Prep family lecture_shepherd

• 1. Shepherd CenterAcquired Brain Injury Program

2. Introduction What is Neuropsychology? What happened to your loved one? Part 1: Basics of the Brain What happens with a brain injury Part 2: 2 Tracks at Shepherd: all patient-specific PREP (Pre-rehabilitation Education Program) Rehab Program Discharge- What happens when you leave here? 3. Brain Anatomy Brain is soft, and has consistency of a Jello mold Fits relatively snuggly in the skull Attached to skull by small veins and meninges Floats in cerebral spinal fluid Provides cushion, shock absorber Enclosed environment Other than veins and arteries, there is only one exitwhere brain stem exits the base of the skull to become the spinal cord This is why we have the pressure problem 4. Brain Anatomy Surface of the brain is wrinkled with deep folds Increase the surface area of thebrain in a small space Compact, efficient Allows for more connections Cortical structures on surface Subcortical structures deeper in brain 5. Brain Anatomy Neo-cortex or Cortical Structures Each hemisphere divided into 4 lobes Frontal, temporal, occipital, parietal Thinking portion of the brain Subcortical Structures Life sustaining structures/functions White matter communicationbetween different brain regions Brain stem controls heartrate, breathing, temperature, arousal/wakefulness May be affected by focal damage orgeneralized mechanisms(swelling, compression, diffuse/shearinjury, anoxia) 6. Anatomical Relationships Grey-white distinction Grey = cell body White = axons Axons carry informationto/from outside world Converge in brainstem 7. Fulcrum Biomechanics Top heavy cortical regions Rotational forces centered on brainstem 8. Neuropathology of Brain Injury Acquired Brain Injury (ABI): Any injury that happens within the brain itself at the cellular level Traumatic Brain Injury (TBI) Non-Traumatic Brain Injury (TBI) 9. Neuropathology of Brain InjuryTraumatic Brain Injury (TBI): Outside force impacts head hard enough to cause brain to move within the skull or the force directly hurts the brain Examples: motor vehicle collisions, falls, firearms, sports, physical violence, etc. Closed Head Injury vs. Open Head Injury 10. Neuropathology of Brain InjuryNon-Traumatic Brain Injury (TBI): Does not involve external mechanical force Examples: stroke, aneurysm, insufficient oxygen (anoxia/hypoxia) or blood supply (ischemia), infectious disease, AVM, etc. 11. Neuropathology of TBI Contusions: Bruising blood vessels in or around brain are damaged or broken Hemorrhage bleeding from blood vessel leakage rupture Hematoma Localized pooling of blood that occurs from hemorrhaging. Can be large or small 12. Neuropathology in TBI Edema Swelling in brain tissue Or influx of fluid Causes increased intracranial pressure (ICP) Enclosed space: Increased pressure on all brain tissue, can put pressure on stem Treatments: Medically induced coma Brain diuretic (reduce fluid/water) Placement of shunt (drain) Craniectomy (remove portion of skull bone to allow extra space for swelling) 13. Diffuse Axonal Injury in TBI(What Grace Has) Shear injury Results from sudden stopping, rotating, twisting and tearing ofaxons of neurons Capillaries, blood vessels also tear Doesnt always show up immediately on CT scans Usually present in TBI, especially MVA Axons/neurons dont repair, per se, and leads to cell death Some neuroplasticity can compensate 14. Anoxia/Hypoxia Anoxic Brain Injury Brain does not receive any oxygen. Cells in the brain need oxygen to survive Anoxic Anoxia: no oxygen supplied to the brain Anemic Anoxia: blood that does not carry enoughoxygen Toxic Anoxia: toxins that block oxygen in the blood Hypoxic Brain Injury Brain receives some, but not enough oxygen Common causes: Cardiovascular disease or trauma, asphyxia (e.g., drowning), chest trauma, electrocution, severe asthma attack, poisoning, substance overdose 15. Chemical Changes Brain is very efficientproduces at the cellular levelonly what it needs and needs everything it produces Brain injury may cause neurochemical imbalance Neurotransmitters: E.g., Serotonin mood Medications may be given: Parlodel for arousal Ritalin for focused attention & arousal Mood stabilizers, antidepressants may be beneficial Damage to pituitary gland can effect hormonedisruptions, sleep/wake cycles can be affected 16. STORMING Hypothalamic Instability ANS poorly regulated bycentral brain mechanisms Elevated blood pressure Fever Tachycardia Rapid respirations Sweating May or may not be stimulated Not a sign of improvement Can be very difficult to watch 17. Two Tracks at Shepherd Center PREP Program (Pre-Rehabilitation EducationProgram) Rancho Levels 1-3, passive therapies to keep body conditioned, and ready for progression to full rehab Stimulation for coma emergence Rehabilitation Program Full Rehabilitation Program Dual diagnosis SCI patients Patient has both a spinal cord injury and brain injury They frequently co-occur (e.g., car accidents, falls, etc) 18. Overview: Pre-RehabilitationEducation Program Reflexive & generalized responses without purposeful orgoal-directed behaviors Goal: Provide best possible environment for emergence 1.5 hours daily of passive therapies Minimize complications of immobility Increase quality and quantity of responses to stimuli Recovery is not dependent on amount of stimulationmore is not necessarily better Neurostimulants - medications to promote arousal Establish and maintain medical stability Family training, home modifications, preparation fordischarge 19. Levels of Arousal Severity of Initial Injury Glasgow Coma Scale (GCS 3-15) Length of reduced arousal Rancho Scale Levels Only for TBI Range from 1-10 Levels 1-3 are low-level consciousness (Prep Program) Level 4-10 full Rehab program Traditional arousal terminology Assessing functional abilities 20. PREP Program (cont.) JFK Coma Recovery Scale (Speech Therapy) Useful in documenting even slight improvements Visual: Startle, localization, pursuit, tracking, objectrecognition Auditory: Startle, localization, consistency Oromotor: Oral movement, vocalization, verbalization, Communication: Accuracy, consistency Arousal Neurobehavioral Examination (Neuropsychology) Family Education and feedback 21. LEVEL 1 Rancho 1: No Responses : Total Assistance Arousal Level: Coma Functional Abilities Eyes closed No response to any stimuli 22. LEVEL 2 Rancho 2: Generalized Responses Arousal Level: Vegetative State Functional Abilities Eyes open Generalized responses Reflexive behaviors (grasping) Non-purposeful movements Fragments of coordinated movement Vocalization but not verbalization 23. LEVEL 3 (Graces Current Level) Rancho 3: Localized Responses Arousal Level: Minimally Conscious Functional Abilities Localized responses Intelligible verbalization Purposeful behavior Responses still inconsistent 24. PREP Program (cont.) Emergence criteria Interactive communication to simple, concrete questions or requests Following commands Yes/no responses Allow time OR functional use of 2 objects Reliable: With all staff, not reflexive Consistent: 85% of the time Motor and language impairments can interfere 25. Neural Recovery Everyone is DIFFERENT Time & Biology Types of recovery Recovery from secondary effects Cortical reorganization Nearby cells may take on additional work Limitations We do not make new brain cells Limited capacity for reorganization 26. PREP Program (cont.) Speak in a comforting, positive, and familiar way. Bemindful of delayed response time. We cannot be sure how much cognitive processing isoccurring. When visitors are present, focus on the patient. Limit the number of visitors. Keep visits short restis essential Provide the patient with pictures, music, andpersonal items that are comforting and familiar. There are opportunities to assist with patient care asdirected by nurses. 27. PREP - Going Home Each patients recovery rate is unique Recovery continues after discharge For some patients, familiar environment can bestimulation for emergence We want you to feel competent to go home Family Training Day Marcus Bridge Program, telehealth Continued support Return for rehabilitation ifappropriate 28. Factors That Can Affect Recovery Age Prior brain injury Previous health status Length of PTA Time since injury How much tissue was damaged Focal injuries are more resistant to recovery Language, executive functions, ataxia are more resistant Substance abuse, smoking tobacco Adaptive functioning before injury Family involvement More therapy hours are not related to amount of recovery 29. Family You know your loved one better than we do Your knowledge about their emotional and physicalneeds is valuable to us and to their recovery Your participation and involvement is helpful Feelings of loss, sadness, anger, guilt, and frustrationare common and normal You do not have to go through this alone- help isavailable 30. Stages of Family Adjustment1. DENIAL 1. TRUST Just listen Encourage hope Self-care advice One foot in front of other2. BEWILDERMENT 2. OBJECTIVITY3. DESPAIR3. LONG-TERM PLAN4. INSIGHT4. IN DEPTH FEEDBACK5. MOURNING 5. PERMISSION6. ACCEPTANCE6. RESOURCES 31. Self Care is Essential You have to be healthy in order to be ableto take care of someone else Break the stress response cycle Rest, eat well, get some exercise Practice whatever gives you strength, peace, hope Manage your physical & emotional energy Asking for help is a valuable skill, not a weakness Find people who will help you and then let them Share your feelings with trusted others This is your chance for a break before your loved one isdischarged