI Facts
- 56 of adults with brain injuries tested positive
for blood alcohol. - Each year, 2-4 million women are physically
abused by an intimate. The head, face and neck
are the most frequent sites of injury.
Chapter 1 Overview of Brain Injury
9Acquired Brain Injury (ABI)
- An ABI is an injury to the brain that has
occurred after birth and is not hereditary,
congenital or degenerative. The injury commonly
results in a change in neuronal activity, which
affects the physical integrity, the metabolic
activity, or the functional ability of the cell.
The term does not refer to brain injuries induced
by birth trauma. Includes TBI and injuries caused
by an internal insult to the brain. - Brain Injury Association of America (1997)
Chapter 1 Overview of Brain Injury
10Causes of ABI
- TBI
- Tumor
- Blood clot
- Stroke
- Seizure
- Toxic exposure (e.g., substance abuse, ingestion
of lead, inhalation of volatile agents) - Infections (encephalitis, meningitis)
- Metabolic disorders (insulin shock, diabetic
coma, liver and kidney disease) - Neurotoxic poisoning
- Lack of oxygen to the brain (airway obstruction,
strangulation, cardiopulmonary arrest, carbon
monoxide poisoning, drowning)
Chapter 1 Overview of Brain Injury
11ABI cont.
- Acquired brain injury may result in mild,
moderate, or severe impairments in one or more
areas including -
- Cognition (i.e. speech-language communication
memory, attention and concentration, reasoning,
and abstract thinking) - Physical functions (i.e. ambulating, seeing,
hearing, balancing) - Psychosocial behavior (i.e., social skills, anger
management, impulsivity)
Chapter 1 Overview of Brain Injury
12Understanding the Definitions
- While it is important to understand the different
definitions of brain injury, the term brain
injury is used throughout this manual to refer to
acquired brain injury. - When reference is specifically made to injury
caused by trauma due to external physical force,
the term traumatic brain injury (TBI) is used - (Much of the research has been done with persons
with TBI).
Chapter 1 Overview of Brain Injury
13Epidemiology of Traumatic Brain Injury
- Every 21 seconds, one person in the United States
sustains a traumatic brain injury. - 1.5 million Americans survive traumatic brain
injuries each year. - More than 50,000 people die every year as a
result of traumatic brain injury. - 1/3 of all injury related deaths are due to
traumatic brain injury. - 230,000 people are hospitalized each year with
traumatic brain injury.
Chapter 1 Overview of Brain Injury
14Epidemiology of Traumatic Brain Injury
- 80,000-90,000 Americans experience the onset of a
long-term disability following traumatic brain
injury each year. - After one traumatic brain injury, the risk for a
second injury is three times greater after the
second injury, the risk for a third injury is
eight times greater. - 2/3 of firearm-related traumatic brain injuries
are classified as suicidal in intent. - 91 of firearm-related TBIs result in death.
Chapter 1 Overview of Brain Injury
15Injury Severity
- Injuries are classified according to mild,
moderate and severe injuries. - 80 are mild
- 10-30 are moderate
- 5- 25 are severe
- Concussion mild TBI that often goes undiagnosed
as such
Chapter 1 Overview of Brain Injury
16Gender
- Males sustain nearly two to three times as many
brain injuries as females. - Firearms are the leading cause of TBI related
death for men ages 15-84. - Motor vehicle crashes are the leading cause of
TBI related death for women 15-74. - Falls are the leading cause of death from TBI for
women over 75 years of age and for men over 85
years of age.
Chapter 1 Overview of Brain Injury
17Race and Age
- Race
- Studies report conflicting findings regarding the
relationship between race and the incidence of
TBI. - Age
- Highest in the 15-24 age group.
- But, some state registries have reported highest
rates in the over 75 age group, followed by the
15-24 year age group.
Chapter 1 Overview of Brain Injury
18Systems of Care
- Hospital-Based Services
- Acute Hospital Care
- Acute Rehabilitation
- Post-Hospital Services
- Skilled Nursing Facility (Sub-acute)
- Post-Acute Rehabilitation
- Outpatient Services
- Supported Living
Chapter 1 Overview of Brain Injury
19Home and community based services may include
- Case management Homemaker service
- Home health aide services Personal care
- Adult day health Habilitation services
- Respite care
- Day treatment or other partial hospitalization
services, psychosocial rehabilitation services,
clinic services for individuals with chronic
mental illness - Expanded habilitation services (i.e.,
prevocational services to prepare an individual
for paid or unpaid employment) - Other emergency response systems, assistive
technology, etc.
Chapter 1 Overview of Brain Injury
20Access to Services
- Those most likely to have difficulty accessing
services are individuals - with cognitive impairment but who lack physical
disabilities - without an effective advocate
- with problematic or unmanageable behaviors
-
- Without treatment, individuals with problematic
or unmanageable behaviors are the most likely to
become homeless, institutionalized in a mental
facility, or imprisoned. - Government Accounting Office (GAO)
Chapter 1 Overview of Brain Injury
21Costs of Traumatic Brain Injury
- Traumatic brain injuries cost more than 48.3
billion annually. - Hospitalization accounts for 31.7 billion.
- Fatal brain injuries cost the nation 16.6
billion each year. - The costs are often due to the resultant
life-long disability.
Chapter 1 Overview of Brain Injury
22Funding
- Approximately 5 of individuals with severe
brain injuries have adequate funding for
long-term treatment. -
- BIAA
Chapter 1 Overview of Brain Injury
23Funding
- Whatever the funding source, it is essential
that - advocacy is provided
- available funding is appropriately and cost
effectively managed.
Chapter 1 Overview of Brain Injury
24Private Funding
- Indemnity Insurance
- Insurer assumed the responsibility of paying
medical benefits for services performed and
covered under the policy in return for premium
payments - Managed Care
- Health Maintenance Organizations (HMOs)
- Preferred Provider Organizations (PPOs)
- gate-keeping
- elective contracting with providers
- quality controls
- risk-sharing
-
Chapter 1 Overview of Brain Injury
25Public Funding
- Medicaid provides health care for more than 40
million people throughout the US - low-income families
- people who are blind
- people age 65 and older
- people who have disabilities
Chapter 1 Overview of Brain Injury
26Public Funding
- State Home and Community-Based Services Waivers
(HCBS) - A state with Centers for Medicare and Medicaid
approval can waive one or more of the
requirements of eligibility for funding and
provision of services. - Increases accessibility to services.
- Encourages the development of new approaches for
health care delivery to meet the special needs of
particular areas or groups of people (e.g.,
persons with brain injury).
Chapter 1 Overview of Brain Injury
27GAO Report
- The 1997 GAO report on Traumatic Brain Injury
determined that Medicaid and Home and Community
Based Waiver programs covered an estimated 2,478
individuals and spent 118 million. - By comparison in the same year, waivers covered
an estimated 236,000 individuals with mental
retardation/developmental disabilities and spent
approximately 5.8 billion!
Chapter 1 Overview of Brain Injury
28Advocacy
- Traumatic brain injury represents a public health
problem of great magnitude. -
- During the 1970s, improvements occurred in
emergency medical services and acute care
specialized models of brain injury rehabilitation
were initiated.
Chapter 1 Overview of Brain Injury
29AdvocacyBrain Injury Association of America
- In 1980, a group of family members of persons
with traumatic brain injuries founded the
National Head Injury Foundation, now BIAA. - The organization has grown into a national
organization, including 42 chartered state
affiliates.
Chapter 1 Overview of Brain Injury
30Significant Legislature Legal Decisions
- The TBI Act (1996)
- The Olmstead Decision (1999)
Chapter 1 Overview of Brain Injury
31Traumatic Brain Injury Act (1996)
- Purpose
- To expand efforts to identify methods of
preventing traumatic brain injury - Expand biomedical research efforts or minimize
the severity of dysfunction as a result of such
an injury - To improve the delivery and quality of services
through State demonstration projects.
Chapter 1 Overview of Brain Injury
32Traumatic Brain Injury Act (1996)
- TBI Act authorized
- The Centers for Disease Control and Prevention
(CDC) to establish projects to prevent and reduce
the incidence of traumatic brain injury - The National Institutes of Health to award grants
to conduct basic and applied research on
developing new methods for more effective
diagnosis, therapies, and a continuum of care.
Chapter 1 Overview of Brain Injury
33"The Olmstead Decision"
- It requires states to administer their services,
programs, and activities "in the most integrated
setting appropriate to the needs of qualified
individuals with disabilities. - The ADA and the Olmstead decision apply to all
qualified individuals with disabilities
regardless of age. - The decision has resulted in several federal and
state initiatives that will make living in the
community a reality for more people with
disabilities.
Chapter 1 Overview of Brain Injury
34National Accreditation State Licensure
- National accreditation organizations have
established set standards for rehabilitation
programs. -
- JCAHO Joint Commission on the Accreditation of
Healthcare Organizations - CARF Rehabilitation Accreditation Commission
- A number of states have required licenses for
programs serving persons with brain injury. - The goal of accreditation standards and licensure
is to ensure that the organization has the
capacity to meet the needs of individuals with
disabilities.
Chapter 1 Overview of Brain Injury
35Research
- A traumatic brain injury can happen to a child or
adult of any age, race, gender, religion or
socioeconomic status. - It is important to quantify the problem by
conducting surveillance. - Surveillance is the ongoing and systematic
collection, analysis and interpretation of data
used to describe and monitor a health event.
Chapter 1 Overview of Brain Injury
36Research
- Traumatic Brain Injury (TBI) Model Systems of
Care (TBIMS) (1987) - Funding provided by US Department of Education's
National Institute on Disability and
Rehabilitation Research (NIDRR), which maintains
the TBI Model Systems National Data Base - To develop a model system of care for persons
with traumatic brain injury, emphasizing
continuity and comprehensiveness of care - To maintain a standardized national database for
innovative analyses of TBI treatment and
outcomes. - Each center provides a coordinated system of
emergency care, acute neurotrauma management,
comprehensive inpatient rehabilitation and
long-term interdisciplinary follow-up services.
Chapter 1 Overview of Brain Injury
37The Health Resources and Services Administration
(HRSA)
- Provides grants to states to carry out
demonstration programs to implement systems that
ensure statewide access to comprehensive and
coordinated TBI services. - States who receive grants must implement the
following components - Statewide TBI advisory board
- Staff responsible for TBI activities
- Statewide needs assessment to address the full
spectrum of services - Statewide action plan to develop a comprehensive,
community-based system of care (HRSA 1999).
Chapter 1 Overview of Brain Injury
38NIH Research
- The National Institutes of Health conducted
research on the development of new methods and
modalities for - more effective diagnosis
- measurement of degree of injury
- post-injury monitoring
- assessment of care models for brain injury
recovery and long term care.
Chapter 1 Overview of Brain Injury
39Conclusion
- TBI is a silent epidemic that is a major public
health problem - TBI can affect any of us at any time
- Through legislation and research, we can develop
appropriate and effective services to meet the
unique needs of individuals who have experienced
a brain injury -
Chapter 1 Overview of Brain Injury
40Chapter 2Philosophy of RehabilitationAl
Condeluci, Ph.D. and Marty McMorrow, M.S.
41Learning objectives
- Distinguish between historical and contemporary
rehabilitation philosophies - Describe the philosophical basis of the helping
role in rehabilitation -
Chapter 2 Philosophy of Rehabilitation
42Different Approaches
- Needs to be corrected mentality
- Vs.
- Positive Approach
Chapter 2 Philosophy of Rehabilitation
43Cultural Devaluation
- Historical devaluation of people, particularly
people with disabilities, who are different in
some way. - People are often . . .
-
- Labeled, stereotyped, segregated
- Thought to be a problem or to pose some kind of
threat to those in authority - Identified by their label or their difference
- Perceived to be a cost to society, in material or
economic ways
Chapter 2 Philosophy of Rehabilitation
44Cultural Devaluation
- In the U.S., the climate for inclusion and full
community participation for people with
disabilities is still remarkably inconsistent. - People with disabilities
- continue to be labeled at the drop of a hat
- are still readily institutionalized
- continue to be viewed as a problem for society
- are seen as an economic burden
- People with disabilities are caught in this web
of cultural devaluation!
Chapter 2 Philosophy of Rehabilitation
45The Medical Model
- The condition is the problem
- Core of the problem is with the person
- The professional is the expert
- The problem should be treated, healed, fixed
Chapter 2 Philosophy of Rehabilitation
46The Medical Model, cont.
- Most options for control are held by the expert
or other representatives of the paradigm - The patient is exempt from any real
responsibility, except to cooperate. - Most aspects of the ailment are treated in
separate and distinct facilities designed for the
ailment. - Serious problems arise when its components
continue to be used after sickness or medical
stability has been addressed.
Chapter 2 Philosophy of Rehabilitation
47Goal of Brain Injury Rehabilitation
- To establish medical stability
- Not to eliminate sickness, but to return people
to their communities - To help the individual adapt to the expectations
of the community - To help the community accept and respect the
differences that people with disabilities may
have
Chapter 2 Philosophy of Rehabilitation
48Interdependence, Inclusion, Self-Determination
- Interdependence
- Implies a connection or a relationship between
two or more entities - Is about relating in ways that promote mutual
acceptance and respect - Encourages acceptance and empowerment for all
-
Chapter 2 Philosophy of Rehabilitation
49Interdependent Paradigm
- The Problem Limited or non-existent
supports for differences - Core of the Problem In the system or
community - Actions of the Paradigm To create supports and
empower - Power Person The person with the
disability - Goal of the Paradigm Develop mutually
desired relationships -
Chapter 2 Philosophy of Rehabilitation
50Comparison of Paradigms
- Interdependence Medical
- Focuses on capacities Focuses on deficiencies
-
- Stresses relationships Stresses congregation
-
- Driven by the person/disability Driven
by the expert/professional - Promotes micro/macro change Promotes
that the person can be fixed
Chapter 2 Philosophy of Rehabilitation
51Inclusion
- Inclusion the individual is incorporated and
welcomed into the community, regardless of their
disability. - Inclusion brings people to the community
regardless of their differences - It does not try to change or alter differences
against the person's will or capacity. - It does not try to create forced similarity.
- It suggests that people join in as they are.
- It respects differences, honors diversity, and
invites full community participation. - It is a term that implies welcome to all!
Chapter 2 Philosophy of Rehabilitation
52Self-Determination
- Builds on the principles of informed consent,
right to refuse, and consumer empowerment
(individual freedom). - People with disabilities have rights and
authority over how, where, and with whom they
live. - People can and should advocate for their needs.
- In the recent Olmstead decision, the Courts
ruled - people with disabilities have the right to equal,
community based options - states must make these options available.
Chapter 2 Philosophy of Rehabilitation
534 Critical Components of Self-Determination
- Freedom to plan a life with supports rather than
purchase or be referred to a particular program. - Authority to control a certain sum of dollars to
purchase - preferred supports.
- Support Use of resources to arrange formal and
informal supports to live within the community. - Responsibility Can and should have a role within
the community through competitive employment,
organizational affiliations, and accountability
for spending public dollars in life-enhancing
ways.
Chapter 2 Philosophy of Rehabilitation
54Promoting Self-Determination in the Human
Services
- Transfer financial control to the consumer
through individual budgets - Use person centered planning to identify,
organize, and communicate choices - Promote cooperation and collaboration
- Increase community awareness through
communication and information sharing
Chapter 2 Philosophy of Rehabilitation
55Promoting Self-Determination in the Human
Services
- Institute change through legislature and advocacy
- Develop leadership skills among people with
disabilities - Gather and analyze data to evaluate and improve
quality of services
Chapter 2 Philosophy of Rehabilitation
56Basis of Interaction within Rehabilitation
- Rehabilitation involves complex techniques,
procedures, or approaches by a diverse group of
people - It involves the creation, adaptation, and use of
various community services and supports.
Chapter 2 Philosophy of Rehabilitation
57Basis of Interaction within Rehabilitation
- There is a very delicate balance between
assisting someone by encouraging inclusion or
self-determination and interacting in a way that
inadvertently contributes to devaluation, social
isolation and increased dependency - The best guide to determining what to do in a
given situation still may be to consider how you
or any individual would prefer to be treated in
similar circumstances.
Chapter 2 Philosophy of Rehabilitation
58Interacting with Empathy
- A day in rehabilitation is remarkably different
than anything ever experienced before. - Participants are poked and prodded, evaluated and
observed. - Having empathy will improve our interactions
- However, to impact interactions in a noticeable,
consistent, and effective way, we must understand
mutual reinforcement and reciprocity
Chapter 2 Philosophy of Rehabilitation
59Mutual Reinforcement and Reciprocity
- Mutual reinforcement an exchange of reinforcers
or desired events between two or more people. - Behavioral research suggests that
- human behaviors often develop and continue
because of their desirable effects for the
individual who performs them - people probably have a tendency to treat others
as they are treated - self reports of interactional satisfaction (e.g.,
friendship, love, joy) appear related to the
concept of mutual reinforcement
Chapter 2 Philosophy of Rehabilitation
60Mutual Reinforcement Reciprocity, Cont.
- Lasting relationships involve a regular exchange
of reinforcers or desired events - When an exchange of reinforcers develops into a
consistent pattern, it can be called a positive
reciprocal relationship or positive reciprocity.
Chapter 2 Philosophy of Rehabilitation
61Mutual Reinforcement Reciprocity, Cont.
- Ongoing exchange of unwanted events between
people is referred to as a negative reciprocal
relationship or negative reciprocity. - Striving toward the development of mutually
reinforcing relationships, or positive
reciprocity, may help the person achieve greater
success in rehabilitation and in life.
Chapter 2 Philosophy of Rehabilitation
62Promoting Mutually Reinforcing Interactions
- What is not wanted in interactions between
persons in rehabilitation includes - insensitivity to differences
- particularly those that are unlikely to change
- the creation or prolonging of negatively
reciprocal interactions - e.g., overly corrective, disempowering, or
unnecessarily restrictive comments or actions
Chapter 2 Philosophy of Rehabilitation
63Promoting Mutually Reinforcing Interactions
- Active treatment interaction
- An interaction that is intended to result in
greater independence, autonomy, empowerment, or
inclusion for one of those people - The term is intended to imply directed action,
teaching, and a certain degree of risk taking.
Chapter 2 Philosophy of Rehabilitation
64PEARL
- Positive being upbeat, enthusiastic, requesting
rather than demanding, actively prompting and
encouraging participation. - Early being proactive when difficult or
troubling situations arise, intervening early to
facilitate problem solving, and interrupting or
redirecting behavioral consequences that could
lead to more serious problems. - All acting these ways all the time, with all
participants, and in all daily situations. - Reinforce consistently recognizing,
acknowledging, and socially reinforcing
participant accomplishments. - Look looking for situations or opportunities to
facilitate independence, autonomy, empowerment,
or inclusion.
Chapter 2 Philosophy of Rehabilitation
65No Blame!
- Each individual is predisposed to act in
particular ways in particular situations. - Predispositions include all the medical,
cognitive, physical, biochemical, and
environmental factors that influence actions in a
given situation. - If people are predisposed to behave in certain
ways in certain situations, then holding them at
fault or blame for unwanted actions does not make
good sense.
Chapter 2 Philosophy of Rehabilitation
66Can vs. Cant
- Encourage inclusion
- Think that the person can vs. cant do something
- Consider what is possible (instead of what might
possibly happen) and the potential benefit of
doing rather than preventing - Find ways to support a persons interests, rather
than ignoring them or constantly refusing
requests - This approach increases mutually desired actions
-
Chapter 2 Philosophy of Rehabilitation
67Outcome, Partnerships and Agreements
- Rehabilitation involves partnerships between many
different people to accomplish the various goals. - An outcome oriented model is designed to identify
areas of agreement between people that are
related to the goals - The most important partnership is that with the
person who has sustained the injury. - These partnerships must be established very
rapidly after the injury and must be maintained
at every point in the process.
Chapter 2 Philosophy of Rehabilitation
68Conclusion
- Avoid promoting a rehabilitation culture that
devalues persons who behave differently. - The ultimate goal of brain injury rehabilitation
is to return people as fully as possible to their
communities. - Remember the interdependent paradigm, the
principles of inclusion, and self-determination.
Chapter 2 Philosophy of Rehabilitation
69Conclusion
- Consider Mutual Reinforcement and Reciprocity
when interacting with individuals with brain
injuries. - Active treatment with PEARL, No Blame, and Can
vs. Cant are interactional styles that
facilitate outcome goals, partnerships, and
agreement within the rehabilitation process.
Chapter 2 Philosophy of Rehabilitation
70Chapter 3Understanding the Brain and Brain
Injuryby Ronald C. Savage, Ed.D.
71Learning objectives
- Identify basic brain structures and functions
- Describe brain-behavior relationships
- Understand the functional impact of a brain injury
Chapter 3 Understanding the Brain and Brain
Injury
72Introduction
- The brain is the main organ of learning.
- It makes it possible for us to think,
communicate, act, behave, move about, and create.
Chapter 3 Understanding the Brain and Brain
Injury
73Anatomy of the Brain
- The brain . . .
- Is a soft organ, like the consistency of gelatin
- Weighs less than 1 lb. at birth and grows to
about 3 ½ lbs. - Sits inside a rough and bony skull and is bathed
in a cerebrospinal fluid (CSF) - Receives oxygen and glucose through a
sophisticated system of blood vessels that carry
blood to and from the heart
Chapter 3 Understanding the Brain and Brain
Injury
74Anatomy of the Brain, cont.
- Three membranes or meninges cover the brain
- The outer dura mater or hard matter, which is
like a heavy plastic covering. - The arachnoid, which is like a spiderweb that
bridges the brain's many wrinkles and folds. - The pia mater or tender matter, which molds
around every tiny crook and crevice on the
brain's surface. - Between the pia mater and the arachnoid, there is
145cc of cerebrospinal fluid.
Chapter 3 Understanding the Brain and Brain
Injury
75Anatomy of the Brain, cont.
- There are four ventricles which make, store, and
circulate cerebrospinal fluid. - It helps cushion the brain and protect brain
tissue when swelling occurs.
Chapter 3 Understanding the Brain and Brain
Injury
76Neurons
- Neurons the billions and billions of tiny brain
cells making up the nervous system - Glial ("glue") non-communicating cells support
and nourish the neurons. - Three main parts of the neuron cell body, axon,
dendrites
Chapter 3 Understanding the Brain and Brain
Injury
77CELL BODY
Synapses
AXON
Dendrites
Nucleus
Myelin sheath
AXON
Synaptic terminals
Chapter 3 Understanding the Brain and Brain
Injury
78Neurons
- The neurons communicate with each other via a
unique electro-chemical process. - Neurotransmitters receive and transmit
information in a relay of electrical impulses - Neurochemical transmitters leap the synaptic
gaps. - After a person sustains a brain injury, many of
the neuron pathways may be torn apart or
stretched so that information processing is no
longer possible.
Chapter 3 Understanding the Brain and Brain
Injury
79Brain Geography
- Brain stem
- Located at the top of the spinal column and it
relays information in and out of the brain. - Diencephalon
- The thalamus, hypothalamus and other structures,
located centimeters above the midbrain. The
diencephalon is a master relay center for
forwarding information, sensations, and movement.
- Limbic system
- Middle section of the brain, sitting on top of
the brain stem. The limbic system is involved in
emotions and basic feelings.
Chapter 3 Understanding the Brain and Brain
Injury
80The Brain Stem
- Top of the spine and the central nervous system
- The brainstem is made up of three integral areas
- medulla pons midbrain
- Contains many of the centers for the senses of
hearing, touch, taste, and balance
Chapter 3 Understanding the Brain and Brain
Injury
81The Brain Stem, Cont.
- Medulla
- The first area in the lower part of the brain
stem. - The medulla is about one inch of brain tissue
that is vital to life and death. - It contains reflex centers which control many
involuntary functions such as breathing, heart
rate, blood pressure, swallowing, vomiting, and
sneezing.
Chapter 3 Understanding the Brain and Brain
Injury
82The Brain Stem, Cont.
- Pons (just above the medulla)
- Essential for facial movements, facial sensation,
hearing, and coordinating eye movements - Enables the "thinking" part of the brain (cortex)
to work with the "movement" (cerebellum) part of
the brain. - Midbrain
- The smallest part of the brainstem
- Functions for seeing, hearing, alertness, and
arousal
Chapter 3 Understanding the Brain and Brain
Injury
83The Brain Stem
- There are nerve fibers and nuclei called the
reticular activating system (RAS). - Modulates or changes arousal, alertness,
concentration, and basic biological rhythms. - The RAS can be depressed to a point where a
person dies because all main body functions are
shut down permanently.
Chapter 3 Understanding the Brain and Brain
Injury
84The Brain Stem
- Injury to the brain stems can cause . . .
- attention and concentration problems
- difficulty with memory storage and retrieval
- weakened mental stamina
- decreased sensory information
- difficulty in reacting to stress
- difficulty with excessive or not enough emotional
responses - disorders in eating/drinking, sleeping, and
sexual functioning
Chapter 3 Understanding the Brain and Brain
Injury
85Diencephalon
- Includes hypothalamus, thalamus and other
structures. - Hypothalamus controls hunger, thirst, sexual
response, endocrine levels (hormones),
temperature regulation, and many complex
responses like anger, fatigue, memory, and
calmness.
Chapter 3 Understanding the Brain and Brain
Injury
86Thalamus
- Thalamus sits on the very top of the brain stem,
just beneath the cortex - Acts as a major relay station for incoming and
outgoing sensory information.
Chapter 3 Understanding the Brain and Brain
Injury
87The Limbic System
- The middle part of the brain
- Situated above, around, and interconnected with
the diencephalon - Houses basic elemental drives, emotions, and
survival instincts - Injury or disruption to the limbic system can
produce problems with basic emotional
perceptions, feelings and responses to the world
and oneself
Chapter 3 Understanding the Brain and Brain
Injury
88The Limbic System
- Injury is often associated with injury to the
cerebral cortex - The two major structures usually associated with
the limbic system include the hippocampus and the
amygdala.
Hippocampus
Amygdala
Chapter 3 Understanding the Brain and Brain
Injury
89Hippocampus
- A pairedorgan, one on each side of the brain,
that is situated within the temporal lobes. - Associated with memory functioning
- Injury can cause difficulty with short term
memory and organizing and retrieving previously
stored memories
Chapter 3 Understanding the Brain and Brain
Injury
90Amygdala
- A "fight - flight" structure that is closely tied
with emotional memories and reactions. - The amygdala is where the stimulus is evaluated
for emotional content. - The hippocampus and amygdala are directly tied
with the olfactory fibers (smell). Smell or taste
seem to be the most powerful stimulants for
recollection
Chapter 3 Understanding the Brain and Brain
Injury
91Basal Ganglia
- Manages physical movements by relaying
information from the cerebral cortex to the
brainstem and cerebellum. - Helps maintain physical equilibrium.
- Injury affects voluntary motor nerves
- Results in slowness and loss of movement
(akinesia), muscular rigidity, and tremors which
can be localized or diffuse.
Chapter 3 Understanding the Brain and Brain
Injury
92- Cerebellum
- Located in the lower back section of the brain,
the cerebellum coordinates, modulates, and stores
all body movement. - Cerebral Cortex
- Two hemispheres dedicated to the highest levels
of thinking, moving, and acting. The right and
left hemispheres are divided into four lobes
frontal, parietal, temporal and occipital.
Chapter 3 Understanding the Brain and Brain
Injury
93The Cerebellum
- Wedged between the brainstem and the cerebral
cortex is and hitched to the back of the head. - About 1/8 of the brain's mass
- Monitors impulses from the motor and sensory
centers (brainstem, basal ganglia, motor/sensory
cortex) to help control direction, rate, force
and steadiness of a persons movements. - Responsible for coordinating muscle tone,
posture, or eye/hand movements
Chapter 3 Understanding the Brain and Brain
Injury
94Injury to The Cerebellum
- Injury can produce problems with coordination,
fine motor movements, equilibrium (balance) and
ones sense of where the body is in space.
Chapter 3 Understanding the Brain and Brain
Injury
95Injury to The Cerebellum
- A person with a damaged cerebellum may look
"drunk" when they walk. - A person may not even be able to walk a marked
straight line or sit without support. - Eye-hand coordination may be disabled
- A person may not be able to reach out and pick up
a glass of water. - A person's movement may become awkward trying to
brush one's teeth results in a blow to the face.
Chapter 3 Understanding the Brain and Brain
Injury
96The Cerebral Cortex
- Cerebral cortex the most complicated structural
component of the brain - Made up of the right hemisphere and left
hemisphere - The cortex is full of wrinkles and folds.
- If you took out and flattened the cortex, it
would be the size of a pillowcase.
Right Hemisphere
Left Hemisphere
Chapter 3
97The Cerebral Cortex
- The two hemispheres of the brain have unique ways
of processing information. - The right hemisphere is more holistic,
visualspatial, and intuitive. - The left hemisphere is more linear,
verbalanalytic, and logical. - The cerebral hemispheres control opposites sides
of the body. - Each hemisphere has four lobes (frontal,
parietal, temporal and occipital).
Chapter 3 Understanding the Brain and Brain
Injury
98The Cerebral Cortex, Cont.
- Left hemisphere
- Processes information in a logical and linear
manner - Controls speaking, reading, writing, doing
calculations - Right hemisphere
- Responds to information in a more holistic and
spatial sense (shapes, faces, music, art) - The cerebral hemispheres communicate to each
other a thousand times a second through the
corpus callosum (the 4 inch long, pencil thick
band of complex nerve fibers).
Chapter 3 Understanding the Brain and Brain
Injury
99Lobes of the Brain
- Frontal
- Parietal
- Temporal
- Occipital
Chapter 3 Understanding the Brain and Brain
Injury
100Parietal lobe
Frontal lobe
Occipital lobe
Temporal lobe
Cerebellum
Chapter 3 Understanding the Brain and Brain
Injury
101Lobes of the Brain
- The lobes are interconnected by complex neural
fibers, which relay impulses and information to
and from the cortex. - Each lobe has a right and left side.
- The lobes are interconnected by complex neural
fibers, which relay impulses and information to
and from the cortex.
Chapter 3 Understanding the Brain and Brain
Injury
102Frontal Lobes
- Vulnerable to injury since they sit just inside
the front of the skull near a rough bony area - Have extensive connections with many brain
regions, especially with the parietal lobe and
the limbic system (emotions). - Includes the motor strip
- Sends signals to the muscles of the body, telling
them what to do
Chapter 3 Understanding the Brain and Brain
Injury
103Frontal Lobe, Cont.
- Prefrontal cortex located at the very front part
of the frontal lobes - Regulates emotional responses, motivation,
executive functions, working memory - Responsible for teaching a person to learn from
consequences
Chapter 3 Understanding the Brain and Brain
Injury
104Frontal Lobe Injury
- Injury damages an individual's ability to . . .
- synthesize signals from the environment
- assign priorities
- make decisions
- initiate actions
- attend to tasks
- control emotions
- behave and interact socially
- make plans
Chapter 3 Understanding the Brain and Brain
Injury
105Frontal Lobe Injury in Children
- Prefrontal lobe injuries in young children
sometimes go unnoticed - Parents and teachers typically function as their
frontal lobesthey organize, plan, and direct
their childrens lives. - As the child gets older and enters early
adolescence, they are expected to be more
independent and learn to manage themselves over
time. - In the child with a brain injury, the capability
for more independent frontal lobe functioning has
been diminished.
Chapter 3 Understanding the Brain and Brain
Injury
106Parietal Lobe
- Situated behind the frontal lobes
- Includes the primary sensory cortex which is
posterior to the motor strip. - The first part of the brain to consciously
register physical sensations. - Regulates responses to touch, heat, cold, pain,
and body awareness
Chapter 3
107Parietal Lobe
- When one side of the lobe is injured, they may
not recognize that anything is wrong with
movement on the other side of the body. - Even more complex functions like attention can be
affected by damage to the parietal lobes.
Chapter 3 Understanding the Brain and Brain
Injury
108Occipital Lobe
- Located in the lower back part of the brain
- The primary visual center of the brain
- Involves the visual cortex
- connected to the eyes by optic nerves
- optic nerves carrying signals meet at a
"crossing" called the optic chiasm - The left optic track carries signals from the
rightside field of vision, and the right optic
track takes signals from the left so that both
sides of the brain "see" the same thing. - Most of what a person "sees" derives its meaning
from prior learning and symbolic representations.
Chapter 3 Understanding the Brain and Brain
Injury
109Temporal Lobes
- Rest on both sides of the brain
- The centers for language, hearing, and, with
their connections to the hippocampus, help in the
longterm storage of permanent memories.
Chapter 3 Understanding the Brain and Brain
Injury
110Temporal Lobes
- Brocca's area located in the lower portion of
the motor cortex in the left frontaltemporal
lobe - Controls muscles of the face and mouth and
enables the production of speech - Wernicke's area located left temporalparietal
lobe - Governs a persons understanding of speech
Brocas Area
Wernickes Area
Chapter 3 Understanding the Brain and Brain
Injury
111When the Brain is Injured
- After a sudden jolt or bang, the brain . . .
- Bounces around in the skull
- Blood vessels and delicate nerve tissues often
rips, tears, and stretches - Major bleeding can occur when the brain rubs
against the inside of the skull, which is ragged
with sharp bony ridges - Swells with blood and fluid
Chapter 3 Understanding the Brain and Brain
Injury
112When the Brain is Injured, cont.
- After a sudden jolt or bang, the brain . . .
- Swells with blood and fluid
- Becomes compressed due to tremendous pressure
- Can be deprived oxygen and create an additional
or secondary brain injury - Increased pressure can result in
- hematomas
- hydrocephalus
Chapter 3 Understanding the Brain and Brain
Injury
113When the Brain is Injured, Cont.
- A brain injury is often the result of two
injuries - the primary injury caused by the initial blow
or insult to the brain - the secondary injury caused by the swelling,
bleeding, compression and contusions (bruises) to
the brain.
Chapter 3 Understanding the Brain and Brain
Injury
114Other Brain Injuries
- Coup-contracoup the brain moves side-to-side
or back-to-back as from injury to one side of the
brain - Axonal injuries (DAI) are damaged nerve cells
throughout the brain that are stretched and
break. - Hyoxia decreased oxygen to the brain resulting
from severe blood loss - Anoxia complete loss of oxygen causing brain
cells (neurons) to die. - Other causes drowning, heart attack,
suffocation, smoke inhalation, asthma attack, and
strangulation
Chapter 3 Understanding the Brain and Brain
Injury
115Brain Injury Severity
- Glasgow Coma Score (GSC)
- Measures Eye Response Verbal Response Motor
Response Total Score - Scores range between 3 and 15
- The lower the score, the more severe is the brain
injury
Chapter 3 Understanding the Brain and Brain
Injury
116Brain Injury Severity
- Severity of brain injury is described in multiple
ways. - The most common are
- mild
- moderate
- severe
Chapter 3 Understanding the Brain and Brain
Injury
117Severity of Brain Injuries, Cont.
- Mild brain injury
- Loss of consciousness for less than 30 minutes
(possibly no loss of consciousness) - Glasgow Coma Scale of 13-15
- Posttraumatic amnesia for less than 24 hours
- Temporary or permanently altered mental or
neurological state
Chapter 3 Understanding the Brain and Brain
Injury
118Severity of Brain Injuries, Cont.
- Postconcussion symptoms that or may not persist
include - headache changes in personality
- dizziness memory problems
- vomiting depression
- sleep disturbance difficulty problem solving
- irritability diminished attention span
Chapter 3 Understanding the Brain and Brain
Injury
119Brain Injury Severity
- Moderate brain injury
- coma more than 20-30 min., but less than 24 hrs.
- Glasgow Coma Scale of 9-12
- possible skull fractures with bruising bleeding
- signs on EEG, CAT or MRI scans
- some long term problems in one or more areas of
life (i.e., home, work, community)
Chapter 3 Understanding the Brain and Brain
Injury
120Brain Injury Severity
- Severe brain injury
- coma longer than 24 hours, often lasting days or
weeks - Glasgow Coma Scale of 8 or less
- bruising, bleeding in brain
- signs on EEG, CAT or MRI scans
- long term impairments in one or more areas of
life (i.e., home, work, community)
Chapter 3 Understanding the Brain and Brain
Injury
121Many professionals and family members feel that
the severity of the actual injury and the
severity of the problems or consequences do not
necessarily match the strict definitions of mild,
moderate and severe.
Chapter 3 Understanding the Brain and Brain
Injury
122Conclusion
- Individuals with brain injuries often have
difficulty with new learning while exhibiting a
good memory for information learned previous to
the injury. - Virtually every behavior depends on the
interconnectedness of the brain. - Because of the interconnectedness of the brain
and behavior functions, even an injury that is
relatively mild in severity or small in size may
lead to many distressing symptoms.
Chapter 3 Understanding the Brain and Brain
Injury
123Chapter 4Health, Medications and Medical
Management Issuesby Terri Antoinette M.H.S.A.,
R.N.C.,C.R.R.N.,C.B.I.S.C.E., C.L.N.C.David
Strauss, PhD.Tina M Trudel Ph.D., C.B.I.S.-C.E.
124Learning Objectives
- Demonstrate knowledge of the most commonly
prescribed medications used after brain injury. - Identify and report signs and symptoms of illness
that require the attention of medically trained
personnel. - Understand the effects of alcohol and substance
abuse in brain injury. - Identify aspects of aging with brain injury.
Chapter 4 Health, Medications and Medical
Management Issues
125 Introduction
- The brain is a complex and vulnerable organ.
- Injury can result in a multitude of physical and
psychological impairments and medical
complications. - Once a person has been deemed medically stable
by the acute care hospital staff, transfer to
either medically based or community based
rehabilitation programs, or even to home, may
occur. - Direct care staff often first identify possible
conditions and complications that effect a
persons medical stability.
Chapter 4 Health, Medications and Medical
Management Issues
126The Goal of Rehabilitation
- The goal of rehabilitation is to help people
regain the most independent level of functioning
possible. - Treatment must be individualized in accordance
with each persons unique needs. - The first step in assisting the person is a
thorough review and assessment of factors which
have impacted upon the whole person. - Well documented information on the health status
of the individual when admitted is important. - It is a baseline for comparison when health
status changes.
Chapter 4 Health, Medications and Medical
Management Issues
127Initial Assessment
- Review past medical history including
- how the injury happened
- time elapsed since injury
- age at onset of injury
- physical or mental health problems prior to the
injury - history of loss of consciousness or brain injury
prior to this injury - major hospitalizations and surgery
- right handed or left handed
- sleep habits
Chapter 4 Health, Medications and Medical
Management Issues
128Initial Assessment, Cont.
- Review historical information including
- developmental / psychosocial / behavioral history
- family support systems
- educational history including evidence of
learning disability - work history/socioeconomic status
- military service
- marital history
- legal record
- substance abuse
- cultural, religious, and language background
- sexual preference
- recent life stressors (i.e. deaths, family,
marital, financial, academic, vocational, etc.) - nature and extent of financial resources
Chapter 4 Health, Medications and Medical
Management Issues
129Initial Assessment, cont.
- Review information about the accident/injury
including - area of the brain injured
- severity of injury
- etiology of the injury (i.e. traumatic, anoxic)
- complications/ coexisting medical conditions
- acute medical/rehabilitative treatment including
medical conditions/complications - the presence of multiple injuries
Chapter 4 Health, Medications and Medical
Management Issues
130Initial Assessment, cont.
- Review of evaluations including
- medical, psychiatric, nursing, neuropsychological,
neuropsychiatric, physical therapy, occupational
therapy, speech language therapy, social and
vocational history. - Review of current medications, dosages and side
effects - Make information available to direct care staff
- Any questions should be addressed to the
physician in charge of the person's treatment.
Chapter 4 Health, Medications and Medical
Management Issues
131Medical Management of Brain Injury
- The medical management of brain injury is complex
and can be a lifelong challenge
Chapter 4 Health, Medications and Medical
Management Issues
132Cardiovascular and Respiratory System
- Cardiovascular
- May be caused by direct trauma to the heart
itself, complications from trauma, or damage to
parts of the brain that control the functioning
of the heart - Monitor heart rate (normal adult 60-90
beats/minute) - Monitor blood pressure (optimal 120/80 mm Hg)
- Observe for side effects of antihypertensive meds
(dizziness, lightheadedness especially after
standing) - Respiratory
- Complications include infection, airway
obstruction, trauma to the larynx, trachea, chest
and lungs, risk of aspiration pneumonia - Monitor breathing rate ( normal adult 12-20
breaths per minute)
Chapter 4 Health, Medications and Medical
Management Issues
133Musculoskeletal System
- Observe for muscle and skeletal complications and
peripheral nerve injuries - Spasticity (an involuntary increase in muscle
tone-tension) - Contractures - (flexion and fixation of a joint
due to a wasting away and abnormal shortening of
muscle fibers and loss of skin elasticity) - Heterotopic ossification (HO) abnormal growth of
bone in soft tissues or around joints.
Chapter 4 Health, Medications and Medical
Management Issues
Chapter 4 Health, Medications and Medical
Management Issues
134Integumentary System
- Skin lacerations and abrasions
- Acne and profuse sweating may appear or be
worsened by a brain injury - Pressure ulcers are the most frequent
complication of chronic illness and physical
disability. - Bony prominences such as hips, coccyx, heels,
elbows, shoulder blades and the back of the head
are common sites - Persons using wheelchairs must be closely
observed for pressure ulcers of the ischium (the
back lower portions of the hip bones). - Staff members must frequently examine skin,
report any skin abnormalities, use proper
transfer techniques, frequently reposition, and
provide adequate nutrition and hydration.
Chapter 4 Health, Medications and Medical
Management Issues
135Gastrointestinal System
- Injury to the brain directly affects a persons
nutritional needs. - A persons metabolism may increase after brain
injury which causes the body to need increased
energy and calories. - Problems such as poor hand to eye coordination,
difficulty swallowing, diminished attention and
impaired cognition can further compromise a
persons nutritional intake.
Chapter 4 Health, Medications and Medical
Management Issues