Understanding Traumatic Brain Injuries: Causes, Symptoms, and Treatment, Exams of Health sciences

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CBIS Exam Questions and Answers (2023 – 2024) Complete Solution Nuerocognitive Issues Assoicated with Frontal Lobe - Emotional control, behavioral control, verbal expression, problem solving, decision making, social control, attention, motivation Acquired BI - An injury to the brain that is not hereditary, congenital or degenerative or induced by birth trauma TBI - An alteration in brain function or other evidence of brain pathology, casused by an external force Mild TBI Characteristics - Brief or no loss of consciousness for 0-30mins, altered state of consciousness is most common and must be <24 hours, account for 75% of TBIs, 13-15 on the GCS, normal imaging, highest prevalence of maltreatment as 16-25% never seek care, often considered a concussion Moderate TBI Characteristics - Loss of consciousness for up to 24 hours, may appear on scans, skull fractures and bleeding are common, 9-12 on the GCS Severe TBI Characteristics - Loss of consciousness >24 hours, 3-8 on the GCS Likelihood of Additional Injury - 1 BI increases risk of 2nd by 3x and 2nd BI increases risk of 3rd by 8x! Most Frequent Cause of TBI - Falls How many people sustain a BI per year? - 2.5 million. 81% visit ED, 16% hsopitalized, 3% result in death How many people are living with effects of a TBI? - 13.5 million Likelihood of BI by gender - Men are 1.4x more likely than women Most common cause of TBI and death by age - 75+ - Falls! Most common cause of TBI and death by age - 0-3 - AHT! Most common cause of TBI and death by age - 20-24 - MVAs and Firearms Most common cause of TBI and death by age - 16-19 - MVAs! CARF - Accreditation agency for post acute BI programs, residential, outpatient, vocational, home and community, stroke and pediatric programs - ensures quality of services through requirements for accreditation and surveys Joint Commission - Accreditation agency for hospital based programs, may accompany CARF accreditation, ensures quality of services through requirements for accreditation and surveys Olmsted Decison - Supreme court case stimulated by two women living in a nursing home in Georgia for community inclusion - resulted in federal and state initiatives to improve and normalize community living Model Systems of Care 1987 - Resulted in research projects for TBI by the NIDDR, established rehab facilities to provide care and complete clinical research in the process Symptoms of Mild TBI - Headache, fatigue, seizures, nausea, numbness, poor sleep, light sensitivity, noise sensitivity, impaired hearing, blurred vision, dizziness, loss of balance, neurological abnormality, in attentiveness, decreased concentration, poor memory, impaired judgment, slow proccessing speed, executive dysfunction, depression, anxiety, agitation, irritability, aggression, impulsivity Primary causes of Mild TBI - Traumatic intertial - brain moving inside skull Traumatic impact - head hits directly Early Treatment for Mild TBI - Relaxation techniques, rest, slow return to normal activity, and reduction of normal activity if symptoms recur Peristent Post Concussive Symptoms (PPCS) - Symptoms of Mild TBI last >1 month, occurs 10% of the time in Mild TBI cases Chronic Traumatic Encephalopathy (CTE) - Often cause by repeated blows to the head, is a progressive, degenerative condition characterized by broken nuerons which continually release tau protein cashing dementia over time Diffuse axonal injury -> tau protein release -> inflammation of the brain -> progressive dementia Define Skull - Bony shell that protects the brain, has bony prominences inside which can worsen brain injury Cerebral Spinal Fluid (CSF) - Provides cushion to nerve tissue, produced by ventricles (4) which also store and circulation CSF through the brain Meninges - Pia Mater - molds around suclhi and gyri, deepest layer Arachnoid Mater - spiderweb-like, middle layer Corpus Collosum - Pencil-thick band that exhanges info between L and R hemispheres Afferent Signals - Signals sent along the spinal cord through foremen magnum towards the central nervous system Efferent Signals - Signals sent from the central nervous system to the rest of the body through the foramen magnum via the spinal cord Cervical Vertebrae - Made up of 7 vertebrae, primary function to support and move the skull Thoracic Vertebrae - Made up of 12 vertebrae, primary function is stability Lumbar Vertebrae - Made up of 5 vertebrae, primary function is weight bearing Sacral Vertebrae - Made up of 5 vertebrae, located at the base of the spine meeting the pelvis CT Scan - X-ray used in conjunction with a computer, only capable of showing what the naked eye can see MRI - Uses magnetic field in conjunction with a computer, a more detailed scan ideal for seeing soft tissue damage, can detect changes in blood flow and track cellular activity Blood Brain Barrier - A filter within the red blood cells which allows blood to enter the brain but blocks harmful substances from entering Neuroplasticity - The ability of the nervous system to change, grow, or compensate for an injury The brain can change and re-map! Based on the Hebbian Principle which states that every rehearsal of a skill strengthens memory trace in the brain *Hippocampus may contain stem cells which can generate new brain cells if optimized by therapy! Synaptogenesis - A part of nueroplasticity - the formation of synapses between nuerons The more synapses there are the more efficiently nuerons can communicate! Nueroprotection - Preventing secondary damage post injury Apoptosis - Process in which a brain cell self destructs if it is not working as it should be Experience Dependent Learning - Neural connections that are established which depend entirely on and are due to an environmental experience Autonomic Storming - Also called dysautonomia, autonomic hyperreflexia, sympathetic storming A disorder of the autonomic nervous system that involves failure of the sympathetic/parasympathetic components of the ANS. Characterized by resting tachycardia, labored breathing, gastroparesis, sweating irregularities, hypotension, constipation, and erectile disfunction 15-33% of TBIs sustainees experience AS Deep Vein Thrombosis (DVT) - Bloodclots Symptoms include shortness of breath, pain/discomfort that worsens with coughing or breathing, light headedness, dizziness, feeling faint, coughing up blood, rapid pulse Pulmonary Embolism (PE) - Occurs when a blood clot travels to the lungs- same symptoms for DVT Disinhibited Nuerogenic Bladder - Neurological impairment in CNS or PNS causing decreased bladder capacity, increased urgency, increased frequency and incontinence with intact bladder sensation Treatment for Bowel and Bladder Incontinence - Best when initiate early on - treatment includes exterior cathing and suppository schedules, toileting schedules, and close monitoring of intake UTI's extremely common due to cathing - risk of UTI is increased with use of in-dwelling catheters, especially if cognitive impairment is present Aspiration - Caused by dysphagia - when liquid enters into the lungs Commonly leads to aspiration pneumonia Specialized diets are often prescribed if there is a risk of dysphagia - may include thickened liquids and diets with altered consistency Seizures and TBI - Caused by an imbalance of nuerotransmitters or an abnormal and disorderly discharge of electrical activity in the cells of the brain TBI sustainees 22x more likely to die from a seizure than general population Immediate post TBI convulsions are most common but not believed to be a predictor of prolonged seizure disorder Seizures occurring 1 wk post TBI are strong predictor of future patterns Status Epilepticus - A seizure lasting longer than 5 minutes or seizures that occur close together, when one seizure occurs before fully recovering from previous seizure Associated with the following risk factors: penetrating TBI, severity of injury, hematomas, contusions, post traumatic amnesia lasting more than 24 hours, alcohol use, being a child or adolescent Cranial Nerve Damage - Associated with higher level severity BIs Cranial nerve 1 is most commonly injured, all are susceptible to injury due to placement near bony skull prominences Can heal and repair selves if stretched or bruised, tingling and pain can be a sign of repair Cranial Nerve Functions - I Olfactory (smell) II Optic (sight) III Occulomotor (eye movement) IV Trochlear (downward, inward eye movement) V Trigeminal (sense of touch in the face) VI Abducens (horizontal eye movement) VII Facial (facial expressions) VIII Auditory-Vestibular IX Glossopharyngeal (throat, taste, BP) X Vagus (heart, lungs, abdominal organs) XI Spinal Accessory (throat & neck muscles) XII Hyposglossal (speech) Nocioceptive Pain - Pain relating to damage to body tissue Treated with NSAIDS, Tylenol, topical agents, anti-spasticity meds, and opioids Neuropathic Pain - Pain relating to dysfunction of nervous system itself - damage to actual nerves Treated with NSAIDS, Tylenol, topical agents, anti-spasticity meds, opioids, anti- depressants, nerve blocks, trigger point injections, anti-convulsants, and epidural steroids Primary vs. Secondary Headaches - Headache that as no idenfitiable cause vs one with an identifiable cause Difficulty with upright position and balance Depth and Distance Perception Difficulty - Perceptual defecit associated with BI Difficulty sensing depth and distance of an object in relation to oneself Co-Commitance of SCI and TBI - 60% of patients with SCI also have a TBI 12,000 new cases of SCI per year Complete vs Incomplete SCI - All feeling and control completely lost below level of injury vs partial feeling and control lost below level of injury Coma - Disorder of consciousness No arousal, no awareness, lasts weeks to months, impaired brain stem reflexes Vegetative State - Disorder of consciousness Arousal, no awareness, lasts months to years Minimally Conscious State - Disorder of consciousness Arousal, fluctuating awareness, lasts months to years Statistic of People Living with a DOC in the U.S. - 315,000 People Management of DOC - Focuses of full participation in daily routine, provide sensory stimulation, look for generalized and localized responses to stimulation, perform ROM, apply orthotics, upright positioning, bed mobility to combat atrophy/contractures/skin breakdown Fatigue - Decreased capacity for physical of mental activity due to an imbalance of resources needed to complete activity at hand Sleep Disruption - Disorders of initiating and maintaining sleep Primary Fatigue vs. Secondary Fatigue - Results directly from injury vs exacerbation of primary fatigue Physiological Fatigue vs. Psychological Fatigue - Caused by decreased production of hypocretin which increases arousal vs that caused by anxiety, depression and weariness The Coping Hypothesis - Explanation for cause of fatigue in TBI sustainess - says that it may be caused by increased effort required to meet demands of life caused by TBI Measures of Fatigue - Visual Analogue Scale -Fatigue at a single point in time Fatigue Severity Scale -Impact of fatigue on daily functions Barrow Nuerological -Difficulty level of maintaining energy and alertness Global Fatigue Index - 4 Domains of Fatigue severity Causes of Fatigue Questionairre -physical and mental activities that cause fatigue and to what extent Strategies to Increase Energy - Reduce work hours, take breaks, physical conditioning, addressing pain/anxiety/depression, modifying pace or demands of task, reduce distraction, manage info overload Narcolepsy - Sleep Disturbance Sleeps for <1 hour at a time Sleep Apnea - Sleep Disturbance Upper airway obstruction which stops breath during sleep Hypersomnia - Sleep Disturbance Traumatic event of CNS Limb Disorder - Sleep Disturbance Periodic limb movements during sleep Insomnia - Sleep Disturbance Periods of wakening and difficulty getting back to sleep Treatment for Sleep Disturbance - Exercise, limiting fluid intake before bed, avoiding naps, relaxation, sleep hygiene, CBT, meds, and CPAP Sleep Disturbance Assesment Tools - Epworth Sleepiness Scale, Pittsburgh Sleep Quality index, Polysonography, Mutiple Sleep Latency Test Causes of Sleep Disturbance - Change in circadian rhythms, depression, frequent napping, anxiety, pain, changes with REM Aging and TBI - TBI exacerbates normal aging increase likelihood of developing AD Nuerocognitive Issues Associated with Frontal Lobe Damage - Emotional control, behavioral control, verbal expression, problem solving, decision making, social control, motivation, and attention Nuerocognitive Issues Associated with Partial Lobe Damage - Tactile performance, spatial orientation, academic skills, object naming, visual attention and hand eye coordination Nuerocognitive Issues Associated with Occipital Lobe Damage - Visual stimuli processing Nuerocognitive Issues Associated with Temporal Lobe Damage - Memory, face recognition, selective attention, locating objects, object catgorization, receptive language, emotional responses, language comprehension Attention Heiarchy - Focused (turning to see someone behind you) -> Sustained (reading a book) -> Selective (studying with music) -> Alternating (reading recipe and cooking) -> Divided (driving and talking on the phone) Domains of Cognitive Functioning - Metacognition (self-awareness), executive functions, attention, categorization, processing speed, memory Sensory memory - Holds a memory a few moments after perception Short Term Memory - Enables memory recall lasting a few minutes to hours Working Memory - Temporary storage and active processing of information i.e. calculating change Long Term Memory - Permanent consolidation and storage of information Explicit Memory vs. Implicit Memory - Memory requiring conscious recall vs muscle memory Semantic Memory - Memories of words, ideas, and concepts Episodic Memory - Memories of personal experiences Procedural Memory - Memory of skills and tasks Compensatory Approach to Treatment vs. Restorative Approach to Treatment - Assumes certain functions cannot be recovered and focuses on strategies to "compensate" for losses vs. belief that repetition, exposure and experiential learning can change brain circuitry Coma-Emergent Agitation - Emerging from coma can case confusion, anger, hyperactive movements, heightened responses to external stimuli, poor cooperation and violence Quadrant 2 - high severity TBI and low severity SUD - receive treatment in TBI rehab - education, screening, and brief intervention Quadrant 3 - low severity TBI, high severity SUD - receive treatment in SUD treatment setting - screening, accommodations and linkage Quadrant 4- high severity TBI and SUD - receive treatment in TBI and SUD treament setting - integrated program to treat both Biomedical Model of Diability - Concerned with changing the individual and treating the problem (TBI) Functional Model of Disability - Aimed at adapting the functions of individuals for meaningful participation in life, focused on person centered care Environmental Model of Disability - Addressing physical and social environments to meet the needs of an individual Sociopolitical Model of Disability - Goal is inclusion, civil rights, and equal social status - places accountability on society Religious/Moral Model of Disability - Disability is a result of sin Person Centered Care - Encourages individual participation in rehab and hold the individual accountable for their progress. Physicians, healthcare professionals, and family are considered tools and allies. Focuses on participation in the process as opposed to immediate "progress." Encouraging self awareness and autonomy improves outcomes. Components of Therapeutic Relastionships - Autonomy -empowering the indivdual Beneficence- preventing harm Non-Maleficience - do no harm Fidelity - keeping a promise Justice - equality and fairness Veracity- truth and honesty Use person first language, humaneness, open communication, questions vs directives, and a non-judgmental approach! Latrogenesis - Due to.a physician or therapist, inadverdently induced problem or disease Extenders - Unlicensed, non-certified staff that operate under the supervision of a licensed clinician that are specially trained Culture - Any group that shares a theme or issue; can include language, food, clothing, music, art, dance, etc. Sociorace - Recognizes the social and historical aspects of a group of people; providing info about customs, norms, and social aspects of the group Universalism - Loyalty and concern for others without regard to national or other allegiances Multiculturalism - A social-intellectual movement promoting cultural diversity as a core principle while insisting on equality and respect for all cultural groups Academic Intelligence - Ability to solve problems in an academic, classroom setting Practical Intelligence - Ability to solve practical life problems in everyday settings Social Intelligence - A distinct set of skills necessary in order to successfully navigate the environment Emotional Intelligence - The ability to monitor and identify emotions, both one's own and others' and the use of emotional info to guide thinking and behavior The Process of Racial and Cultural Identity Development - Conformity -> Dissonance -> Resistance and Immersion -> Introspection -> Integrative Awareness Worldview - How you perceive your relationship to the world, can greatly influence a person's life Should be considered when treatment plannning Benign Neglect - An attitude or policy of ignoring an often delicate or undesirable situation Males vs. Females and TBI - Men experience TBI 2:1 compared to women RTW rates 26.6% for men vs 4.4% for women- may be due to womens' increased responsibility in the home and at work For women TBI often causes depression, PTSD, sexual difficulty, increased symptamology over time, and body image concerns Primary and Secondary Causes of Sexual Dysfunction - Nueroendocrine changes, hypothalamus and pituitary damage Physical changes, cognitive impairments, emotional and behavioral changes, marital dysfunction, social isolation, financial stress, role changes, and decreased communication Brain Peak Maturation Periods - 3-5 years old - rapid overall growth 8-10 years old - rapid sensory motor growth, executive functions begin to develop 14-15 years old- rapid growth of visual spatial, somatic systems, and auditory *TBI disrupts normal developmental milestone progression Individuals with Disabilites Education Act (IDEA) - Made free and appropriate education available to all children with disabilities, ensures access to public education and related services 504 Accommodation Plans - Designed to help children learn alongside peers, provides written documentation for needs required by child with a presumed disability i.e. preferential seating, increased time, verbal testing, note takers, etc. Can be carried into higher education but may not have a formal 504 plan.. A result of section 504 of Rehabilitation Act of 1973 that prohibits discrimination based on disability Individualized Education Plan (IEP) - Written for specialized academic instruction, can be used by students in public school until age 21 - all public schools MUST provide services outlined in IEP by law Individualized Transition Plan (ITP) - Section of an IEP that outlines transition goals and services and how to achieve goals from transition to high school into real world. All students with IEP must have an ITP by age 16 Abusive Head Trauma (AHT) and Shaken Baby Syndromes Statistics - AHT is most common cause of TBI in 0-5 year olds, boys most commonly abused Accounts for 58% of TBIs in boys compared to 42% in girls Most often committed by a male caregiver - 56% of offenders are biological fathers Outcomes: 75-80% experience LT disability, 40% have severe defecits and 15-30% die Common Stressors for Families - Caregiver Burden is reported by 90% of caregivers! Stressors include catastrophe and unexpected responsibility in the acute phase; added unfamiliarity, confusion, uncertainty, and pressure in the rehab phase; and isolation and distress post discharge. Relief Strategies for Use with Families - Developing realistic goals, facilitating optimism, education about resources, and encouraging use of school supports Keep families informed, use active listening, validate and normalize, keep conversation positive, refer to resources, consider cultura competence Early Measures - Abbreviated Injury Scale, Loss of Consciousness, JFK Coma Recovery Scale, Measure of PTA, GCS Extended Scale Acute Meaures - FIM, Functional Assessment Measure, Dsaibility Rating Scale, Level of Cognitive Functioning Scale Popular Post-Acute Measure - Mayo-Portland Adatibility Inventory - measures physical, cognitive, social, behavioral, and emotional defecits associated with BI *can measure participation Post Acute Measures - Craig Handicap Assessment and Reporting Technique - objective measure of community participation Participation Assessment with Recommended Tools Objective - measures frequency of activity engagement * both can measure participation Required Aspects of Outcome Tools - Must measure baseline and post intervention, should be reliable/valid/widely accepted When choosing an outcome measure consider cost, expertise and training required to administer, timing and common data elements Common Data Elements - A data element that is common to multiple data sets across different studies Sequentially vetted, standardized report forms that streamline data collection structure and material development Return to Work (RTW) - The gold standard of TBI rehab progress and outcomes 10-40% of TBI sustainees return to work, numbers are variable due to varying definitions of "full time work" Barriers to RTW - Older age, severe injury, minority race, lack of social support, decreased employment education prior to injury, history of substance abuse, significant defecits Rehab Act of 1973 and Vocational Rehabilitation - Provided federal grants to states to operate comprehensive programs of vocational rehab State VR Services and Supports - Assessment, vocational counseling, guidance and referreal to needed services, rehab technology, on the job training, job placement, and supported employment 4 Approaches to VR - Minimal intervention ->education/prep -> advocacy level services -> workplace supports Supported Employment - Individualized support for persons with disabilities and long term barriers to work.a sustainable, paid job in the open labor market Vocational Case Coordinator - Follows individual on a long term basis to ensure success with employment. Provides support via assessment, job development, on the job training and case management