Flashcards in Traumatic Brain Injury Deck (51)
Anterograde amnesia is the loss of the ability to create new memories, leading to a partial or complete inability to recall the recent past, even though long-term memories from before the event which caused the amnesia remain intact
Define: Retrograde amnesia
Retrograde amnesia is a form of amnesia where someone is unable to recall events that occurred before the development of the amnesia, even though they may be able to encode and memorize new things that occur after the onset.
Define: Working memory
Working Memory is the thinking skill that focuses on memory-in-action: the ability to remember and use relevant information while in the middle of an activity.
Define: Declarative (or explicit) memory (“knowing what”)
a type of long-term memory that refers to memories of facts/events that can be consciously recalled (or declared); it is called explicit memory because it consists of information that is explicitly stored & retrieved…(FYI, declarative memory can be further sub-divided into episodic memory and semantic memory)
a type of long-term memory that refers to the unconscious memory of skills and how to do things (e.g. the use of objects or movements of the body like tying a shoelace or riding a bike); memories acquired through repetition and practice and are composed of automatic sensorimotor behaviors that are deeply embedded (we are not aware of them); it is called implicit because previous experiences help in the performance of a task without explicit/conscious awareness of these previous experiences
Procedural (or implicit) memory (“knowing how”)
Use of memory and attention to identify oneself and to place oneself in time, place, & situation. Ongoing awareness of oneself, the current situation, the passage of time, and the environment
Patient’s orientation to person, place, date, awareness of situation, and post-morbid anterograde memory
the spontaneous production of false memories: either memories for events which never occurred, or memories of actual events which are displaced in space or time. These memories may be elaborate and detailed. Some may be obviously bizarre, as a memory of a ride in an alien spaceship; others are quite mundane, as a memory of having eggs for breakfast, so that only a close family member can confirm that the memory is in fact false.
What Rancho level is someone that is displaying confabulation?
4 or 5
What is important to remember if someone is displaying confabulation?
It is important to stress that confabulators are not lying: they are not deliberately trying to mislead. In fact, the patients are generally quite unaware that their memories are inaccurate, and they may argue strenuously that they have been telling the truth.
difficulty with math calculations (e.g. poor comprehension of math symbols, may struggle with memorizing and organizing numbers, have difficulty telling time, or have trouble with counting)
*A prototypical lesion caused by rapid deceleration (individual nerve cells throughout the brain are stretched and then break)
*Degree of injury may vary from primary axonotomy, with complete disruption of the nerve, to axonal dysfunction, wherein the structural integrity of the nerve remains but there is loss of ability to transmit normally along neuronal pathways (extensive injury throughout the breain)
*Clinical severity is measured by the depth and length of coma (i.e., the time from the onset of injury until the individual performs purposeful activity) and associated signs such as pupillary abnormalities
Diffuse axonal injury
*When a coma resolves and a person becomes either partially aware of self and the environment (pg. 886, Pedretti)
*Transition from persistent vegetative state to MCS is defined by definite behavioral evidence of awareness of self, environment, or both (pg. 887, Pedretti)
Minimally conscious state (MCS)
What state is someone in if they display these characteristics:
*Clearly discernible, reproducible behavior in one ore more of the following areas must be demonstrated (pg. 887, Pedretti):
-ability to follow commands
-gestural or verbal yes/no responses (regardless of accuracy)
-purposeful movements or affective responses that are appropriate responses to environmental stimuli (e.g. reaching for objects; touching or holding objects that accommodate their size and shape; engaging in eye pursuit movements or sustained fixation in direct response to stimuli; and smiling, crying, vocalizing, or gesturing in response to relevant stimuli)
Minimally conscious state (MCS)
What state is described?
*absence of awareness of self & the environment despite maximal external stimuli…wakefulness without awareness
What are some characteristics of a vegetative state?
*No awareness of self or the environment and an inability to interact with others
*No sustained, reproducible, or voluntary behavioral responses to sensory stimuli
*No language comprehension or expression
*Sleep-wake cycles of variable length
*Ability to regulate temperature, breathing, and circulation to permit survival with routine medical and nursing care
*Incontinence of bowel and bladder
*Variably preserved cranial-nerve and spinal reflexes
What state is described?
*refers to a condition of past and continuing disability with an uncertain future; the typical onset is within 1 month of traumatic or nontraumatic brain injury or after a month-long metabolic or degenerative condition
Persistent vegetative state (PVS)
What state is someone in if they display these characteristics?
*Autonomic function intact
*No purposive activity (medullary-mediated movement, but no sign of higher cognitive function)
Persistent vegetative state (PVS)
*If the client does not improve, then the term permanent vegetative state is appropriate, signifying that the change of regaining consciousness before death is exceedingly small
FYI: recovery of consciousness is rare in a PVS 12 months after a TBI or 3 months after a non-TBI
What two factors are the best predictors for long-term outcome following brain injury?
post-traumatic amnesia (PTA), which is probably the single best measurable predictor of functional outcome in the research literature” (PTA: the length of time from the injury to the moment when the individual regains ongoing memory of daily events (e.g. evidence suggests that longer PTA is associated with poorer long-term cognitive & motor abilities & a decreased ability to return to work/school...PTA lasting longer than 4 weeks is correlated with significant long-term disability))
“Monitoring an individual’s personal rate of recovery is probably more predictive of future recovery than any other factor”
“After a brain injury, an individual’s progression along this continuum of consciousness depends on age, prior health status, severity of injury, and the methods of medical, therapeutic, and environmental management” (pg. 885-886, Pedretti)
What six areas are typically addressed by OT for patients at Rancho I-III?
General aim of intervention for those at Rancho Levels I-III is to increase the individual’s level of response and overall awareness of self and environment:
Sensory stimulation (goal is to increase the client’s level of awareness by trying to increase arousal with controlled sensory input such as olfactory stimulation with variety of scents to elicit an eye opening or a head turn)
Bed positioning (goal is to prevent abnormal posture, prevent pressure sores, facilitate normal muscle tone, prevent loss of pelvis/trunk ROM)
Casting or splinting (goal is to maintain functional positions when at rest and reduce tone, as well as increase joint ROM)
Wheelchair positioning (goal is to allow patients to interact with immediate environment in upright, midline posture)
Emotional & behavioral management (goal is to track improvement in arousal/awareness & establish a way to communicate)
Always include: family and caregiver education (goal is to include family/caregiver in therapy interventions)
What are the primary strategies used in ICUs for managing intracranial pressure?
Treatments include mannitol, high-dose barbiturate therapy, ventriculostomy for drainage of cerebrospinal fluid, and craniectomy (i.e.removal of portions of the skull to allow for external brain swelling - bone flap)
Levels must stay below 20 mm Hg
Emergency treatment: craniotomy
Chronic treatment: placement of a shunt
How do OTs utilize procedural memory during inpatient treatment for brain injury?
ADL IS KEY!
-access procedural memory
-provides window into patient’s condition
-may reduce agitation
-“glimmer into old self”
What is agitation? How does it differ from aggression?
-using violence to get what you want
-as the individual becomes acclimated, they put cause and effect together
-comprehensive behavioral management program established for those who exhibit behavior that interferes with active participation in therapy/achievement of goals (pgs. 896-897, Pedretti)
-medication used with violent/aggressive patients to calm them down
-Adaptive (confused) attempt to explore the environment
-Typical at Rancho Levels 4-5
-“An excess (any behavior that interferes with functional activities) of one or more behaviors that occurs during an altered state of consciousness (amnestic phase of recovery)”
-“Post-traumatic amnesia plus a behavioral excess of aggression, disinhibition, and/or emotional lability”
Characteristics captured by the Agitated Behavior Scale
-Increased psychomotor activity
-Reduced ability to maintain or appropriately shift attention
Be able to describe strategies for managing agitation.
Vail bed or mattress or Craig bed
Hand mit to prevent pulling at lines/leads
Out of bed therapies followed by rest breaks
Wean off medications
Provide orientation supports (e.g. wall clock/calendar)
NO restraints, therapies outside of room, television, overmedication, overstimulation, being left alone
Treatment is based on developing a safe environment, consistent routine, focus on over-learned tasks, and gradual re-introduction of more complex parameters/tasks (with consistent team member participation)
-cool, calm, collected, self-assured;
-speak slowly/concisely using 1-2 word commands
-redirections to de-escalate
-be aware of your own safety
List three early assessment tools that are typically used with people who have emerged from coma (from lecture or text). What do they measure?
1. Glasgow Coma Scale: assesses LOC after a TBI (pg. 886, Pedretti)
-eye opening response
-motor response to painful stimuli
**FYI, the motor response is best indicator to signify no longer in a coma (score of 5 signifies purposeful response to pain and a score of 6 represents an ability to follow simple commands)
2. Rancho Los Amigos Scale of Cognitive Functioning: descriptive measurement of levels of awareness and cognitive function (Levels 1-8 (2 additional levels used at some outpatient facilities) described on pgs. 888-889, Pedretti)
3. Galveston Orientation & Amnesia Test (GOAT) OR the Orientation Log (O-Log): measurement to track levels of post-traumatic amnesia (PTA)
Describe Rancho Level 4
Confused and Agitated
-be very confused and frightened
-not understand what he feels or what is happening around him
-overreacts to what he sees, hears, or feels by hitting, screaming, using abuse language, or thrashing about (due to confusion)
-be restrained so he doesn’t hurt himself
-be highly focused on his basic needs (e.g. eating, relieving pain, going back to bed, going to the bathroom, or going home)
-may not understand that people are trying to help him
-not pay attention or be able to concentrate for a few seconds
-have difficulty following directions
-recognize family/friends some of the time
-with help, be able to do simple routine activities such as feeding himself, dressing, or talking
Describe Rancho Level 5
Confused and Inappropriate
-be able to pay attention for only a few minutes
-be confused and have difficulty making sense of things outside himself
-not know the date, where he is, or why he is in the hospital
-not be able to start or complete everyday activities, such as brushing his teeth, even when physically able ( may need step-by-step instructions)
-become overloaded and restless when tired or when there are too many people around
-have a very poor memory (will remember past events from before the accident better than his daily routine or information he has been told since the injury)
-may get stuck on an idea or activity (perseveration) and need help switching to the next part of the activity
-focus on basic needs such as eating, relieving pain, going back to bed, going to the bathroom, or going home
Describe Rancho Level 6
Confused and Appropriate
-be somewhat confused because of memory and thinking problems (e.g. he will remember the main points from a conversation, but forget and confuse the details, like remembering that he had visitors in the morning, but forget what they talked about)
-follow a schedule with some assistance, but becomes confused by changes in the routine
-know the month and year, unless there is a severe memory problem
-pay attention for about 30 minutes, but has trouble concentrating when it is noisy or when the activity involves many steps (for example, at an intersection, he may be unable to step off the cub, watch for cars, watch the traffic light, walk, and talk at the same time)
-brush his teeth, get dressed, feed himself etc. (with assistance)
-know when he needs to use the bathroom
-do or say things too fast, without thinking first
-know that he is hospitalized because of an injury, but will not understand all of the problems he is having
-be more aware of physical problems than thinking problems
-associate his problems with being in the hospital and think that he will be fine as soon as he goes home
Be able to explain why consistency in treatment is important during inpatient brain injury rehabilitation.
1. Important to build a therapeutic milieu by:
-working everyday to structure a non-intrusive, comfortable, normalized environment
-maintaining a strict adherence to same daily schedule & same therapists
-upgrading amount, rate, complexity, and duration of tasks as patient recovers
-involving all team members & family
2. Even the slightest change in treatment parameters can ruin a treatment session, sparking agitation and frustration by the patient (without consistency, agitation can increase and can quickly turn into recalcitrant negative behavior)
3. Also, patients have memory difficulties, so predictable routines will assist with memory making/re-learning tasks
4. Chris Gentry also told us that any change can lead to a breakdown in the transfer of skills