RS3330 Clinical Sciences (Medical & Neurological Conditions) PDF

RS3330 Clinical Sciences (Medical & Neurological Conditions) What Impact Will TBI Have on a Person's Life? Dr Hoe Lee, PhD  Objectives To be able to elaborate the long term problems associated with TBI To be able iden...

RS3330 Clinical Sciences (Medical & Neurological Conditions) What Impact Will TBI Have on a Person's Life? Dr Hoe Lee, PhD  Objectives To be able to elaborate the long term problems associated with TBI To be able identify factors affecting “recovery” of TBI clients To understand the clinical implications of TBI on the OT practice  S/S 7 How the functional performance of individual being affected? Memory Executive Attention skills/functions Concentration Problem solving Processing speed Organization -X understand Aphasia (receptive Self-Perception and expressive of Perception exconvey idea language) Inflexibility Reduced perseverance 3 & easily give up = esp for young patients Summary of Long term problems Physical F post-traumatic epilepsy X when premorbid paralysis, ataxia Incoordination hand and upper limbs X control body muscle tone unsteady gaits headache dysarthria ~ poor control of vocal muscles ->->Xtemper voice that others understand tantrum due to frustration sensory deprivation May lost visual field/err sensation eg oversensitive to heat + heat stroke easily 4 residual physical impairments Psychological Fully aware lack of drive or motivation lethargy = lack of energy to do everything depression (Long term psychiatric condition, distorted view of world) frequent changes of moods introversion Withdraw sexual drive affected Poor EF control -> disinhibit -> seek attention More egocentric, no insight personality change and loss of identity Post-concussion stress syndrome Anxiety abt having another accident or panic abt their s/s 5 Cognitive/Intellectual inability to communicate patchy memory lack of concentration, easily distracted slow in understanding information disorganized in planning, implementing tasks inability to cope with pressure Can differentiate but anxious * indecisiveness to make choices slow down of thoughts and reaction * poor or partial insight on own circumstances E.g. adjustment in their lives Argue when reality test 6 7 Mix-of-3 disabilities? In what proportion (short-term and long-term effect) Physical disabilities TBI Emotional and Cognitive disabilities behavioral disabilities Syndromes to describe impaired Constantly with a group of symptoms functions of TBI client ↓ Dorsolateral Prefrontal Cortex Syndromes Superior Medial Prefrontal Cortex Syndromes / Ventromedial Prefrontal Cortex Syndromes Rare Developmental Syndromes (present as Social Cognition Dysfunctions/Impairment) / Dysexecutive Syndromes (Frontal Lobes Syndromes)  Dysexecutive syndrome (Frontal Lobes Syndromes) a common pattern of dysfunction in executive functions, such as planning, abstract thinking, flexibility and behavioral control hypothesized impaired in working memory system and the central executive functions Poor disinhibition Cognitive symptoms, Emotional of behaviour that affects social relationships symptoms, Behavioural symptoms, egtenants scare female but doesnt Comorbid disorders. match client bg (childish)  Cognitive symptoms – Impaired planning and reasoning affect, short attention span, poor working memory Emotional symptoms – disinhibiting many types of emotions such as anger, excitement, sadness, or frustration Behavioural symptoms – lose social skills, judgments and insights into what others DES also found in ……. – schizophrenia, Alzheimer's Too disease and other high -> organic damage to cerebral cortex forms of dementia, chronic alcoholism Post-concussional syndrome Eg social fight loss of = partial memory Headache, dizziness, weakness, amnesia, diplopia, tinnitus, deafness etc. # 11 Other Neuropsychiatric/somatic/psychiatric syndromes Post-traumatic seizure (PTS) and post-traumatic Epilepsy (PTE), Post-traumatic Headache / (PTH), PT hydrocephalus, PT Fatigue, PT Sleep Disorders, PT Imbalance and Dizziness, PT sexual dysfunction, PT Heterotopic Ossification = bone tissue develops in soft tissue PT Depression, PT Anxiety Disorders, Post- traumatic Stress Disorder (PTSD), PT Psychosis, PT Personality Changes and PT Aggression The problems can occur in any combination, but cannot be predicted as every brain injury is different: 1. exact site of the injury 2. force of the impact 3. pre-accident personality and abilities 4. length of time between injury and intervention 5. personal, family, social and educational or working life attributes 13  Brain Injury and Mental Health: Depression Depression is the most common psychiatric disorder after TBI, followed by alcohol abuse, panic disorder, specific phobia and psychotic disorders (Gordon et. al 2004) Major depressive episodes occur in 20-30% of TBI patients in the first year. Depressive symptoms occur even more commonly. 14  Other Mental Health Disorders Related to TBI Anxiety, common comorbidity with depression Those with depression or anxiety perceive their injury and cognitive impairment as more severe then non-depressed individuals with TBI (Fann et.al 1995) Oquendo and colleagues (2004) found that males with mild TBI with a history of substance abuse coupled problems of aggression and hostility were more likely to attempt suicide then non-injured males 15  TBI & Suicide Findings using the Beck Suicide Ideation and Hopelessness Scales found 35%felt hopeless and 23%expressed suicide ideation (Simpson et al 2002). – 18% had attempted suicide post injury 16  Alcohol Use & TBI-Incidence Analysis of the Literature (Corrigan 1995) Alcohol, the drug of choice- Corrigan and his colleagues report that for 70% of TBI individuals with problem of substances abuse, alcohol is the preferred option. Intoxication - 7 studies looked at incidence of intoxication. Intoxication ranged from 36% to 50% at time of injury History of Substance Abuse - Findings also suggest adolescents and adults in rehabilitation following a TBI as much as 60% have histories of alcohol use or dependence. 17 Lengthy recovery I Anatomical reorganization or substitution (short-term recovery) – “spontaneous recovery” – & Axonal regeneration or sprouting – / Plasticity, neuo-regeneration Provide stimulation for the promotion of axonal growth + independence Functional -> ensure QoL adaptation or compensation: Functional compensation refers to the process by which individuals who have suffered damage to the CNS resulting in permanent injury compensate for deficits in various domains of functioning through the adaptive implementation of behavioral, cognitive, or physical strategies designed to enhance residual skills or to introduce alternative skills. Before the car accident, John could put on a tie with minimal visual reference, he performed the activity successfully through tactile and proprioceptive feedback of upper limbs. The TBI and the lesions he suffered had selectively affected his motor sensory feedback. With training, John managed to complete the task through visual feedback obtained from a mirror. Factors influencing the success of recovery nature of injury or damage (diffuse or focal) rate of injury (slow or sudden) severity of injury age of patient ability to re-learn environmental influences, social support timing of intervention/rehabilitation client’s attitudes (apart from age, personality, motivation….) Interaction effects of lesions on different cerebral lobes drugs and alcohol restriction… client’s insight on own circumstances 20 RS3330 Clinical Sciences for Medical & Neurological Conditions Traumatic Brain Injury in children and adolescent How is TBI in adults different (or the Same) from those Injured as children…? More optimistic due to better neuroplasticity One of the common causes is child abuse Dr Hoe Lee 1  Objectives 1. To describe the distinctive characteristics of peadiatric TBI that differ from adults 2. To understand the long-term impacts of TBI on occupational performance of children 3  Factors contributing to distinctive characteristics peadiatric TBI More serious consequences comparing with adults with same force bcz structurally different and bones not calcified (not rigid skeleton to protect the cerebral cortex) age-related anatomical and physiological differences mechanism of injuries based on physical ability of the child difficulty in neurological evaluation ---- advances in diagnostic tools (MRI) improve prognosis recently 4  Injury characteristics in age & development Newborns The surface of baby’s skull is full of vein Eg forceps or suction -> pressure on skull -> damage the veins Delivery head injury Intracranial hemorrhages Head Cephalic hematoma Subgaleal hematoma & b/w skin & skull Vein rupture -> leakage of blood in that space -> circulation of baby becomes unhealthy-> fatal *  Infants Accidental head injury Abusive Head Trauma Toddlers and School children Accidental head injury Adolescents Bicycle and motorcycle related accidents Sports- related head injuries  Management of peadiatric TBI Primary TBI – skull fracture – growing skull fracture into suture cranial bones – epidural hematoma, subdural hematoma, subarachnoid hemorrhage, diffuse axonal injury and intracerebral hematoma Secondary TBI – diffuse cerebral swelling  Prognosis and recovery Glasgow outcome – Good recovery (GR) – Moderate disability (MD) – severe disability (SD) – persistent vegetative state (PVS) – Death (D) Related to – Glasgow Coma Scale (3/12 to be coma) – Length of amnesia for the events surrounding the accident – Altered mental status 9 Effect of TBI during childhood or adolescence : Labelled as naught, hard to manage student in the skl Delayed cognitive abilities development of the stage Reduce rate of mental processing speed Diminished organizational abilities Mental inflexibility Difficulty self-monitoring and regulating emotional experiences As the consequence, produce – Patchy memory, inconsistent acquisition of new information – Mental fatigue – Stress and anxious – Poor frustration tolerance – Confusion, anger 10 Paediatric TBI Neuropsychiatric I Impairment/syndrome Attentional Impairment following Paediatric TBI Memory Impairment following Paediatric TBI Language Impairment following Paediatric TBI Intellectual Impairment following Paediatric TBI Executive Function Impairment following Paediatric TBI  Sequelae of TBI in children Neurological : Sleep disturbances Fatigue Headaches Sensory and motor: Loss of coordination, balance and motor planning abilities Difficulty perceiving sensation from fingers Difficulty maintaining awareness of body positions Blurred or double vision Hypersensitivity to sounds, tastes, smells or loss of smells Visual-perceptual distortions (affect child’s energy and availability for higher order cognitive activity) 12 Cognitive and emotional functioning: Often less obvious than the physical symptoms in younger age Likely to be more individualized Types and severity of problems depends on – Severity of injury – stage of development at the time of injury Previously learned and knowledge recovers quickly But emotional and social impact of TBI increases with age Adolescents be most prone to serious depression during recovery 13  TBI under the age of 10 Most reported problems are behavioral: Temper tantrums Unpredictable swings of emotion and display of emotion Non-compliance Resistance to change Impulsive, aggressive, and/or dangerous behavior 14  TBI during adolescence Symptoms are more subtle By adolescence, behavioral control should be well established and they have a solid foundation of academic, personal and social competencies Older child can draw on his/her previously learned information in school, while teacher may not recognize the impact of TBI on the ability to learn new material Slow rate of mental processing and difficulty organizing and managing complex information (N.B. very difficult to function in the quick-paced and complex world of the school classroom) 15  Post-injury return to school and social activity can be very confusing, agitating and disappointing – Activities that once were routine now require thought, planning and assistance – Feels overwhelmed by the pace of material being presented in class and feels discouraged by inability to keep up with the demands to process multiple sources of information simultaneously – Typical adolescent social life is spontaneous, with fewer rules and little predictability – easily overwhelmed by social areas, afraid of making a mistake (call attention to their problems), often withdraw and loss the support of peer groups – Injury may prevent or diminish their involvement in activities, like sports, physical activities, further increase stress and their loss of social support 16 Effects on family and the support system Disruption of family life Undue anxiety on parents for the future Feelings of isolation and abandonment by the system Excessive financial and legal demands High levels of stress in day-to-day routine Stress on friendships, relationships and support system 17  Trends affecting OT practice context Greater number of children survive TBI More children survive very serious TBI Spend less time in hospital rehabilitation program Return home, schools, community at an early stage to TBI recovery Responsibility for ongoing care (rehabilitation), often falls primarily on family, pediatrician and school personnel in the community 18