Exam 1 Flashcards
(179 cards)
1
Q
Cognition (definition, areas included):
A
the act or process of knowing; includes every mental process that may be described as an experience of knowing;
includes attention memory reasoning problem solving
2
Q
Rehabilitation (definition)
A
to restore or bring to a condition of health or useful and constructive ability
3
Q
Cognitive Rehabilitation
A
a systematic applied set of medical and therapeutic services aimed to improve cognitive functioning and participation in activities; these activities may be affected by deficits in one of more cognitive domain. Its often part of a comprehensive interdisciplinary program (e.g. PTs, OTs, physicians, social workers, etc.)
4
Q
Roles of Speech-Language Pathologist in cognitive-communication disorders
A
o Identification o Assessment o Intervention o Counseling o Collaboration o Case Management o Education o Prevention o Advocacy o Research
5
Q
Criteria for Empirically Validated Treatment
What are some well-established treatment criteria?
(One sentence description)
A
Well-established treatments:
I. At least two good between-group design experiments, demonstrating efficacy in one or more of the following ways:
A. Superior (statistically significant differences) to pill or psychological placebo or to another treatment.
B. Equivalent to an already established treatment in experiments with adequate sample sizes.
Or
II. A large series of single-case design experiments (n> 9) demonstrating efficacy. These experiments must have:
A. Used good experimental designs and
B. Compared the intervention to another treatment as in IA.
Further criteria for both I and II:
III. Experiments must be conducted with treatment manuals or detailed descriptions.
IV. Characteristics of the client samples must be clearly specified.
V. Effects must have been demonstrated by at least two different investigators or investigating terms.
6
Q
What are probably efficacious treatment criteria?
A
Probably efficacious treatments
I. Two experiments showing the treatment is superior (statistically significant so) to a waiting-list control group.
Or
II. One or more experiments meeting the Well-Established Treatment criteria IA or IB, III, and IV, but not V.
Or
III. A small, series of single-case design experiments (n>3) otherwise meeting the Well-established Treatment criteria.
7
Q
Traumatic brain injury
A
a traumatically induced physiological disruption of brain function and/or structure resulting from the application of a biomedical force to the head, rapid acceleration/deceleration, or blast related forces. (Kay et al. 1993)
8
Q
Focal lesions
A
occur precisely at a specific point
Result from cerebrovascular events such as: -hemorrhage
- neoplasms
- tumors
- brain abscesses
- focal trauma
- Effect of a focal lesion is directly related to the size, the location, and the depth
- Sudden onset lesion vs. tumor (gradual progression)
- Sudden onset lesions are more serious than tumors of the same size. There is more time to react to a tumor because the progression can be seen.
- Tumors typically create noticeable clinical effect
9
Q
Multifocal lesions
A
o Multiple distributed occurrences of any of the pathologies described in focal lesions, multiple tumors, hemorrhages, focal trauma, or abscesses
Severe CVAs and TBI
• More likely to be severe when there are multiple lesions
Bilateral lesions vs. unilateral lesions
• Bilateral lesions lead to more functional impairments
Simultaneous lesions vs. staged lesions
• Simultaneous lesions more likely to be severe than staged lesions
o Stages lesions happen one instance at a time (e.g. several falls over the course of a year or two)
10
Q
Diffuse brain injury
A
o Occur due to wide damage of brain tissue
o Examples:
• Injuries due to significant acceleration/deceleration forces
• Hypoxic-ischemic injuries where there is lack of oxygen to the brain
• Metabolic disorders
• Infectious disorders
• Inflammatory disorders
o Effect of these injuries depend on the nature and density of the damage to brain structures
11
Q
Frontal lobe
A
Planning, organizing, problems solving, memory, impulse control, decision making, selective attention, controlling behavior and emotion.
Injury to the frontal lobe may effect
- emotions
- impulse control
- language
- memory
- social and sexual behavior.
The left frontal lobe plays a large role in speech and language.
12
Q
Parietal lobe
A
Integrating sensory information from various parts of the body, contains primary sensory cortex, tells us which way is up, helps us keep from bumping into things when we walk.
Injury to the parietal lobe may effect:
-ability to locate and recognize parts of the body.
13
Q
Occipital lobe
A
Receive and process visual information, perception of size, shape and color.
Injury to the occipital lobe may cause: -distortion of the visual field
-distorted perceptions of size, color, and shape
14
Q
Cerebellum
A
Controls balance, movement, coordination. Allows us to stand upright, keep our balance and move around.
Damage may effect
- movement
- muscle tone
- gait
15
Q
Temporal Lobe
A
Responsible for recognizing and processing sound, understanding and producing speech, and various aspects of memory.
Damage may effect
- hearing
- language
- ability to recognize familiar people’s faces, -processing sensory information.
16
Q
Hippocampus
A
Important for memory creation and retention, helps with orientation in surroundings, facilitates our ability to navigate and find our way around the world.
Damage may effect
- new memory creation and retention
- mood
- confusion
- disorientation.
17
Q
Brainstem
A
Regulates basic involuntary functions such as breathing, heart rate, blood pressure, swallowing. Also plays a role in alertness and sensation.
Damage may effect
- breathing
- heart rate
- swallowing.
18
Q
Focal damage
A
Skull fractures and focal damage to the underlying brain tissue occur when the head is struck by or forceful contraction of a ridged surface (e.g. hit by something or fall and hit floor)
19
Q
Acceleration-deceleration forces
A
occur when the head suddenly stops but the brain continues to move in the original direction of motion and then re-bounce in the opposite direction
o These forces can tear some blood vessels of meninges and brain surface.
o The bleeding can result in bleeding into space surrounding the brain surface (extradural and subdural hematomas).
o The blood accumulations can cause damage or create pressure on the brain itself.
o Deep cerebral damage may occur due to torn arteries resulting in intracerebral hematomas or due to infarcts where tissues are deprived of blood perfusion for some time.
o Acceleration-deceleration forces may also cause stretching, deformation, and shearing effects on the neurons.
o Long fiber tracts coursing throughout the brain are vulnerable to acceleration-deceleration injuries.
20
Q
Cortical contusions
A
o They happen because of focal areas of bleeding and swelling
o They are very common in motor-vehicle accidents and falls
o Rubbing of the tissues together so there is a lot of tissue damage
21
Q
Coup and contre-coup injuries (actual damage caused by acceleration/deceleration, fall forward and then fall backwards)
A
o Injuries in which the brain is thrust forward on impact and then rebounds to the opposite direction causing damage to opposite sides of the brain
o Very common in motor-vehicle accidents
o Front part (hits front of head) is coupe, then contre-coup when it bounces and damages the opposite side of the brain
22
Q
Diffuse axonal injury (DAI)
A
• During rapid and powerful acceleration/deceleration forces the axons of the nerves cells may be damaged due to the widespread shearing and stretching action of the nerve tissues
o A significant destruction or damage of neuron involves the entire neuron including the cell body.
o It is also possible that neighboring neurons which receive inputs from the damaged neuron may also die.
o Large portions of cerebral hemispheres and brainstem may be damaged depending on the amount and location of DAI.
o DAI follows a gradient, there is a sequence in which the injuries happen. Least injury in the peripheral areas and most damage to the central and midbrain areas
o In addition to axonal damage, DAI may also lead to destructive processes including axonal transport and axonal swelling which may further result in separation of proximal and distal ends of axons. Affects communication between the neurons.
o The extent of DAI is directly related to the overall severity of the TBI and the functional outcomes (things they want to do for their basic needs and wants).
o Some commonly affected areas: the medial frontal lobe, corpus callosum, and superior cerebellar peduncles.
23
Q
Coma
A
Period of unconsciousness or unawareness following brain damage
Depth of coma is an important early indicator of severity.
• Classification of level of coma during the first 24 hours after the injury and the duration of post-traumatic amnesia (PTA) help define whether it is mild, moderate, or severe
24
Q
Tests to assess coma:
A
Glasgow Coma Scale (GCS)
• P. 34 Table 2.3: Classification of Severity of TBI
-has scores ranging from 3-15. Scores of 8 or less indicate severe injury.
Galveston Orientation and Amnesia Test: used to assess different levels of PTA
-used to assess different levels of post traumatic amnesia. Assesses major levels.
25
Post-traumatic Amnesia (PTA)-
PTA includes the period of coma and extends until the patients memory of ongoing events become reliable, consistent and accurate
Duration of PTA correlates with residual physical and cognitive impairments
Classification of level of coma during the first 24 hours after the injury and the duration of post-traumatic amnesia (PTA) help define whether it is mild, moderate, or severe
26
Patterns of Recovery (brief 1-2 sentence descriptions)
Initial Stage
First 4 weeks since the time of injury
• Unconsciousness and sleep/wake cycles and opening eyes
• May or may not have purposeful behavioral responses or understanding of what is going on around them
• If this stage continues for more than a year it is then called a vegetative state, and that can continue for weeks or years. Vegetative state: arousals but are not alert or aware.
First signs of recovery
• Tracking of visual stimuli or orientation to auditory stimuli
• May respond to automatic or reflexive responses (e.g. feed and opens mouth or wipe face closes eyes)
• Gradually come to have greater volitional control
Other features
• May also begin to respond to some commands
• Some restlessness and agitation
27
Patterns of Recovery (brief 1-2 sentence descriptions)
Next Phase
o Orientation and continuous memory may be restored.
o Deficits in memory and learning may persist.
o Length of this phase varies with severity of the injury.
o This stage involves emphasis on training and resumption/stabilization of self-care activities, and on ambulatory and other motor activities (rehabilitation)
```
o Cognitive deficits may still persist and efforts are made to:
• Stabilize orientation
• Facilitate effective communication
• Improve attention
• Use compensatory strategies
```
o Many individuals with TBI have no or limited awareness of the extent or implications of their deficits or functional impairments. Educate them and the family members.
28
Patterns of Recovery (brief 1-2 sentence descriptions)
Later Stages
o Following discharge from inpatient rehabilitation, majority of individuals with TBI return home.
o Based on severity of injury and degree of residual functional impairment, most individuals are able to redevelop some level of independence in self-care.
o Residual problems are seen in a wide range of cognitive abilities such as attention, memory, organization, and carrying out goal-directed behaviors.
29
Cerebral hemorrhage: definition
bursting of a blood vessel and release of blood into the brain
30
Cerebral infarction: definition
| i. Thrombosis vs. Ischaemia
A type of ischemic stroke resulting from a blockage in the blood vessels supplying blood to the brain
o Thrombosis
• Blockage of a blood vessel by a blood clot
o Ischemia
• An atherosclerotic tissue where a tissue is deprived of blood because of a blockage
• Mortality is typically related to size of infarct. Big infarct the person may die
• Cognitive and behavior abnormalities may be seen even with smaller infarcts
• Causes of infarcts
o Complete or partial blockage of an artery due to arteriosclerosis
o Artery blockage due to an embolus
o Specific degeneration of small blood vessels resulting in lacunar infarcts
31
CVA involving middle cerebral artery: areas involved, symptoms
• Supplies to lateral surfaces of frontal, temporal, and parietal lobes
o It is most commonly involved artery.
o Origin of MCA and innervated areas
o Most common physical effects of stroke
• Deficits in ambulation
• Upper extremity paralysis
• Tactile sensory impairment in contralateral limb
• Visual effects involving the contralateral visual field
o Common cognitive impairments for left MCA
• Aphasia
• Oral and limb apraxia
• Verbal learning impairments
o Common cognitive impairments for right MCA
• Visual spatial impairments
• Non-verbal learning impairments
• Impair awareness of self-deficits
• Deficits in pragmatic aspects of communication
• Impaired attention
32
CVA involving posterior cerebral artery: areas involved, symptoms
o Relatively rare in occurrence compared to MCA lesions.
o Areas innervated by PCA include occipital lobes, medial and inferior parts of the temporal lobes, and the thalamus
```
o Bilateral thalamic strokes have devastating effects
• Effects can include:
• Severe deficits in attention and memory
• Confabulations
• Lack of spontaneity
• Apathy
• Flat affect
• Trouble with eye movements
```
o In some cases thalamic pain syndrome may occur: there is initial contralateral feeling of numbness or tingling with compromised tactile sensation (not sure exactly where the pain is)
33
CVA involving anterior communicating artery: areas involved, symptoms
o Anterior communicating artery crosses the midline right at the base of the brain and it forms the anterior portion of the Circle of Willis.
o It communicates with anterior cerebral arteries.
o Common site for aneurysms which involve balloon-like structures developed from weak or abnormal vessel walls.
o Common risk factors for aneurysms are -age
- cerebrovascular disease
- increased blood pressure
o Symptoms
• Confabulations
• Disinhibition
• Amnesia (Severe anterograde amnesia: no memory after the injury )
• Severe retrograde amnesia: no memory before the injury
• Deficits in executive functions
• Limited awareness
34
Hypoxic-hypotensive brain injury: definition, areas involved
| i. Mild injuries vs. severe injuries
o Cerebral hypoxia (AKA cerebral anoxia): lack of oxygen in brain areas
o Cerebral hypotension: Refers to inadequate cerebral perfusion due to insufficient blood pressure or flow to maintain oxygenation
o Cerebral hypoxia and hypotension may occur during abnormal cardiac or respiratory functions.
o Mild hypoxic-hypotensive injuries: They will have rapid recovery in most cases
o Severe hypoxic-hypotensive injuries: Poor prognosis in terms of functioning
o Areas vulnerable to hypoxic-hypotensive injuries include occipo-parietal cortex and cerebellum
35
Coma durations and effects on prognosis
o Anoxia is often followed by period of coma. Prognosis is better with coma durations of less than 24-48 hours. A coma lasting longer than 48 hours may lead to higher mortality incidence.
o Period of coma is followed by gradual recovery of orientation along with a persistent and often severe memory impairment.
o Memory deficits may be seen over a much longer period of time compared to other brain injury events.
36
Encephalitis: definition, areas affected, symptoms
Infection of the brain itself
o Meningoencephalitis: Infection affecting the brain and the meninges
o Herpes simplex virus is one of the most common infectious agents. It can affect individuals of all ages.
o Epidemic and seasonal viruses are often transmitted from infected vertebrate carriers to humans by mosquitoes.
o Effects of most viral infections are difficult to predict:
• Widespread destruction of neurons in many locations throughout the brain/
• Usually there is extensive damage to the inferior and medial temporal lobes, to the basal and orbital portions of the frontal lobe, and to insular cortex.
• Acute phase of viral encephalitis is characterized by fever and meningeal involvement.
• Depending on nature, severity, and course of the infection, the individual may present range of symptoms or more specific neurological signs
• A week or two after onset, patients who survive the infection begin to regain consciousness after which specific neurological impairments may become evident.
• It is also possible to see global cognitive, motor, and behavioral problems.
• Lesions affecting medial temporal lobe can cause anterograde episodic amnesia and can also cause problems with learning new information
• Lesions affecting anterior temporal association areas and insula can cause retrograde amnesia and semantic memory loss (won’t understand the meaning of words)
37
Meningitis:
infection of the meninges of the brain
38
Cerebral Tumors
o Brain tumors are abnormal growths of tissue found inside the skull.
o Tumors may be classified as benign (or noncancerous) or malignant (or cancerous).
• Benign tumors: look very similar to normal cells, they grow relatively slowly, and they are confined to one location (won’t spread)
• Malignant tumors: have a different kind of cells, grow quickly, and can spread to other locations
```
o Symptoms
• Headaches
• Seizures
• Nausea
• Vision problems
• Motor problems
• Balance problems
• Hearing problems
• Or a combination of behavioral and cognitive symptoms
```
o Commonly used treatments
• Surgery
• Radiation
• Chemotherapy
o Doctors may recommend additional treatments including radiation and/or chemotherapy for malignant tumors.
39
Angiogram
| 2-4 sentence descriptions
o Description: Primarily used to detect vessel abnormalities including occlusion, malformation, or aneurysms.
o Can also be used to determine position of vessels in relation to other intracranial structures.
o A contrast medium (dye) is injected into the major blood vessels and a series of x-rays are conducted following each injection.
o Can help in identifying occlusions, abnormalities, swellings within the vessels, as well as displacement of the vessels or ventricles indicative of tumors.
o Outdated in some cases today because of CT scans and fMRI
40
```
Computed tomography (CT)
(2-4 sentence descriptions)
```
o One of the revolutionary diagnostic tools, which is noninvasive, fast, safe, and painless.
o Principle: the body tissues absorb x-rays differently based on their electron density (bones have different density than the muscles)
o Preferred method for diagnosing congenital brain abnormalities, abnormal calcifications, demyelinating diseases, brain edema, tumors hemorrhages, and CVAs
o Critical tool for individuals with TBI involving skull fractures, seizures, focal neurological deficit, and a Glasgow coma scale score (GCS) of less than 15 for 24 hours or more (range 3-15).
o A contrast media may be used to improve the spatial and density resolution of the images
o Allows direct visualization of intracranial soft tissues, bone, ventricles, cisterns and subarachnoid spaces, sinuses and vessels.
o Useful for imaging of major blood vessels
41
Magnetic Resonance Imaging (MRI)
| 2-4 sentence descriptions
o It involves computer processing of radiofrequency-induced excitations of protons aligned in a strong magnetic field.
o 3-D images of brain and surrounding skull can be created.
o Provides more in-depth imaging of anatomical structures than CT.
o Useful to identify:
• Small lesions within the brainstem and the sub-cortex.
• Intracranial tumors
• CVAs
• Multi-infarct disease
• Multiple sclerosis
• Brain degeneration and atrophy related to degenerative diseases (Alzheimer’s)
o Can identify small lesions within the brainstem and subcortical areas.
o Allows study of blood flow within medium-sized and larger arteries and veins without any contrasting agents.
o Limitations: no Pacemakers, no electronic devices, must be very still and patient (longer imaging time), incompatible with life-support systems, can be noisy and confining, exposure to magnetic field, very expensive (may not be available in some medical settings).
42
Functional Magnetic Resonance Imaging (fMRI)
| 2-4 sentence descriptions
o Some fMRI applications include magnetic resonance spectrography, diffusion-weighted MRI, and magnetic resonance angiography.
o Principle: the blood flow within the body varies with the level of metabolism and functional activity in those tissues. The areas that are really active need more blood supply and oxygen and that will show up on the fMRI. Higher activity is linked to greater oxygen supply.
o Brain functions are studied by monitoring the cerebral metabolism and blood flow.
o It involves much less risk than PET and SPECT and can be used repeatedly. Can be repeated safely.
o More functional because patient can do tasks while brain is examined (look at a picture)
43
Positron Emission Tomography(PET)
| 2-4 sentence descriptions
o Involve imaging of cerebral blood flow, brain metabolism, and other chemical processes of brain during tasks.
o These techniques are considered dynamic as they provide information while a participant is engaged in motor, sensory, cognitive, or behavioral tasks.
o PET utilizes positron emissions from radioactive isotopes of different elements.
o Patients inhale or are injected with a radioactivity-labeled form of glucose, and emissions from different compounds are measured. Radioactivity will be increased in active brain areas utilizing more glucose.
44
Infants and children:
• Neurons undergo massive changes in form and connections during normal development and aging.
• Sequence of development:
➢ 1 month (after birth): the nerve cells migrate to appropriate targets in the CNS. Once the neurons reach their destinations they develop axons and dendrites and form synapses.
➢ 8 months: the most intense dendritic growth happens.
➢ 1 year: the synaptic density activity reaches the maximum.
➢ Pruning: occurs with deletion of unwanted synapses. (Capability of babies to speak any language up to 8 months when synapses are pruned around 8 months to 1 year). Pruning can happen in terms of other development if that skill is not being used up to 8 months of age (hearing).
• Kennard principle: If someone gets a TBI early in life they will have a quicker recovery from the injury.
• In contrast to Kennard, Hebb (1949) postulated that brain injury results in more severe behavioral disruption than similar damage in later life.
• Although the “earlier is better” theory hold true for focal lesions, recovery from prenatal injuries, early diffuse injuries, or early injuries to particular brain regions may have serious implications and long-lasting effects (e.g. CP).
• Early injury can significantly affect the acquisition and development
• Although there is more potential for plasticity in younger children, critical lesions may result in permanent deficits.
45
Young adults:
* Better recovery levels than older individuals.
* Age has an effect on long-term adaptation to brain injuries
* According to Corkin et al. (1989), individuals with prior brain injuries show a greater decline in performance than individuals with no history of brain injury.
46
Old adults:
* Impact of an injury on an older individual may vary with age-related maintenance or decline of cognitive abilities.
* Age-related neuronal cell shrinkage in the frontal areas (most commonly happens in older individuals)
* With normal aging, the frontal lobes show greater volume reduction, neuronal loss, and reduced blood flow compared to the parietal, occipital, or temporal regions. As a result, cognitive processes supported by frontal lobes show earlier and greater decline than cognitive processes supported by other brain areas.
• From a rehab point of view, it can be easier to work with the older adults because they have a stable lifestyle, better coping skills, more support, and fewer life demands than young adults. All of these things can have positive impact on the rehab outcomes.
47
Brain reserve capacity:
hypothesis which states that there is a pool of available brain capacity that provides protection from clinical symptoms but is still vulnerable to depletion via intrinsic and extrinsic events.
48
Premorbid intelligence and educational level
| i. Lower vs. higher education
o Varied cognitive requirements associated with educational activities may contribute to greater connectivity of neural networks.
University education vs. high school education.
• Brains of deceased people with university education tend to have more cortical neurons and dendrites then people with high school education
Role of innate ability and exposure
• Role and involvement in various experiences contributes to brain physiology and functional capacities
Educated individuals are more likely to have better or more practiced premorbid learning abilities and potentially more motivation for participation in rehab, more family support, and more access to rehab services
49
Gender
Limited research on possible gender effects on recovery of function.
o Evidence for brain differences are present between males and females in terms of the shape and size leading to both interhemispheric and intrahemispheric (differences in brain function between males and females in terms of right and left hemispheres and within the hemispheres)
o Potential recovery mechanisms including dendritic branching and synaptic contacts appear to be influenced by fluctuations in gonadal hormones.
o According to Kimura (1983), aphasia is more frequently in males.
o Sex hormones and hormonal cycling play a really important role in an individual’s response to injury.
50
Cultural background
o Includes: language disturbances, differences in group identity, beliefs and values.
o The literature indicates that multicultural clients are likely to end treatment prematurely due to misunderstandings, frustration, role ambiguities, difference in priorities of treatment.
o There is a need to develop culturally relevant and appropriate treatment materials and activities.
51
Premorbid functioning
o Individuals with TBI tend to have a higher rate of drug and alcohol abuse prior to injury. In many cases, the substance use may contribute to brain injury.
o Factors predictive of poor vocational outcomes in TBI
• Unstable work history
• Alcohol use following injury
52
Injury-related Variables
| -Time since injury
o Early vs. later stages
• Rate of recovery is faster during the early stages of brain injury and usually decreases over time
• Spontaneous recovery: natural recovery within the first 6 months after the injury. Maximize that period with rehab.
o Most rapid recovery occurs during the first 6 months (spontaneous recovery) with slow but significant recovery occurring over the next 2 years.
o Some evidence suggests that underlying motor and cognitive skills including attention can improve with structured interventions even years following injury.
o For mild TBI injuries the recovery rates are faster with resolution of symptoms within 3-6 months in 70% of those injured and 85% asymptomatic by 12 months after injury.
o The differences in rates of recovery may occur as undamaged areas may get deprived of neuronal input from and to the damaged areas. As a result, the undamaged areas may have altered functioning and leading to a large area of functional lesion.
53
-Spontaneous recovery- definition, time range
Spontaneous recovery: natural recovery within the first 6 months after the injury. Maximize that period with rehab.
o Most rapid recovery occurs during the first 6 months (spontaneous recovery) with slow but significant recovery occurring over the next 2 years.
o The spontaneous recovery occurring during the first 6 months includes:
• The reconnection of undamaged areas with other areas
• Adjustments of functions to compensate for the lack of input from lesion areas.
54
Diaschisis:
refers to reduced activity in remote and undamaged areas that is functionally connected to a lesion area (could result in poorer outcomes and more problems).
55
Injury extent and severity
| i. Focal vs. diffuse
o Mild TBI vs. severe TBI injuries.
• Severe- slower recovery
• Mild- faster recovery
o According to Dikmen et al. (1995), there is a close relationship between the TBI severity and expected recovery curve. Recovery tends to occur rapidly for focal pathologies compared to diffuse injuries, although recovery may also relate to overall size of injury. Focal lesions may still have a significant and long-term impact based on areas of damage.
o Some types or degrees of brain damage are irreversible.
o With focal lesions, it is possible to restitution of functions. However, with severe injuries the recovery involves greater amount of compensation and behavioral adaptation.
o Diaschisis plays an important role in recovery; however, some types or degrees of brain damage are irreversible such that no synaptic reorganization would allow reconnection of affected brain areas.
56
Recovery rate
| i. Simple overlearned tasks vs. complex activities
Simple highly familiar tasks vs. complex tasks
• Highly familiar tasks typically occur faster than recovery of more complex or novel activities
• Writing your name vs. filling out a medical form
Complex activities tend to require multiple underlying and interconnected skills
• Require multiple skills and more conscious and flexible control
• The frontal lobe is important for a lot of complex functions
• It can be concluded: The frontal lobe functions including effortful attention, flexible planning, organization, and problem solving are often the most persistent impairments following diffuse brain injury.
Differential recovery may also relate to the extent of lesion. Some areas may have a higher chance of recovery sooner than other areas
• Broca’s and Wernicke’s demonstrate gradual and usually incomplete recovery
57
Psychological Factors
Depression and anxiety are very common.
Conditions posing serious challenges to progress.
o Anger
o Resistance
o Refusals to participate
* During early stages of rehabilitation, individuals with severe TBI may benefit from behavior-based interventions. As self-awareness and self-regulation of client improves, therapists may work toward creating a more effective context for rehabilitation.
* Management of depression and anxiety through pharmacotherapy and supportive psychotherapy may be helpful to rehabilitation efforts.
58
Neuroplasticity:
the brain’s capacity to change and alter its structure and function. It is very critical to rehabilitation following a brain injury.
59
Synaptic plasticity
o Learning and experience cause physical changes in the adult brain.
o All adults have an ongoing neural connectivity.
o A neuron that has lost input from a damaged neuron can develop new dendrites or dendritic spines to receive information from another neuron in the same circuit, or even from another, more distant circuits. This synaptic plasticity is important for both normal learning as well as recovery processes.
o “Cells that fire together wire together”
• The synaptic connections become stronger when pre- and post synaptic neurons are activated at the same time
60
Recommendations during early stages of recovery:
o Make sure the patient is rested.
o Make informed use of pharmacological interventions.
o Make use of natural windows of increased arousal and responsiveness.
o Monitor and control the attentional load of your clients. Watch out for overstimulation.
o Many behaviors may be elicited by an effective cue.
o Distributed practice over short periods is more effective than massed practice conducted in a single session.
61
Recommendations during later stages of recovery:
o Use shaping and behavioral chaining strategies.
o Emphasis on modification of antecedents and consequences in behaviorally oriented training.
o Teaching personalized attention and memory strategies.
o Work towards speed and efficiency of processing and responding while minimizing error rates.
62
Impairment: definition
loss or disorder of cognitive, emotional, or physiological function
63
Activity/functional limitations: definition
resulting from impairments and refer to effects or impairments on a person’s daily like functioning
64
Participation: definition
the nature and extent of a person’s involvement in life situations in relation to impairments, activity limitations, health conditions, and contextual factors.
o Represented by both the person’s degree of participation and society’s response
o Seven domains of participation that we might assess
1. Personal maintenance (hygiene)
2. Mobility
3. Exchange of information
4. Social relationships
5. Areas of education, work, leisure, and spirituality
6. Economic life
7. Civic and community life
65
Validity- definition
Accuracy, how accurate the test is, whether it is giving you the right information
66
Reliability- definition
Consistency, Same consistent result over and over again
67
Generalizability- definition
the extension of research findings and conclusions from a study conducted on a sample population to the population at large.
68
Noncognitive factors influencing cognitive assessments:
```
Variety of nonspecific factors
➢ Hunger
➢ Fatigue
➢ Headache
➢ Other sources of pain
```
```
Some additional physical factors
➢ Visual field deficits
➢ Hemiparesis
➢ Poor visual acuity
➢ Hearing problems
```
```
Emotional problems
➢ Anxiety
➢ Worry
➢ Boredom
➢ Preoccupation with other thoughts and concerns
```
69
Functional Approaches
a. Structured observations
b. Rating Scales
Functionally oriented psychometric measures (ecologically valid measures)
• These tests have been developed by testing people at home or in more natural settings (more information is acquired than in a clinic environment)
Structured observations and functional rating scales
• Survey, rating form, have them talk with family member and observe their interactions
Direct observations can be extremely useful in functional setting.
• Observe them while they are talking or explaining their problem to you
Rating scale can be particularly effective to examine differences in ability across different settings.
• How bad is your memory in a noisy environment?
• Compare performance across settings
Limitation
• May not have adequate psychometric properties
70
Orientation and arousal: Tests used
The Agitated Behavior Scale (Corringan, 1989; Corrigan & Bogner, 1994):
a. It is useful for assessing individual’s recovering from severe injuries demonstrating slow emergence of cognition
b. It is helpful in monitoring time-related patterns of agitation and restlessness
c. It is useful for documenting aggression when it is a product of agitation and confusion
d. It can be used to get different scores: a Disinhibition score, and aggression score, and a lability score (inappropriate laughter or crying).
71
General cognitive/intellectual abilities: Test used
The Wechsler Adult Intelligence Scale- III (WAIS III) is the most widely used measure of general intellectual ability.
➢ Represents a composite of performance on variety of skills:
o Retrieval of general information
o Vocabulary knowledge
o Abstract reasoning
o Both verbal and non-verbal problem solving or reasoning tasks
o Memory recall
o Tests involving psychomotor speed
```
WAIS-III gives four factor scores
o Verbal comprehension score
o Perceptual organization score
o Working memory score
o Processing speed score
```
Verbal vs. nonverbal subtests
o Verbal subtests tend to be less sensitive to acquired brain damage
72
Attention:
basic cognitive skill that is required to do any task or activity
73
Immediate attention
How much information that can be held at one time
Measures of forward and backward digit span are administered.
• Forward digit span (count from 1-50)
• Immediate memory
• Sustained attention for a brief period
• Backward digit span (50-1)
• Storage and manipulation of numerical information
• Helps us to find information about divided attention and working memory
• Nonverbal measures of spatial span are also sometimes used.
74
Focused attention
Attending to a stimulus while rejecting irrelevant information
A person may need to use selective/focued attention when attending a large gathering or when out in a public area, such as a restaurant. In a room full of people, all carrying on multiple conversations, she will need to focus on the conversation or activity she is participating in, ignoring the other conversations going on around her.
Selective/focused attention may be used when a person is studying in a room that is noisy as well.
Cancellation tasks
• Mark out all 0s or 1s
Trail Making Test (Part A and Part B) P. 103
A. Randomly distributed numbers
B. Sequential alternation between letters and numbers
75
Sustained attention
Prolonged attention during a task
When a person is able to sit and focus on a single task for a long period of time, she is using sustained attention.
Examples of sustained attention may include reading a book for hours or completing a task such as sweeping the floor.
Measured by auditory or visual continuous-performance tests. e.g. Computer-based tasks such as the Conners Continuous Performance test;
Digit Symbol Coding subtest of WAIS-III
76
Divided attention
Engaging in more than one task at the same time. Multitasking.
Someone may use divided attention when on the phone if she checks her mail at the same time.
Unlike alternating attention, a person using divided attention does not change from one task to another completely different task. Instead, she attempts to perform them at the same time.
Brief Test of Attention
-requires the individual to listen to a string of numbers and letters and to count the number of letters in the string.
Another example is Letter-Numbering Sequencing Subtest of the WAIS-III where an individual has to listen to a set of mixed letters and numbers and recite back first the numbers and then letters in order.
77
Alternating Attention
When a person uses alternating attention, her brain is able to switch from one task to another.
Usually, the tasks require the use of different areas of the brain.
A common example of using alternating attention is reading and then making a recipe. Other examples of this kind of attention include singing and dancing or driving a vehicle.
When driving, a person's attention shifts from accelerating, checking the road for obstacles, and signaling to make turns, among other tasks.
78
Declarative Memory
• Birthday, independence day, birthday, birth place
79
Procedural Memory
• Memory for performing specific skills (ride a bike, drive, cook)
80
Prospective Memory
• Memory for upcoming or future events (friend’s wedding, appointment, project
81
Immediate Memory (Working memory)
The information just presented
82
Short-term Memory
• Information that has been encoded and stored
83
Long-term Memory
• The memory which is forwarded from short-term and is used for future retrieval
84
Speed of information processing:
Measured by simple and complex reaction time tasks.
The Paced Auditory Serial Addition Task (PASAT) requires the individual to carry out sequential additions over four trials at increasing speeds. Advantage: really sensitive to brain injuries and it has a wide range of variability
Limitation: it involves a lot of numbers so may not be useful for individuals with limited mathematical skills
Test of Everyday Attention: More ecologically valid measure
Attention Rating Scale: A self-reported measure in which an individual lists the attentional problems in a hierarchical view. (Examples on p. 156)
85
Standardized tests measure following three aspects of memory:
* Encoding
* Retention of information over time
* Recognition
86
Encoding
• Acquiring new information
87
Retention
• Retention of information over time
| Assessed by delayed recall
88
Recognition
• Assessed by yes/no questions to previously presented items
89
What does poor recall indicate?
Poor recall after initial word list presentation may be indicative of deficits in ...
• Attention
• Processing of information
• Working memory
90
What does poor recall and recognition indicate?
Poor recall and recognition are indicative of ...
• Poor initial learning
• Limited ability to retain information in memory once it’s processed and coded
91
Memory problems in mild vs. moderate-to-severe TBI
Mild TBI:
• Low recall initially with more accurate performance after repetition
• No deficits in delayed recall
o Means that they have intact memory and storage, problems more to attention deficits
```
Moderate to severe TBI:
• Slow rate of learning
• Impaired delayed recall
• Cued recall
• Recognition memory
o Problems may be likely due to deficits in memory and attention
```
92
Memory Tests
o California Verbal Learning Test: Consists of two word lists containing shopping items from four different semantic categories. * Read about in text
o Recognition Memory Test: here an individual is shown words, faces, and designs and then asked to indicate the image that was presented (SCAN)
o Wechsler Memory Scale- III (WMS-III; Wechsler, 1997b): Provides information about immediate and delayed recall, recognition of short paragraphs, a word list, unfamiliar faces, and abstract design. It also includes measures of immediate and working memory (digit span, spatial span, letter-number sequencing).
o Other tests include The Rivermead Behavioural Memory Test (RBMT; Wilson, Cockburn, & Baddeley, 1985) and
Prospective Memory Screening Test (PROMS; Sohlberg, Mateer, & Geyer, 1985).
93
Executive functions: definition
Executive function is a set of mental processes that helps connect past experience with present action. People use it to perform activities such as planning, organizing, strategizing, paying attention to and remembering details, and managing time and space.
Attention, orientation, memory, reasoning, problem solving
94
Executive functions: tests used
Commonly used tests:
- Wisconsin Card Sorting Test (assesses set shirfting)
- Stroop Color and Word Test (assess set shifting and inhibition of prepotent (strong urge) responses)
- Tower test: London, Hanoi, Controlled Oral Word Association Test (p. 111-115)
Executive functions are difficult to quantify so often a set of different tests are utilized to assess the related domains.
95
General measures of disability and outcome: names of 2-3 tests
Functional Independence Measure (FIM; Grander & Hamilton, 1987): One of the most widely used test consisting of an 18-item ordinal scale.
• Assesses the level of assistance that people need to perform different activities of daily living
• Uses a 7-level scoring system with scores ranging from 126 (normal) to 18 (totally dependent).
• Correlates moderately well with Glasgow Outcome Scale.
• Sometimes may be used in conjunction with the Functional Assessment Measure (FAM; Hall, Hamilton, Gordon, & Zasler, 1993). Both these measures when used together are still considered as gross measures.
The Disability Rating Scale for Severe Head Trauma (Rappaport, Hall, Hopkins, Belieza, & Cope, 1982): More sensitive than GOS and has fewer ceiling effects than the FIM and FAM.
More sensitive tests:
The Katz Adjustment Scale (Katz & Lyerly, 1963) assesses personality changes following brain injury and their psychosocial effects.
• 127 items
• Both patient and caregiver rating forms
• Detects changes following rehab
• Correlates well with other measures
The Neurobehavioral Rating Scale (Levin et al., 1987) assesses wide range of cognitive, behavioral, and psychiatric symptoms.
• Also sensitive to personality changes and changes over time
The Mayo-Portland Adapatability Inventory (previously called Portland Adaptability Inventory; Lezak, 1987) assesses temperament and emotionality (anxiety, depression, agitation), activities and social behavior (social contacts, leisure activities), and physical capabilities (use of hands, dysarthria).
The Sickness Impact Profile (Bergner et al., 1981; Temkin et al., 1988) assesses impact of illness or injury on multiple life domains from the injured person’s perspective.
• Limitations
o Too lengthy
o Too much emphasis on physical limitations
The Supervision Rating Scale (Boake & High, 1996) identifies 13 levels of supervision, reflecting all forms of activity that require the caregiver to be in the physical vicinity to ensure patient safety. Completed by informants who have detailed information about level of supervision needed by the patient.
The Craig Handicap Assessment and Reporting Technique (Whiteneck et al., 1992) determines the levels of handicap with respect to a broad range of independence and social integration, including an individual’s ability to fulfill roles in different capacities.
96
Common causes of TBI in children
```
Common causes
o Falls
o Vehicle accidents
o Sports injuries
o Child abuse, (shaken baby syndrome)
```
Areas affected
o Damage in frontal and temporal lobes (similar to adults)
97
Early vs. late onset of TBI
• Pediatric TBI is also associated with DAI (Diffuse axonal injury, neurons are pulled and damaged) where widespread injury leads to stretching and tearing of axons.
• Despite similar mechanisms between children and adults, children are less likely to sustain loss of consciousness given the same level of injury as an adult.
• Children tend to have more rapid recovery of basic motor, sensory, and language functions than adults. They might look better sooner after injury despite underlying damage. (more rapid response compared to adults)
• Mixed evidence about effects of TBI in children:
o Kennard Principle suggests more plasticity and flexibility in children and thus less susceptibility to brain damage.
o Other studies indicate significant deficits in children with greater deficits in younger age groups (Brink et al., 1970’ Taylor & Alden, 1997).
o It is possible that the capacity for functional compensation may vary across brain regions and cognitive domains. Damage to multiple systems may interact to produce greater disability.
o Infants and young children may appear to recover relatively well from early focal injuries due to considerable plasticity in surrounding tissues and homologous regions of the unaffected hemisphere. As brain regions are not assigned for specific functions it is possible that the reorganization occurs more rapidly in children.
o The causes of TBI in children may also contribute to the prognosis. Child abuse accounts for most severe injuries in children less than 1 year of age and accounts for 10% of all injuries for children less than 5 years of age.
o Significant deficit associated with early brain injury is also related to rapid development of many important skills during childhood. The skills are more vulnerable to brain injury at different ages because rates of skill acquisition vary with age.
98
Growing into deficit: What does it mean?
o Definition: refers to the interaction between development and brain injury where a child with substantial recovery from TBI or other brain injury may begin to demonstrate specific cognitive and/or behavioral deficits as he or she grows older. (Can happen even years after the injury when there are more demands and challenges on the brain as the child develops)
o Role of frontal lobes- The frontal lobes are the last region to develop. A child with brain injury may not adequately develop many of the executive functions in early adolescence when they normally emerge and stabilize. The combination of increased complexity in the adolescent’s academic and social environment and delayed or impaired development or executive functions may resolve in emergence of deficit in an adolescent who might have demonstrated a full recovery during childhood.
o Emergence of deficit during adolescence in spite of apparent recovery during childhood
99
How to retrain cognitive abilities?
a. Direct retraining approach
b. Attention-related approaches
o Direct retraining approach involves tasks which provide practice in an underlying cognitive ability (including attention, memory).
o Attention: Attention Process Training (APT), Pragmatics: Peer group training, Improving Pragmatic Skills in Persons with Head Injury.
100
Clinical Model of Attention
| • Focused attention
includes ability to respond discretely to specific visual, auditory, or tactile stimuli. This type of attention is often affected in early stages of emergence from coma. A patient may initially be responsive only to internal stimuli.
101
Clinical Model of Attention
| • Sustained attention
it is the ability to maintain a consistent behavioral response during continuous and repetitive activity.
o Vigilance: Focus on a task for a considerable amount of time.
o Mental control/ working memory: tasks that involve manipulation and storage of information.
102
Clinical Model of Attention
| • Selective attention
the level of attention needed to maintain a behavior in the presence of distracting or competing stimuli. Includes concentration on one stimulus.
103
Clinical Model of Attention
| • Alternating attention (AKA set shifting):
the capacity to shift attentional focus and move between tasks with different cognitive requirements
104
Clinical Model of Attention
| • Divided attention:
the ability to respond simultaneously to multiple tasks (doing 2 things at the same time)
105
Factors affecting Attention
| a. Relationship between arousal and performance
Arousal level:
• ↑d arousal = ↑d performance
• ↓d arousal = ↓d performance
106
Assessment of Attention
| • Types of assessment tools
```
Standardized Testing (SCATB, Detroit, APT)
• Advantage: it is effective in assessing the level of impairment and information relative to the nature of the problem
• Limitation: difficulty in predicting how well an individual is going to function in real-world activities
```
Digit span, Stroop test, Trail Making, Letter Cancellation, Paced Auditory Serial Addition Test (PASAT)
Rating Scales/ Questionnaires:
• Goal of Rating Scales: provide an indication of individuals perceptions or functioning
• Examples: Attention Questionnaire, Dysexecutive Questionnaire, Brock Adaptive Functioning Questionnaire
Structured Interviews/ Observations
• Characteristics:
• They provide information, which may not be revealed in questionnaire data.
• It is helpful to interview both clients and their family members about their perspectives on strengths and weaknesses
• These are functionally relevant tools
• They can be time consuming and subjective
107
Attention Process Training:
Use of cognitive exercises to remediate and improve attentional systems.
108
Attention
Self-management strategies: orienting, pacing, notes
o Self-management strategies: These include self-instructional routines that facilitate attention on a task.
* Orienting: useful for clients with deficits in sustained attention. The goal is to encourage clients to monitor their activities consciously and thereby avoid attentional lapses.
* These activities can be designed for specific tasks or environments
* As client to monitor time, more oriented to time to complete task
* Pacing: goal is to 1. Develop realistic expectations for productivity and to 2. Facilitate client’s to keep going for a longer period of time
* Sometimes the time of the day can be a helpful aspect of pacing (morning person)
* Notes: clients can benefit by maintaining a written logs with key questions or ideas that come to mind but can be addressed later
* This allows them to continue with a particular task rather than abruptly discontinue a task
* Strategy success tips: it is important to understand how, when, and where the attention problem is troublesome for a client.
* Clients should be involved as much as possible in strategy selection and development
109
Environmental Supports
The client’s environment should be carefully assessed. Environmental supports can be grouped into two types:
* Task Management Strategies: this includes generation of strategies for effective task performance
* The client can be reminded that they may choose the more helpful environment whenever possible
• Environmental modifications: include the modification aimed at client’s physical space to reduce the load on their attention, memory, and organizational abilities.
110
Stages of Memory
| Attention (definition)
o Goes hand in hand with memory, includes arousal and alertness at the basic level.
o At higher levels it includes different components, including:
• Maintaining concentration over time (sustained attention)
• Resisting interference (selective attention),
• Being able to allocate attentional resources (alternating and divided attention)
111
Stages of Memory
| Encoding
o Considered to be an initial stage of memory, it involves putting the information in storage.
112
3 ways to encode information
Encoding may be performed in different ways.
1. Semantic features (meaning of a name)
2. Phonological or phonetic features (name starts with A)
3. Visual features
113
Ways to increase encoding
Ways to enhance encoding:
• Understanding of the item
• Semantic organization
• Relationship with that item
114
Consolidation- definition
refers to the fact that memory consists of neural networks
• Neural networks (circuits): a group of neurons held together
• Consolidation creates a permanent change in neural network
• Permanent change can include a neuronal movement (including dendritic branching and axonal sprouting).
• According to Hebb, consolidation takes 15-60 minutes. Memories become more permanent with rehearsal.
115
Neurological correlates
| Memory/encoding
* Memory is mostly a subcortical function.
* Controlled by structures deep within the brain
* Areas include
* Limbic system
* Temporal lobe
* Frontal lobe
* Left hippocampus (semantic features)
* Right hippocampus (visual features)
116
Stages of Memory
| Storage (definition)
fleeting memory, which is transformed into long-term memory. Also includes the storage of information once it has been encoded (anything that is not long-term is in storage)
o Failure of storage leads to forgetting.
117
Reverberating circuits: definition
| storage
continuous firing of neural areas lead to reverberating circuits
118
Long-term potentiation: definition
| storage
long-term strengthening of connection between nerve cells. With effort you make the neural connections stronger.
119
Neurological correlates
| Memory/storage
the areas which are involved in encoding are also important for storage
• Limbic system
• Temporal lobe *especially important for storage
• Frontal lobe
• Left hippocampus *especially important for storage
• Right hippocampus *especially important for storage
120
Stages of Memory
| Retrieval (definition)
searching from an existing memory and bringing it into consciousness. It includes monitoring the accuracy of information and the appropriateness of memories pulled from storage.
121
Good recall means
good encoding, good storage, and good retrieval
122
Good recognition means
suggests good encoding and good storage but poor retrieval (need choices)
123
Retroactive interference
interference in learning new information due to presentation of prior learning material
• Indicative of deficits in with encoding and inadequate working memory
124
Proactive interference
deficits in recall of old memories due to presentation of new information
• Indicative of deficits in limited capacity and extended encoding time (good to take breaks in between)
125
Neurological correlates
| retrieval
Frontal lobe (strategy formation, temporal order of information, self-monitoring, and initiating retrieval)
Limbic system (hippocampus, amygdala- emotional memories).
126
Working memory: definition
(AKA immediate attention): mental manipulation of information at any point in time. May last for 30 seconds without rehearsal. Information is very temporary and can be manipulated (add to or change).
127
Short-term memory: definition
(AKA short-term storage): can be stored from 30 seconds to 1 hour. The information is much more controlled and more permanent than working memory and can’t be distorted like working memory. Interruptions may have an impact on short-term memory.
128
Long-term memory: definition
(AKA long-term storage): permanent in nature and has an unlimited capacity. Information can be effectively stored with semantic features
*includes declarative and non-declarative
129
Declarative memory
(AKA explicit memory): forms and individual’s knowledge base (date of birth, parent’s names, high school, capital of Texas)
➢ Episodic memory: includes recall of personal experiences that are tagged in time and place, involves your personal experiences. May be effected following TBI and may also have trouble forming new memories.
➢ Semantic memory: a broader domain of cognition. It is the knowledge about the world (meaning of words, facts, ideas, classes of information). May be preserved during earlier stage of Alzheimer’s and may be effected towards the later stages
130
Non-declarative memory
(AKA implicit memory): the information that is more passively processed and about which we are not consciously aware of
➢ Procedural memory: skills, habits, or learning how to do things (riding a bike, make a sandwich, coffee)
➢ Priming: a way of entering information into the brain. Priming may be intact even in people with severe TBIs. People may do errorless learning as a part of priming.
131
Episodic memory
includes recall of personal experiences that are tagged in time and place, involves your personal experiences. May be effected following TBI and may also have trouble forming new memories.
132
Semantic memory
a broader domain of cognition. It is the knowledge about the world (meaning of words, facts, ideas, classes of information). May be preserved during earlier stage of Alzheimer’s and may be effected towards the later stages
133
Prospective memory
the memory for intentions, or memory to do something in the future. Has a time element to it (next appointment, paper due). It is co-related with attention
134
Perceptual salience
things which seem important to us are encoded, stored, and retrieved more efficiently
135
Rehearsal
repetition of information leads to better storage of information
136
Association
associating new information with prior information is helpful
137
Factors helping Memory
a. Perceptual salience
b. Rehearsal
c. Association
138
Retrograde amnesia
loss of information for events prior to an accident (doesn’t remember what happened before)
139
Anterograde amnesia
loss of information for events following an accident (doesn’t remember what happened after)
140
Post-traumatic amnesia
inability to store information during the initial recovery phase
141
Material-specific memory loss
specific memory deficits based on damage to specific areas of the brain
142
How to assess encoding?
present information to client and ask them to repeat it back (immediate recall).
• Immediate correct response indicates intact working memory.
• Delayed response indicates possible deficits in encoding
143
How to assess retention?
can be tested by delayed recall, given them information ask them 5 minutes later
144
How to assess recognition?
tested by yes/no questions (e.g. did I show you this picture)
145
Assessment of Memory
| Commonly used tests (names only)
o Auditory Verbal Learning Test (AVLT) (See handout from Lezak): helpful for testing learning memory and for assessing interference effects
o California Verbal Learning Test (CVLT) (See Lezak): gives you information about recognition of learned information
o Rivermead Behavioral Memory Test (RBMT): gives real-life scenarios, can be most appropriate for moderate to severely impaired TBI or dementia. May not be as sensitive to assess the mild deficits. Advantage: there are alternate test versions available for administration.
146
General Advice for Memory Treatment
o Give short directions.
o Monitor your rate of speech- slow controlled rate can be more effective.
o Use of emphatic stress on important words (including directions and overall treatment).
o Include overlearning and extra rehearsal whenever possible.
o Utilize part to whole learning strategy (breaking big tasks into individual components)
o Complete rehearsal training before other memory training
o Keep items functionally related.
147
Orientation
awareness of self in relation to one’s environment
```
• Includes awareness of
o Self
o Time (day, date, month, year)
o Place
o Situation (what kind)
```
o Relation to post-traumatic amnesia
• GOAT (Galveston Orientation and Amnesia Test)
148
External and internal organization
Therapy for mental organization problems
Train to extract structure / organization from experiences (not specific elements)
• Have patient recall organization then objects. Let patients choose strategy.
• Self Questioning
• Inhibit answering early … count to 3, answer to self, then respond out loud.
External organization
1. Consistency: Put things in consistent places
2. Accessibility: Keep most commonly used items close.
3. Grouping: Items used together should be kept together.
4. Separation: Keep things in logically distinct locations
5. Proximity: Things that are used together should be kept together
149
Executive functioning
i. Main components:
ii. Assessment tasks
* Definition: a broad set of abilities required for independent, appropriate and self-serving behaviors
* Executive functioning problems can exist with intact memory and intelligence
* Dependent on attention abilities
Volition
o Capacity for intentional behavior
o Determining needs / wants and actions associated with them
o Formulating goals and intentions
o No formal tests – evaluated in daily living / family report
➢ Do they have initiation/desire to participate?
Planning
o Identification and organization of steps necessary to carry out an intention
o Requires planning ahead and taking an abstract perspective (what if …)
o Mazes are good (but not functional) tests if you do not allow corrections.
```
Purposive Action
o A productive, self-serving activity
• Initiation
• Maintenance
• Switching
• Stopping
o Not difficult for overlearned, routine tasks
```
Effective Performance
o Monitor performance (requires divided attention)
o Self-correct
o Regulate intensity and tempo of behavior
150
Executive functioning
| ii. Assessment tasks
* Standardized assessments
* Route-finding task
* Work-like tasks
* Functional tasks (let patient succeed / fail safely)
151
Self-awareness: definition
the capacity for self-reflection. It interacts with other brain processes so that individuals can function adaptively in their environment.
```
• Components of self-awareness (Prigatano, 1991):
o Affective (mood, stress level)
o Cognitive (attention, reasoning)
```
Related to executive functioning
o Planning, self-monitoring, behavioral control, etc.
152
Unawareness: definition
* Definition: often results from focal or diffuse brain damage that has altered the functioning of systems necessary for intact awareness
* Problems in self-awareness: frontal lobe lesions may lead to deficits in self-control, self-monitoring, error correction, and insight
* Problems in modality-specific functioning: damage to posterior and subcortical connections of right hemisphere may lead to unawareness of motor, sensory, memory, and language skills (e.g. left neglect)
153
Damage to parietal lobe:
leads to unawareness of hemiplegic limb (left damage, right arm and leg)
154
Damage to supramarginal gyrus:
leads to unawareness for aphasiac errors (e.g. paraphasias)
155
Damage to posterior areas (right parietal region and its connections) and left hemisphere language centers:
altered knowledge or fact about self
156
Damage to prefrontal areas:
deficits in self-awareness with intact functioning of knowledge or facts
157
Focal lesions in left temporal lobe:
unawareness of disordered speech
158
Forms of unawareness: denial
a psychological process where individuals may demonstrate resistance and sometimes angry reactions when given feedback about their identity
159
Forms of unawareness: anosognosia
caused due to a neurological lesion where individuals appear to lack information about themselves. They may seem perplexed or even indifferent when given information about their deficits or how to manage these deficits
160
Assessment options of Awareness
• Client’s verbal description of functioning:
o Interviews
o Spontaneous observation while interacting with clinician or family member
o The researcher of clinician makes a judgment about an individual’s level of awareness
• Comparison of client’s reports with other persons’ reports:
o Examples: Patient Competency Rating Scale compares clients’ ratings of ability with those by family/ health professionals.
Self-Awareness of Deficits Interview includes both qualitative and quantitative data on self-awareness of deficits.
• Comparison of client’s predicted performance with their actual performance:
161
Management of unawareness : restorative and compensatory techniques
* Limited information on effectiveness of awareness intervention strategies. (Cicerone et al. 2005)
* No controlled treatment trials identified on anosognosia (Orfei et al. 2007)
* In a study by Robinson et al. 2004, use of antidepressants prevented worsening of anosognosia symptoms in 24 stroke patients over 12 weeks. (Orfei et al. 2007)
• Two approaches to cognitive rehabilitation (Fleming et al. 2006):
(A) Restorative or facilitatory techniques
(B) Compensatory techniques
• Use assistive devices
162
_______and TBI may coexist.
Aphasia
163
Assessment of Pragmatic Deficits
| • Assessment techniques include:
o Systematic observations: use checklists or indices listing different communication parameters
* Pragmatic Protocol: considered to be the gold standard for observational checklists. Includes 32 pragmatic behaviors that are divided into 4 categories. Items are judged as appropriate, inappropriate, or not observed.
* Communication Profiling System: includes a cyclic collection and analysis of naturalistic communication data
164
Assessment of Pragmatic Deficits
| Conversational analysis
natural conversations are tape recorded, transcribed, and then analyzed
165
Assessment of Pragmatic Deficits
| Use of elicitation tasks
```
Based on work by Turkstra, p. 317→
• Negotiate requests
• Hints
• Semi-structured discourse
• Sarcasm
```
166
Management of pragmatic skills: self-strategies, environmental support, external devices, psychosocial support
a. Individualized Communication Skills Training: specific deficits in communication skills are first identified, then exercises are then selected to target those functions.
b. Group Intervention: the pragmatic skills may be addressed in the form of exercises or activities and with the group setting you have more opportunities for modeling target skills and promote generalization.
c. Social Networks: involves family and friends – may be included in the group planning and review meetings. Can include gathering info about the client, recruiting team members, conducting initial team meeting, and conducting regular review meetings. Make it more personalized when you include family and friends
167
Common behavioral problems:
a) Disinhibition
b) Impulsivity
c) Socially inappropriate behavior
d) Lack of initiation
168
Sources of emotional distress
a) Fear or startled responses
b) Confusion
c) Lack of understand what is expected
d) Fatigue
169
Common behavioral deficits
a. Distractibility
b. Agitation
c. Poor decision making
170
Approaches for managing challenging behaviors
| a. Environmental management: Goal is to establish external, situational, and contextual influences on behavior.
o Reducing visual or auditory distraction and modulation of noise levels.
o Introduction of calm stimuli in the environment.
o Providing comfortable, well-fitting, and familiar clothing.
o Various forms of restrain may sometime be necessary for safety.
o Engaging in shorter but frequent therapeutic interactions is more effective than longer sessions.
171
Approaches for managing challenging behaviors
| b. Caregiver communication strategies
o Selectively ignoring inappropriate behaviors.
o Redirecting the person’s attention.
o Providing choices
o Reducing expectations
o Backing off and trying again
o Speaking quietly and maintaining a natural stance
o Identifying signs of the patient’s escalating distress
172
Approaches for managing challenging behaviors
| c. Behavioral Therapy
more structures intervention tools focusing on one or more behaviors at a time. The goal is to establish adequate behavioral responses in specific situations.
o Applied Behavior Analysis: it takes into account multiple contributions to behavioral difficulties. Here the clinician observes and records targeted aspect of behavior and then makes careful note of the situation, conditions, and the setting in which the behavior happened.
173
Approaches for managing challenging behaviors
d. Basic techniques for eliciting desired behaviors
i. Prompts
ii. Shaping
iii. Chaining
iv. Discrimination techniques
o Prompts: verbal requests or other signs or signals to perform something important.
o Shaping: includes reinforcing variations of forms of behaviors that increasingly resemble the target response.
o Chaining: teaching a complete sequence in a particular order (teaching a skill)
• Forward chaining: the trainer begins with and stabilizes the first behavior in the sequence and then cues the rest, eventually take away cueing.
```
• Backward chaining: teach the last step of a task first
o Other techniques:
• Discrimination training
• Reciprocal inhibition
• Response-cost techniques
• Supported behavior routines
```
174
Approaches for managing challenging behaviors
| • Positive Programming
a gradual educational process for behavioral change that is based on a functional analysis or the presenting problems and includes systematic instruction in more effective ways of behavior. It stresses on long-term skill building rather than specified behavior reduction.
o Applications:
• Can be used to teach new behaviors
• Can be used to teach alternative communication strategies as substitutes for unconventional behaviors
• Can be used to teach more appropriate alternative behaviors
• Can be used to assign meaning to individual’s behavior even when intentionality is not clear
175
Anxiety: definition, symptoms
typically manifested as nervousness, insecurity, or fear.
Other symptoms include tingling or loss of sensation in extremities, pseudo seizures, sweating, and skin reactions
176
Depression: related symptoms
diagnosed by a psychologist. May include other overlapping symptoms such as decreased energy, decreased initiation, irritability, difficulty with decision making, and sleep disturbances
177
Cognitive Behavioral Therapy (CBT): definition, brief description
Frequently used with brain-injured populations.
o Principle: the beliefs and nature of self-statements have a large influence on behavior
o Areas focused on CBT
• Identify and modify extreme or unrealistic beliefs (e.g.
there is no reason to live) and assist the individual to develop more adaptive coping beliefs and attitudes
o A key component of CBT is scheduling and tracking positive events and activities.
o Details on CBT (pp. 383-388).
178
Preexisting Personality Features: Grandiosity, Overachiever
* Premorbid factors should not be seen as cause of symptoms but rather factors that interact with response to and recovery from common symptoms of brain injury.
* Grandiosity and narcissistic features: individuals with pre-morbid pattern of grandiosity and narcissistic features may tend to see their problems as unique and unable to understand their own deficits. With such individuals it is important to assess which losses have injured the client’s underlying self-image. Then it is important to confront the unrealistic client’s expectations.
* Overachievers with perfectionistic tendencies: Individuals’ with a long-term pattern of high achievement needs, perfectionistic tendencies, and stress may have a complicated recovery from brain injury. These individuals have a tendency to experience stress a lot more than other individuals.
179
Perception-focused strategies vs. Emotion-focused strategies
* Perception-focused strategies: Use to control the meaning of stressful experiences. These include ignoring, relying on oneself, and persevering in the face of problems.
* Emotion-focused strategies: Attempts to control the emotional response to a stressor.
