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:
Brain injury rehabilitation at Shepherd
Your entire rehab team
2 Tracks: Patient-specific
PREP (Pre-Rehabilitation Education Program)
Rehab Program
Discharge- What happens when you leave here?
3. Brain Anatomy
Brain is soft & has the consistency of a Jello mold
Fits relatively snuggly in the skull
Attached to the skull by small veins and meningies
Floats in Cerebral Spinal Fluid (CSF)
Provides a cushion, “shock absorber”
Enclosed environment
Other than veins and arteries, there is only one
exit—where 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 the
brain in a small space
Compact, efficient
Allows for more connections
Cortical structures on surface
Subcortical structures deeper in
brain
5. Brain Anatomy
Two relatively symmetrical hemispheres (halves)
Contralateral Control
Left side of brain controls Right side of body, etc.
6. 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
Brain stem controls heart rate,
breathing, temperature,
arousal/wakefulness
White matter – communication
between different brain regions
May be affected by focal damage or
generalized mechanisms (swelling,
compression, diffuse/shear injury,
anoxia)
8. Frontal Lobes
• Common site of injuries due to bony shelf
structures in skull
• Facilitates executive functions/goal-directed
thoughts:
• Attention/concentration
• Planning, organization, sequencing
• Abstract reasoning/thinking/adjustment
• Judgment/decision-making
• Self-monitoring/stopping & starting
• Personality/ Behavioral & emotional regulation
• Motor strip at back of frontal lobe controls body’s
ability to move itself
• Weakness (hemiparesis) or paralysis (hemiplegia)
• Some expressive language abilities
9. Injury to the Frontal Lobes
Decreased initiation
Difficulty getting started
The “gas” is not working properly: “Abulia”
Cueing can help
Disinhibition
Problem with “social filter”, opposite of initiation
problems
colorful language, socially inappropriate behaviors
Can be difficult to remember it is due to brain injury
Not intentional, usually not directed towards any particular
person
Unaware of inappropriateness of behavior
Or as recovery progresses, may become more aware, but
still unable to control behavior= can lead to guilt
10. Injury to the Frontal Lobes
Confabulation
Disorientation & confusion “neurological lying”
Perseveration
Repetitive topics, phrases, or behaviors
Emotional lability (mood swings)
Behavioral dysregulation
Fatigue, over-stimulation, frustration
Decreased insight and awareness
May deny physical and/or cognitive deficits
Remember: your loved one is not doing it on
purpose.
11. Parietal Lobes
Sensory strip at front of parietal
lobe, behind motor strip
Organized similarly to motor
strip
Detects pain, touch, pressure
Senses where the body is in space,
movements
Visuospatial judgments
Attention to entire environmental
field
Inattention vs. neglect
“Left Sided Neglect”
12. Occipital Lobes
Processes basic visual
information
Visual problems common
after brain injury
Input enters through eyes,
but you “see” with your brain
Many injuries affect vision
Double vision, blurred vision
Visual field cut
13. Temporal Lobes
Auditory processing cortex
Recognizing/Discriminating
between sounds
Expressive and Receptive
Language abilities
Expressive or Receptive “aphasia”
Hippocampus facilitates memory
storage
Short-term vs. long-term memories
14. Cerebellum
Fine motor coordination and
balance
Fluid motor movements
Eye-hand coordination, timing,
adjustment
Posture, gait
Motoric memory (e.g., how to play
an instrument, walk)
Ataxia, balance problems when
damaged
Contains half of all neurons of the
nervous system
Condensed; more neurons here
than in the neocortex
15. Nomenclature
Acquired Brain Injury (ABI):
Any injury that happens within the brain itself at
the cellular level
Traumatic 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
Non-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.
16. Mechanisms of TBI
Coup-Contrecoup
Back-n-Forth contact with skull
Diffuse Axonal Injury
•“Shear injury”
•Results from rotating, twisting
and tearing of axons of neurons
•Tears capillaries & blood
vessels
•Doesn’t always show up
immediately on CT scans
•Usually present in TBI,
especially MVA
•Axons/neurons don’t repair, per
se, and leads to cell death
•Some neuroplasticity can
compensate
18. 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
19. Neuropathology in TBI
Edema
Swelling in brain tissue
Causes increased intracranial
pressure (ICP)
Enclosed space: Increased
pressure on all brain tissue
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)
20. 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 enough
oxygen
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
21. Chemical Changes
Brain is very efficient—produces at the cellular level
only 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 stabalizers, antidepressents may be beneficial
Damage to pituitary gland can result:
hormone disruptions,
sleep/wake cycles can be affected
22. Post-traumatic Amnesia (PTA)
Patients with PTA may:
Not be able to lay down new memories
Be disorientated
Have a short attention span
Be agitated or have more mood swings
Perseverate on words, ideas, or activities
Need more structure
probably better working on one activity at a time
Have difficulty processing complex information about
the accident
May not have the capacity to assign Power of Attorney
Power of Attorney vs. Guardianship
23. Neuropathology of Stroke
Loss of brain function due to interruption in blood supply
to all or part of the brain
Results in depletion of oxygen and glucose in affected area
Two types:
24. Neuropathology of Stroke
Infarct: Area of damaged or dead tissue
Ischemia: Lack of adequate blood flow
Thrombosis: Solidified blood plugs/clots a blood vessel
Embolism: A plug/clot brought through the blood from a
larger vessel and forced into a smaller one where it
obstructs circulation
25. Neuropathology in Stroke
Aneurysm: Balloon-like expansion of blood vessel
Usually weak and prone to rupture
Risk factors: hypertension, arteriosclerosis, embolisms, or
infections
Prior to rupture, may be treated with stent or clipping
26. Neuropathology in Stroke
3rd most common cause of death
After heart disease and cancer
Risk Factors:
Hypertension
Smoking
High Cholesterol
Diabetes
Poor diet
Age (especially from 60’s on)
Stroke Prevention:
Diet
Exercise (physician approved)
Smoking cessation
Medication compliance
28. Tracks at Shepherd Center
PREP Program (Pre-Rehabilitation Education
Program)
Rancho Levels 1-3, passive therapies to keep body
conditioned, and ready for progression to full rehab
Stimulation for coma emergence
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)
29. Rehabilitation Program
Increase independence as much as possible
Return to meaningful life
Short-term goals (daily or weekly)
Long-term goals (discharge home, return to work, etc)
Relearn skills
Learn new ways to do things, compensate
Increase mental & physical endurance/stamina
3 hours of therapies daily (plus groups, outings,
psychology)
Reduced therapies on weekends for rest and family time
30. Rehabilitation Treatment Team
The Rehab team works together:
Medical doctors
Nursing
Neuropsychology
Occupational Therapy (OT)
Physical Therapy (PT)
Speech and Language Therapy (ST/SLP)
Therapeutic Recreation/Other Therapists (TR)
Case Managers
Technicians
Nutrition
Chaplaincy/Spiritual Guidance/Therapy
31. Individualized Treatment Plan
Occupational Therapy (OT)
Rehabilitation for arms, hands, fine motor skills, vision
Casting
Basic and advanced activities of daily living (ADL’s)
Showering, grooming, hygiene, dressing, toileting,
home management skills, kitchen skills, money
management, structuring routines
Assess for safety
Physical Therapy (PT)
Rehabilitation for legs, torso, balance, walking and gait,
sequencing movements, wheelchair training, transfers
Casting
Assess for safety
32. Individualized Treatment Plan
Speech & Language Therapy
Swallowing, consistency of liquid and diet orders, safe
eating behaviors, speech and language, cognition,
memory, attention, functional problem solving
Therapeutic Recreation
Fun activities to maximize progress
toward goals and integrate skills
Practice what is learned in OT, PT,
S<, Neuropsych, etc.
Nutrition
Diet, weight, nutritional aspects of wound healing
Importance of/Education for nutrition habits for discharge
33. Neuropsychological Screening
Formal, standardized assessment of thinking skills
Targets major cognitive domains:
Attention/concentration, memory, visuospatial
abilities, language, executive functioning
Mood functioning
Findings & Recommendations
Ability/Capacity to make decisions, need for
supervision, return to work/school recommendations,
treatment and discharge planning
Baseline for comparative follow-up testing
Often used for disability claims
34. Power of Attorney vs. Guardianship
Power of Attorney: Legal document that allows a person
(the “principal”) to name another person to act in their place
Patient must:
Be fully oriented
Demonstrate
Understanding of what PoA is
Full appreciation of the situation
Reliably identify whom they want to have PoA
Positives: inexpensive; revocable; patient retains ability to
manage their affairs when able to do so
Negatives: some financial institutions don’t honor PoA;
agents can abuse their power
35. Power of Attorney vs. Guardianship
Guardianship: Legal process in which the court
appoints an individual/association/corporation to act
on behalf of another who has been declared
incompetent or incapacitated
Applicable when patient is in acute stage of recovery
Patient’s rights are (temporarily) taken away
Emergency guardianship – required when consent for
medical treatment is needed; hearing not required
Temporary vs. Permanent Guardianship
3-month temporary guardianship can be considered, as
patient’s cognition may improve over time
However, it is expensive; process is lengthy; court
hearing required
36. Discharge from Rehab Track
Family Training Day
Shepherd Pathways or other outpatient therapy
clinics
Importance of supervision
Due to deficits in judgment, memory, safety
awareness, problem solving, insight into limitations,
distractibility, impulsivity and behavioral regulation
Help make the environment safe, training (e.g.,
praise safe decisions, provide explanations, external
memory devices, etc)
37. After Discharge
Recovery does not end at discharge
First 6 months: most rapid recovery
Continued recovery for 1 – 2 years after injury
Residual differences: cognitive, emotional,
behavioral, interpersonal
Physical limitations are easier to see and to watch
heal
Retest cognitive functioning to identify changing
strengths and areas for improvement
38. Ongoing Difficulties & Limitations
Physical
Movement, coordination, balance
Stamina and endurance
Cognitive
Safety awareness, impulsivity
Memory, Post-traumatic Amnesia, Confusion
New learning can be difficult
Emotional and behavioral issues
Dysregulation, depression, anxiety, adjustment
issues
Other cognitive issues & difficulties
39. 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, ETOH & smoking tobacco etc.
Adaptive functioning before injury
Positive Family involvement
More therapy hours are not related to amount of recovery
40. Post-traumatic Epilepsy
10% risk with closed head injury
50% risk with open head injury
Learn what to do
Know when to call 911
Drinking alcohol increases risk
May receive medications/medical management
See attachment for “What to do in an emergency”
41. Substance Use
Use of alcohol (in any amount) increases risk for
seizures
Drinking alcohol increases risk for falls
Second brain injury likely to be much more severe, even
if actual injury is mild
Substance abuse is more common after brain injury,
even if not present before
More stress, losses
Fewer coping strategies
Poor decision making/judgment
Be more aware- patients may try to hide substance use
42. Family
You know your loved one better than we do
Your knowledge about their emotional and physical
needs is valuable to us and to their recovery
Your participation and involvement is helpful
Feelings of loss, sadness, anger, guilt, and frustration
are common and normal
You do not have to go through this alone- help is
available
43. Self Care is Essential
You have to be healthy in order to be able
to 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 is discharged
44. Some Last Housekeeping Notes…
Time off
Please respect visiting hours on the unit
Reduces distraction, provides structure,
promotes independence, promotes rest
For your loved one
For other patients
For yourself
Meal time expectations
No family/visitors during breakfast & lunch
1 family member/visitor during dinner