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Brain Injury and Recovery

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Title: Brain Injury and Recovery


1
Brain Injury and Recovery
  • What is a brain injury
  • Types of brain injury
  • Levels of Brain injury
  • Factors that impact recovery
  • How are brain injuries treated
  • Stages of recovery and how to respond

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What Is a Brain Injury?
  • The term refers to an injury to the brain that
    is usually the result of an accident, or
    sometimes and assault. Injuries can result from
    blows to the head such as suffered in an
    automobile accident or fall, as a result of lack
    of oxygen or blood supply to the brain.

5
Traumatic Brain Injury (TBI)
  • A traumatic brain injury occurs when an outside
    force impacts the head hard enough to cause the
    brain to move within the skull or if the force
    causes the skull to break and directly hurts the
    brain.

6
Types of TBI Closed Head Injury
  • Closed Head Injury the result of a bow to the
    head which causes the brain to move or shake
    within the skull. The sharp and hard internal
    surfaces of the skull can cut and bruise the
    brain.
  • Movement or shaking can cause the brain to be
    damaged in many areas, not only at the point of
    the blow. For this reason, persons with closed
    head injuries can show a wide range of problems.
  • Often called diffused injuries

7
Types of TBI- Open Head Injury
  • An open head injury is the result of a sharp
    object entering the brain through the skull, such
    as a bullet. In this type of injury, damage to
    the brain tissue is seen mostly in one area-the
    area of penetration
  • These types of injuries are called focal injuries

8
Primary Injuries
  • Diffuse Axonal Injury- A Diffuse Axonal Injury
    can be caused by shaking or strong rotation of
    the head, as with Shaken Baby Syndrome, or by
    rotational forces, such as with a car
    accident. Injury occurs because the unmoving
    brain lags behind the movement of the skull,
    causing brain structures to tear.
  • Concussion-caused when the brain receives trauma
    from an impact or a sudden momentum or movement
    change. The blood vessels in the brain may
    stretch and cranial nerves may be damaged.
  • Coup-Contrecoup Injury-This occurs when the force
    impacting the head is not only great enough to
    cause a contusion at the site of impact, but also
    is able to move the brain and cause it to slam
    into the opposite side of the skull, which causes
    the additional contusion
  • Penetration Injury-Penetrating injury to the
    brain occurs from the impact of a bullet, knife
    or other sharp object that forces hair, skin,
    bone and fragments from the object into the
    brain.
  • Contusion-A contusion is a bruise (bleeding) on
    the brain

9
Secondary Injuries
  • When a TBI occurs, other factors can affect the
    brain, called secondary injuries. These can cause
    further problems in addition to the trauma
  • Bleeding (hemorrhage)- when deep blood vessels in
    the brain are injured an bleed causing injury
    from loss of blood or pressure
  • Blood clots (hematomas)- clots can form when
    there is bleeding. Clots can create pressure,
    which can lead to further damage
  • Swelling (edema)- causes pressure which can
    damage the brain
  • Lack of oxygen (anoxia)- because of bleeding in
    the brain or injury to other parts of the body,
    the flow of oxygen to the brain may be poor and
    cause damage.

10
Symptoms of a TBI
  • Spinal fluid (thin water-looking liquid) coming
    out of the ears or nose
  • Loss of consciousness however, loss of
    consciousness may not occur in some concussion
    cases
  • Dilated (the black center of the eye is large and
    does not get smaller in light)or unequal size of
    pupils
  • Vision changes (blurred vision or seeing double,
    not able to tolerate bright light, loss of eye
    movement, blindness)
  • Dizziness, balance problems
  • Respiratory failure (not breathing)
  • Coma (not alert and unable to respond to others)
    or semicomatose state

11
Symptoms of TBI cont.
  • Paralysis, difficulty moving body parts,
    weakness, poor coordination
  • Slow pulse
  • Slow breathing rate, with an increase in blood
    pressure
  • Vomiting
  • Lethargy (sluggish, sleepy, gets tired easily)
  • Headache
  • Confusion
  • Ringing in the ears, or changes in ability to
    hear

12
Symptoms of TBI cont
  • Difficulty with thinking skills (difficulty
    thinking straight, memory problems, poor
    judgment, poor attention span, a slowed thought
    processing speed)
  • Inappropriate emotional responses (irritability,
    easily frustrated, inappropriate crying or
    laughing)
  • Difficulty speaking, slurred speech, difficulty
    swallowing
  • Body numbness or tingling
  • Loss of bowel control or bladder control

13
Acquired Brain Injury
An acquired brain injury is an injury to the
brain, which is not hereditary, congenital,
degenerative, or induced by birth trauma. An
acquired brain injury is an injury to the brain
that has occurred after birth.
14
Causes of Acquired Brain Injury
  • Airway obstruction
  • Near-drowning, throat swelling, choking,
    strangulation, crush injuries to the chest
  • Electrical shock or lightening strike
  • Trauma to the head and/or neck
  • Traumatic brain injury with or without skull
    fracture, blood loss from open wounds, artery
    impingement from forceful impact, shock
  • Vascular Disruption

15
Causes Continued
  • Heart attack, stroke, arteriovenous malformation
    (AVM), aneurysm, intracranial surgery
  • Infectious disease, intracranial tumors,
    metabolic disorders
  • Meningitis, certain venereal diseases, AIDS,
    insect-carried diseases, brain tumors,
    hypo/hyperglycemia, hepatic encephalopathy,
    uremic encephalopathy, seizure disorders
  • Toxic exposure
  • Illegal drug use, alcohol abuse, lead, carbon
    monoxide poisoning, toxic chemicals, chemotherapy
    (not all the time).

16
Levels of Brain Injury
  • the severity of neurological injury to the brain
    by using an assessment called the Glascow Coma
    Scale (GCS) to. The terms Mild Brain Injury,
    Moderate Brain Injury, and Severe Brain Injury
    are used to describe the level of initial injury
    in relation to the neurological severity caused
    to the brain. There may be no correlation between
    the initial Glascow Coma Scale score and the
    initial level of brain injury and a persons
    short or long term recovery, or functional
    abilities.
  • Keep in mind that there is nothing Mild about a
    brain injuryagain, the term Mild Brain injury
    is used to describe a level of neurological
    injury. Any injury to the brain is a real and
    serious medical condition

17
Mild Traumatic Brain Injury Glascow Coma Scale
score 13-15
  • Loss of consciousness is very brief, usually a
    few seconds or minutes
  • Loss of consciousness does not have to occurthe
    person may be dazed or confused
  • Testing or scans of the brain may appear normal
  • A mild traumatic brain injury is diagnosed only
    when there is a change in the mental status at
    the time of injurythe person is dazed, confused,
    or loses consciousness. The change in mental
    status indicates that the persons brain
    functioning has been altered, this is called a
    concussion

18
Moderate TBI Glascow Coma Scale Score 9-12
  • A loss of consciousness lasts from a few minutes
    to a few hours
  • Confusion lasts from days to weeks
  • Physical, cognitive, and/or behavioral
    impairments last for months or are permanent.
  • Persons with moderate traumatic brain injury
    generally can make a good recovery with treatment
    or successfully learn to compensate for their
    deficits.

19
Severe Brain Injury Glascow Coma Score 8 or less
  • Severe brain injury occurs when a prolonged
    unconscious state or coma lasts days, weeks, or
    months. Severe brain injury is further
    categorized into subgroups with separate
    features
  • Coma
  • Vegetative State -Arousal is present, but the
    ability to interact with the environment is not.
    Eye opening can be spontaneous or in response to
    stimulation.General responses to pain exist, such
    as increased heart rate, increased respiration,
    posturing, or sweating Sleep-wakes cycles,
    respiratory functions, and digestive functions
    return
  • Persistent Vegetative State
  • Minimally Responsive State-demonstrate Primitive
    reflexes,Inconsistent ability to follow simple
    commands, and an awareness of environmental
    stimulation
  • Akinetic Mutism-a neurobehavioral condition that
    results when the dopaminergic pathways in the
    brain are damaged.
  • Locked-in Syndrome

20
Before we can understand what happens when a
brain is injured, we must realize what a healthy
brain is made of and what it does. The brain is
enclosed inside the skull. The skull acts as a
protective covering for the soft brain. The brain
is made of neurons (nerve cells). The neurons
form tracts that route throughout the brain.
These nerve tracts carry messages to various
parts of the brain. The brain uses these messages
to perform functions. The functions include our
thought processes, physical movements,
personality changes, behavioral changes, and
sensing and interpreting our environment. Each
part of the brain serves a specific function and
links with other parts of the brain to form more
complex functions.
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Thinking Changes Memory
Decision making Planning Sequencing Judgment Atten
tion Communication Reading and writing
skills Thought processing speed Problem solving
skills Organization Self-perception Perception Tho
ught flexibility Safety awareness New learning
Physical Changes Muscle movement Muscle
coordination Sleep Hearing
Vision Taste Smell Touch Fatigue
Weakness Balance Speech seizures Sexual
Functioning
30
Personality and Behavioral Changes Social
skills
Emotional control and mood
swings Appropriateness of
behavior Reduced self-esteem Depression Anxiety Fr
ustration Stress
Denial Self-centeredness Anger management Coping
skills Self-monitoring remarks or
actions Motivation Irritability or
agitation Excessive laughing or crying
31
Right or Left Brain The functional sections or
lobes of the brain are also divided into right
and left sides. The right side and the left side
of the brain are responsible for different
functions. General patterns of dysfunction can
occur if an injury is on the right or left side
of the brain.

32
  • Injuries of the Right Side of Brain can cause
  • Visual-spatial impairment
  • Visual memory deficits
  • Left neglect (inattention to the left side of the
    body)
  • Decreased awareness of deficits
  • Altered creativity and music perception
  • Loss of the big picture type of thinking
  • Decreased control over left-sided body movements
  • Left Side of the Brain
  • Difficulties in understanding language (receptive
    language)
  • Difficulties in speaking or verbal output
    (expressive language)
  • Catastrophic reactions (depression, anxiety)
  • Verbal memory deficits
  • Impaired logic
  • Sequencing difficulties
  • Decreased control over right-sided body movements

33
  • Diffuse Brain Injury
  • (The injuries are scattered throughout both sides
    of the brain)
  • Reduced thinking speed
  • Confusion
  • Reduced attention and concentration
  • Fatigue
  • Impaired cognitive (thinking) skills in all areas

34
                                                
            Just as no two people are alike, no
two brain injuries are alike. Appropriate
treatment and rehabilitation will vary from
individual to individual. Programs and treatments
change, as a person's needs change. It is
important to recognize that "more therapy" does
not make a person "better", but that
"appropriate" therapy may.
35
Factors that Affect Recovery
  • Age at the time of injury
  • Area and amount of injury
  • Time since the injury happened
  • Skills and behavior before injury
  • Motivation for recovery
  • Substance use and/or abuse
  • Past brain injury or concussion

36
How Are Brain Injuries Treated Medically (ICU)
  • Treatment is aimed at stopping any bleeding,
    preventing an increase in pressure within the
    skull, controlling the amount of pressure and
    removing any large blood clots
  • Treatments may include positioning, fluid
    restriction, medications, ventricular drain,
    ventilator, surgery (craniotomy, burr holes, bone
    flap removal)

37
The Recovery Process
  • Ranchos Los Amigos Scale of Cognitive Functioning
  • As recovery progresses, the Ranchos Los
    Amigos Scale of Cognitive Function becomes the
    tool most widely utilized to assess cognitive and
    behavioral functioning. This describes the
    cognitive and behavioral status of the individual
    at the time, and directs the planning and
    evaluation of treatment plans and goals
    throughout the entire recovery process. It also
    represents a non-medical framework for family
    members to begin to understand brain injury in a
    way that helps them interact with their loved one
    in a more sensitive, positive manner,
    contributing to the rehabilitation process.

38
The Ranchos Los Amigos Scale consists of eight
levels, and is described below. Individuals go
through these levels at different rates, and
improvement may vary at any level. Individuals
may fluctuate between two levels at the same
time. Suggestions for working with your family
member at each stage of recovery is provided.
39
Stages of Recovery
  • Level I - No Response Patient appears to be in a
    deep sleep and is completely unresponsive to any
    stimuli presented to him.

40
How to Respond to Level 1
  • It is not really known what an individual can
    hear and understand while in a coma or early
    stages of recovery. Family and staff should
    therefore monitor their interactions and
    conversations at bedside, always keeping in mind
    the possibility some activity may be remembered.

41
Stages of Recovery
  • Level II - Generalized Response
  • Patient reacts inconsistently and
    non-purposefully to stimuli in a non-specific
    manner.
  • Responses are limited in nature and are often
    the same regardless of stimulus presented.
  • Responses may be physiological changes, gross
    body movements, and/or vocalization.
  • Often, the earliest response is to deep pain.
    Responses are likely to be delayed.

42
How to Respond to Level II
  • During periods of wakefulness, provide simple and
    meaningful stimulation.
  • Describe activities to your loved one such as
    "now I am washing your right hand".
  • Speak in slow, calm, and normal tones, and show
    affection often, in whatever way you can.
  • When eyes are opened, try to have him/her look at
    you and at other visitors.
  • Keep periods of stimulation brief (5-15 minutes),
    as your family member has to rest.
  • Family and friends should share stimulation
    responsibilities as you too have to rest.

43
Stages of Recovery
  • Level III - Localized Response
  • Patient reacts specifically, but inconsistently,
    to stimuli.
  • Responses are directly related to the type of
    stimulus presented as in turning head toward a
    sound or focusing on an object presented.
  • The patient may withdraw an extremity and/or
    vocalize when presented with a painful stimulus.
  • May follow simple commands in an inconsistent,
    delayed manner such as closing eyes, squeezing or
    extending an extremity.

44
  • Once external stimuli is removed, patient may lie
    quietly.
  • May also show a vague awareness of self and body
    by responding to discomfort by pulling at
    nasogastric tube or catheter or resisting
    restraints.
  • Patient may show a bias toward responding to some
    persons (especially family, friends) but not to
    others.

45
How to respond to Level III
  • Increase and direct stimulation efforts at
    reorienting your family member with who they are
    and what has happened.
  • At each visit, describe who you are, provide the
    date, where they are and why.
  • Bring familiar and significant objects to the
    individual provide photographs of family and
    friends, identified by name on the back to assist
    staff who can also help stimulate his/her memory.
  • With increased periods of alertness, discuss
    significant past, such as school, employment,
    longtime relationships, hobbies.

46
  • Continue to ask for simple commands to be
    followed, initiate and assist with self-care
    tasks.
  • Ask simple questions that require only "yes" or "
    no " answers, allowing time to respond.
  • Remain patient and sensitive to signs of
    frustration.

47
Stages of Recovery
  • Level IV - Confused/Agitated
  • Patient is in a heightened state of activity with
    severely decreased ability to process
    information.
  • Is detached from the present and responds
    primarily to his/her own internal confusion.
  • Behavior is frequently bizarre and non-purposeful
    relative to his/her immediate environment.
  • May cry out or scream out of proportion to
    stimuli even after removal, show aggressive
    behavior, attempt to remove restraints or tubes,
    or crawl out of bed in a purposeful manner.
  • Patient does not, however, discriminate among
    persons or objects and is unable to cooperate
    directly with treatment efforts.

48
  • Verbalization is frequently incoherent and/or
    inappropriate to the environment.
  • Confabulation may be present patient may be
    euphoric or hostile. Thus, gross attention to
    environment is very short and selective attention
    is often nonexistent.
  • Being unaware of present events, patient lacks
    short-term recall and may be reacting to past
    events.
  • Is unable to perform self-care (feeding,
    dressing) without maximum assistance.
  • If not disabled physically, he/she may perform
    motor activities such as sitting, reaching, and
    ambulating, but as part of his/her agitated state
    and not as a purposeful act or on request,
    necessarily.

49
Responding to Level IV
  • The goals of this stage are to decrease agitation
    and increase awareness.
  • Use calm, soft speech and slow careful movements
    to lessen the tendency for agitation.
  • Continue to provide opportunities for the
    individual to respond to stimuli and simple
    commands, encourage and assist with self-care
    tasks, continue to associate the individual with
    familiar things.
  • Remove distractions such as TV or radio, to
    restrict stimulation to one sense (auditory,
    visual or tactile) at a time.
  • Attempt to correct an inappropriate or inaccurate
    response, but do not argue the point.

50
Responding to Level IV cont
  • If confusion and agitation is ongoing, do not try
    to rationalize with the person, allow him/her
    time to relax.
  • Do not ignore them however, instead provide
    human contact and soothing reassurances.
  • Avoid sedatives as they can slow the thinking
    process, and add to the confusion.
  • Seeing a family member engage in unusual and
    aggressive behavior is very difficult to endure.
  • Try to remember not to take any of the comments
    and behaviors personally.
  • The Confused-Agitated stage is a sign of
    improvement, and a necessary step towards
    recovery.

51
Stages of Recovery
  • Level V - Confused, Inappropriate Non-Agitated
  • Patient appears alert and is able to respond to
    simple commands fairly consistently however,
    with increased complexity of commands or lack of
    any external structure, responses are
    non-purposeful, random, or, at best, fragmented
    toward any desired goal.
  • May show agitated behavior, but not on an
    internal basis (as in Level IV), but rather as a
    result of external stimuli, and usually out of
    proportion to the stimulus.
  • Has gross attention to the environment, but is
    highly distractible and lacks ability to focus
    attention to a specific task without frequent
    re-direction back to it.
  • With structure, person may be able to converse on
    a social-automatic level for short periods of
    time.

52
  • Verbalization is often inappropriate
    confabulation may be triggered by present events.
  • Memory is severely impaired, with confusion of
    past and present in patients reaction to ongoing
    activity.
  • Patient lacks initiation of functional tasks and
    often shows inappropriate use of objects without
    external direction.
  • May be able to perform previously-learned tasks
    when structured, but is unable to learn new
    information.
  • Responds best to self, body, comfort, and, often,
    family members.
  • The patient can usually perform self-care
    activities, with assistance, and may accomplish
    feeding with maximum supervision.
  • Management on the ward is often a problem if the
    patient is physically mobile, as patient may
    wander off, either randomly or with vague
    intentions of "going home".

53
Responding to Level V
  • Continue to help the individual get back in touch
    with the world, discuss family and friends, and
    events he/she has experienced during the day.
  • Try to have information recalled, providing hints
    to stimulate memory, for example, ask immediately
    after breakfast what he/she ate.
  • If unable to remember, be more specific. Ask what
    he/she drank. If it was milk, describe it as
    white.
  • Encourage success with generous praise, noting
    accomplishments.

54
  • Do not allow tasks to become overwhelming
    however, as tolerance for frustration is
    decreased.
  • Simple memory and card games may be tried at this
    stage.
  • Try to keep routines consistent to help organize
    the individual.
  • Discuss problems he/she is having related to the
    brain injury honestly and matter-of-factly.
  • Use a calm soothing manner always remembering to
    address the individual in an age-appropriate
    fashion.

55
Stages of Recovery
  • Level VI - Confused, Appropriate
  • Patient shows goal-directed behavior, but is
    dependent on external input for direction.
    Response to discomfort is appropriate and patient
    is able to tolerate unpleasant stimuli (as NG
    tube) when need is explained.
  • Follows simple directions consistently and shows
    carry-over for tasks he has relearned (as
    self-care).
  • Is at least supervised with old learning unable
    to maximally be assisted for new learning with
    little or no carry-over.
  • Responses may be incorrect due to memory problem,
    but they are appropriate to the situation.
  • They may be delayed to immediate and shows
    decreased ability to process information with
    little or no anticipation or prediction of
    events.
  • Past memories show more depth and detail than
    recent memory.

56
  • May show beginning immediate awareness of
    situation by realizing he doesn't know an answer.
  • He no longer wanders and is inconsistently
    oriented to time and place.
  • Selective attention to task may be impaired,
    especially with difficult tasks and in
    unstructured settings, but is now functional for
    common daily activities (30 min. with structure).
  • He may show a vague recognition of some staff,
    has increased awareness of self, family and basic
    needs (as food), again, in an appropriate manner
    as in contrast to Level V.

57
Responding to Level VI
  • Work towards increasing independence during this
    stage, by gradually decreasing assistance
    provided for simple activities.
  • Offer games and crafts that become more mentally
    challenging but not frustrating.
  • Discuss TV shows, conversations, and events
    immediately after he/she has seen or heard them.
  • Use each situation as a learning experience to
    help the individual begin to arrange and
    understand each part of daily life.

58
  • Activities we take for granted may be difficult
    for the individual to accomplish.
  • Ask to have familiar tasks such as making coffee,
    changing money, or washing clothes described in
    steps or well-traveled trips such as to school,
    stores, or friends' homes mapped out.
  • Be sensitive to tolerance levels and signs of
    fatigue.
  • Keep activities at a moderate pace, and always
    allow time for rest.

59
Stages of Recovery
  • Level VII - Automatic, Appropriate
  • Patient appears appropriate and oriented
  • goes through daily routine automatically, but
    frequently robot-like, with minimal-to-absent
    confusion, but has shallow recall of what he has
    been doing.
  • He shows increased awareness of self, body,
    family, foods, people, and interaction in the
    environment.
  • He has superficial awareness of, but lacks
    insight into, his condition, decreased judgment
    and problem-solving and lacks realistic planning
    for his future.

60
  • Patient shows carry-over for new learning, but at
    a decreased rate.
  • Requires at least minimal supervision for
    learning and for safety purposes.
  • Patient is independent in self-care activities
    and supervised in home and community skills for
    safety.
  • With structure, Patient is able to initiate tasks
    as social or recreational activities in which
    he/she now has interest.
  • Judgment remains impaired such that he/she is
    unable to drive a car.

61
Responding to Level VII
  • The major goals of this and the next level of
    recovery are to promote independent skills to
    permit supervision to be safely withdrawn.
  • During this stage, "real-life " activities of
    increasing complexity such as shopping or use of
    a telephone directory and/or map should be
    attempted.
  • Situations of daily living at home and in the
    community should be discussed, with multistep
    planning and possible dangerous aspects explored.
  • Use and expansion of judgment skills should be
    emphasized.
  • Patience during interactions is needed as the
    processing of new information may be slowed.

62
Stages of Recovery
  • Level VIII - Purposeful, Appropriate
  • Patient is alert and oriented, is able to recall
    and integrate past and recent events, and is
    aware of, and responsive to, his culture.
  • Shows carry-over for new learning if acceptable
    to him/her and his/her life role, and needs no
    supervision once activities are learned.
  • Within physical capabilities, person is
    independent in home and community skills,
    including driving.
  • Vocational rehabilitation, to determine ability
    to return as contributor to society (perhaps in a
    new capacity) is indicated.

63
  • May continue to show a decreased ability,
    relative to premorbid abilities, in abstract
    reasoning, tolerance for stress, judgment in
    emergencies or unusual circumstances.
  • Social, emotional, and intellectual capacities
    may continue to be at a decreased level, but
    functional in society.

64
Responding to Level VIII
  • Maximum involvement in home, school, or job
    within the individual's physical and intellectual
    capabilities should be encouraged.
  • Responsibilities for one's own needs as well as
    in home and community should be resumed.
  • Complex tasks such as total meal planning and
    preparation, organizing chores into a daily
    routine, and planning leisure activities can be
    initiated independently.
  • The individual should be encouraged to develop
    and utilize aids such as memory books or reminder
    lists to assist him/her with accomplishing goals.

65
  • During these later stages, counseling may be
    indicated to assist the individual in gaining
    insight into the changed levels of functioning
    that he/she may be experiencing, and to develop
    coping strategies if deficits preclude a return
    to previous educational or vocational status.

66
Acute Rehabilitation
  • In the Acute Rehab setting, a team of health
    professionals with experience and training in
    brain injury rehabilitation work with the person
    and their family. The goal of Acute
    Rehabilitation is to assist persons with brain
    injuries to achieve their highest level of
    independent life skills used in activities of
    daily living. Activities of daily living include
    dressing, eating, toileting, walking, speaking,
    and several other basic, yet essential activities
    that we perform in our daily lives. After a brain
    injury, people may have to relearn how to do
    these types of tasks. Rehabilitation requires the
    expertise of several healthcare professionals and
    Acute Rehab team members.

67
Subacute Rehabilitation
  • Subacute Rehabilitation provides services for
    persons with brain injury who need a less
    intensive level of rehabilitation services, over
    a longer period of time.
  • Sub-acute rehabilitation programs may also be
    designed for persons who have made progress in
    the acute rehabilitation setting and are still
    progressing, but are not making rapid functional
    gains.
  • Subacute rehabilitation may be provided in a
    variety of settings, but is often in a skilled
    nursing facility or nursing home

68
Outpatient Therapy
  • Following acute rehabilitation or sub-acute
    rehabilitation, a person with a brain injury may
    continue to receive outpatient therapies to meet
    continued goals. Additionally, a person with a
    brain injury that was not severe enough to
    require inpatient hospitalization may attend
    outpatient therapies to address functional
    impairments.

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Rehabilitation Treatment Team
  • Physiatrist is a doctor of physical medicine
    rehabilitation. The physiatrist typically serves
    as the leader for the rehabilitation treatment
    team and makes referrals to the various therapies
    and medical specialists as needed. The
    physiatrist works with the rehabilitation team,
    the person with a brain injury, and the family to
    develop the best possible treatment plan.
  • Physical Therapists evaluate and treat a persons
    ability to move the body. The physical therapist
    focuses on improving physical function by
    addressing muscle strength, flexibility,
    endurance, balance, and coordination. Functional
    goals include increasing independent ability with
    walking, getting in and out of bed, on and off a
    toilet, or in and out of a bathtub. Physical
    therapists provide training with assistive
    devices such as canes or walkers for ambulation.
    Physical therapists can also use physical
    modalities, treatments of heat, cold, and water
    to assist with pain relief and muscle movement.

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Rehabilitation Treatment Team
  • Occupational Therapists
  • use purposeful activities as a means of
    preventing, reducing, or overcoming physical and
    emotional challenges to ensure the highest level
    of independent functioning in meaningful daily
    living.
  • Areas addressed by occupational therapists
    include Feeding swallowing grooming bathing
    dressing toileting mobilizing the body on and
    off the toilet, bed, chair, bathtub thinking
    skills vision sensation driving homemaking
    money management fine motor (movement of small
    body muscles, such as in the hands) wheelchair
    positioning and mobility home evaluation
    durable medical equipment assessment and training
    (such as, use of a raised toilet seat to assist
    with getting on and off the toilet easier).
  • The occupational therapist also fabricates
    splints and casts to reduce deformities and
    optimize muscle functioning

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Rehabilitation Treatment Team
  • Speech/language pathologist
  • responsible for evaluating and treating language
    and cognitive difficulties that may cause
    challenges your daily life. Language refers to
    the skills of comprehension, verbal expression,
    reading, and writing. Cognitive skills refer to
    thinking skills such as attention/concentration,
    memory, reasoning, problem-solving, etc.
  • work with any motor speech or swallowing
    difficulties. Therapy will focus on improving
    and working around any difficulties to make you
    more independent in the home, work, educational,
    and community environments.

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Rehabilitation Treatment Team
  • Rehabilitation Nurses
  • monitor all body systems.
  • attempts to maintain the persons medical status,
    anticipate potential complications, and work on
    goals to restore a person's functioning.
  • responsible for the assessment, implementation,
    and evaluation of each individual patient's
    nursing care and educational needs based on
    specific problems as well as coordinating with
    physicians and other team members to move the
    patient from a dependent to an independent role.

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Rehabilitation Treatment Team
  • Social Worker
  • provides you and your family with information
    from weekly team staffings so that you remain
    updated on your progress, your discharge goals,
    and your estimated length of stay.
  • can also give you information on community
    resources that you might need, such as support
    services in the home or Social Security
    Disability.
  • will help you and your family set up your
    discharge to home or, if needed, will assist you
    in finding a living arrangement that provides you
    with more assistance.

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Rehabilitation Treatment Team
  • Recreational Therapists
  • provide activities to improve and enhance
    self-esteem, social skills, motor skills,
    coordination, endurance, cognitive skills, and
    leisure skills.
  • plan community outings to allow the person to
    directly apply learned skills in the community.
  • Additional programs may include pet therapy,
    leisure education, wheelchair sports, gardening,
    special social functions or holiday functions for
    persons and their family.

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Rehabilitation Treatment Team
  • Neuropsychologist
  • The Neuropsychologist has specialized training in
    evaluating and understanding how brain injuries
    affect thinking, behavior, and emotions.
  • works with the rehabilitation physician to
    monitor your progress and response to
    medications.
  • conducts formal tests to measure progress in
    thinking, behavior, and emotions.
  • works closely with the treatment team to assist
    with recommendations on how independent you can
    be and how, or when, you can return to work.
  • can help you and your family understand what long
    term difficulties you may have as a result of
    your injury.
  • available to provide support to you and your
    family as you adapt to your injury and to the
    changes in your life.

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Other Community Based Treatment/services
  • Home Health Services
  • Vocational Rehabilitation
  • Support Groups BIAI every 4th Thursday at IERH
    7-9pm
  • Brain Injury Association of Idaho
  • 1-888-336-7708 www.biausa/idaho.org
  • Brain Injury Association, Inc. www.biausa.org
  • 1-800-444-6443

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HOW DOES BRAIN INJURY AFFECT BEHAVIOR?
  • The majority of TBIs result in some degree of
    behavior change
  • It is very important that the family realizes
    that misbehavior can be the result of brain
    damage as well as the frustration and anger that
    the survivor feels
  • Impairments seen in self-care skills, cognition,
    and interpersonal skills

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Personality traits may become exaggerated or more
extreme after a brain injury.
A reserved, quiet person may become even more
even more withdrawn and quiet An assertive,
active person may become aggressive and even more
outspoken
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Behavior and Personality Issues
  • Fatigue
  • Amotivation
  • Agitation
  • Emotional Lability
  • Impulsivity
  • Perseveration
  • Sexual behavior
  • Memory Problems
  • Poor concentration
  • Lack of Awareness
  • Lack of emotion
  • Self-centered thinking

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Emotional Responses to TBI
  • Irritability
  • Fear/Anxiety
  • Anger
  • Depression
  • Role changes
  • Self-Esteem

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FATIGUE
  • Fatigue is tiredness of the body (physical) or
    mind (mental). All people feel fatigue but it is
    especially common after an injury. The body use a
    lot of energy to recover. This tiredness may come
    and go, lasting for a few months to many years
  • Symptoms of fatigue include
  • Takes more energy to do everyday things like
    brushing teeth walking, and dressing
  • Activities normally done without thinking may
    take great care and planning
  • Simple communication may take more effort
  • May take more than one try and a lot of energy to
    finish a task
  • People often have a lot of sadness, fear, and
    anger after an illness or injury. These feelings
    use up a lot of energy.

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Causes of Fatigue
  • Things that can use up a persons energy include
    the following
  • Stress
  • Poor sleep
  • Pain
  • Medications
  • Depression
  • Lack of exercise
  • Poor nutrition

83
What Are the Types of Fatigue?
  • There are different areas of life that fatigue
    (tiredness) can affect
  • Physical
  • Emotional
  • Mental
  • Spiritual

84
Ways to Increase Energy
  • The first step to increasing energy is to
    identify the causes of the tiredness
  • Follow a regular schedule for activity and rest.
    Make sure it does not affect nighttime sleeping
  • Celebrate progress, no matter how small
  • Find something enjoyable in everyday life
  • Keep track of your schedule to see when you tend
    to be most awake and most fatigued

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How to Use Energy Better
  • Make a daily schedule and follow it
  • Do harder tasks (high energy and/or thinking
    tasks) at times when you are most energetic
  • Have two plans for the day. One for high-energy
    days and one for low energy days
  • Use aids, such as notebooks for memory and
    wheelchairs to go long distances, to help save
    energy
  • Find a way to let go of anger, sadness, and fear.
    Holding these feelings in uses energy. Do the
    following talk, relax, meditate, exercise, get
    counseling, if needed
  • Ask for help

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Amotivation/Apathy
  • Past Studies state that it is common for
    individuals with traumatic brain injury to
    experience apathy as a result of neurological
    changes.
  • Apathy refers to a syndrome of disinterest,
    disengagement, inertia, lack of motivation, and
    absence of emotional responsivity. The negative
    affect and cognitive deficits seen in patients
    with depression are not seen in patients with
    apathy. Apathy may be secondary to damage of the
    mesial frontal lobe

87
Agitation/Irritability
  • Damage to several areas of the brain can lead to
    difficulty controlling ones behavior, including
    control of temper
  • Irritability after brain injury sometimes relates
    to difficulties and frustration in doing things
    that the person was able to do easily before.
  • Person may become angry over seemingly small
    matters

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Ways to Manage Anger
  • After the person calms down, encourage them to
    write down what happened to cause the anger, what
    the person thought and did when angry, and what
    happened after he/she was angry.
  • Encourage the injured person to take a time-out
    when anger starts to build. The person can say
    I am beginning to feel angry angry and would
    like to take a time out
  • Get enough sleep
  • Avoid caffeine or alcohol
  • Identify triggers then change or avoid them

89
Ways to Diffuse Hostile Behavior
  • Remain calm as you can, ignore the behavior
  • Agree with the person (if appropriate).
  • Validate feelings- let person know their feelings
    are legitimate
  • Do not challenge or confront person. Rather,
    negotiate.
  • Offer alternative ways to express anger
  • Try to understand source of anger- is there a way
    to address the persons need/frustration
  • Ask person if there is anything that would help
    them feel better

90
  • Isolate the disruptive impaired person
  • Try to establish consistent, nonconfrontational
    responses from all family members
  • Seek support for yourself as a caregiver

91
Suggestions to Prevent Agitation
  • Keep noise levels down
  • Adjust lighting in room
  • Limit visitors to one or two at a time for no
    more than 20 minutes
  • Follow rest schedule set by team
  • Allow no visitors in room during rest times
  • Give simple directions
  • Show calm behavior
  • Respect the persons right for space and privacy

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REMEMBER
  • Physical contact may increase aggression
  • Call for help if aggression is escalating
  • Do not leave person alone
  • Keep person in sight
  • Remove objects that may be thrown (maintain a
    safe environment)

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Emotional Lability
  • Feelings are often show in an extreme and
    inappropriate way
  • Expressions and moods may change suddenly

94
Helpful Suggestions
  • Keep a matter-of-fact attitude
  • Ignore inappropriate emotions. It is natural to
    want to comfort the person, but this type of
    attention may make unwanted emotions last longer
  • Change the topic
  • Praise the person when he or she controls
    unwanted emotions
  • Have the person take many rest periods
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