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BJ LeJeune, CRC, CVRT Mississippi State University.

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1 BJ LeJeune, CRC, CVRT Mississippi State University

2 What is it all about??

3 `Traumatic brain injury is an insult to the brain…caused by an external physical force, that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning. It can also result in the disturbance of behavioral or emotional functioning. These impairments may be either temporary or permanent and cause partial or total functional disability or psychosocial maladjustment.’

4  An acquired brain injury commonly results in a change in neuronal activity, which effects the physical integrity, the metabolic activity, or the functional ability of the cell. An acquired brain injury may result in mild, moderate, or severe impairments in one or more areas, including cognition, speech- language communication; memory; attention and concentration; reasoning; abstract thinking; physical functions; psychosocial behavior; and information processing.

5  Diffuse Axonal Injury  Concussion (mildest and most common)  Contusion (bruising)  Coup-Contrecoup Injury (two part blow)  Second Impact Syndrome "Recurrent Traumatic Brain Injury“  Skull Fracture  Penetration Injury  Shaken Baby Syndrome

6  Anoxia (lack of oxygen to the brain)  Brain Swelling – can restrict blood flow, oxygen and can lead to death  Hematoma (pool of blood)  Hypovolemic Shock (loss of blood in brain tissue)  Hydocephalus – build up of liquid that can cause a secondary brain injury  Increased Intracranial Pressure (ICP)  Seizure Disorders

7  Severity of insult to the brain  Length of time in coma  Deepness of coma  Functional physical and behavioral attributes  Area of the brain impacted may cause devastating effects of even a mild injury.

8  Range of high of 15 to low of 3 ◦ Higher the score the lower the degree of impairment. ◦ Mild Injury – ◦ Moderate injury 9-12 ◦ Severe – less than 8  Motor response (1-6)+ eye opening (1-4)+ verbal response (1-5)

9 Mild Brain Injury Severe Brain Injury  Loss of consciousness for less than 30 minutes  Glasgow Coma Scale  Post Trauma amnesia of <24 hours  Temporary or permanent altered mental or neurological state  Post concussion symptoms  Coma longer than 24 hours  Glasgow Coma Score 3-8  Bruising/ bleeding in the brain  Signs on EEG, CAT or MRI scans  Long Term Impairments on one or more areas of life (i.e. home, work, community)  Craniotomy - Surgical intervention Moderate Brain Injury Loss of consciousness for more than 30 minutes, but less than 24 hours Glasgow Coma Scale 8-12 Possible Scull fractures with bruising/bleeding Signs on EEG, CAT or MRI scans Some long term problems in one or more areas of life (i.e. home, work, community)

10  Pre-injury Health (General health, substance abuse, IQ, and previous brain injuries)  Nature and severity of injury (Severity, location, extent and complications)  Complications associated with injury (litigation, secondary injuries, other disabling conditions, etc.)  Post-injury course of recovery (Recovery time, continuum of care and psycho-social issues)  Network of support

11 Where is the injury and what is the impact?


13  Frontal Lobe- associated with reasoning, planning, speech, movement, emotions, personality, motivation, judgment, inhibition, and problem solving  Parietal Lobe- associated with sense of physical awareness, touch, movement, orientation, recognition, perception of stimuli

14  Occipital Lobe- associated with visual processing  Temporal Lobe- associated with perception and recognition of auditory stimuli, memory, taste, smell, putting things into memory, interpretation of words, organization of time, and speech

15  Visual-spatial impairment  Visual memory deficits  Left neglect (inattention to the left side of the body)  Decreased awareness of deficits  Altered creativity and music perception  Loss of “the big picture” type of thinking  Decreased control over left-sided body movements  Manic episodes

16  Difficulties in understanding language (receptive language)  Difficulties in speaking or verbal output (expressive language)  Catastrophic emotional reactions (depression, anxiety)  Verbal memory deficits  Impaired logic  Sequencing difficulties  Depression  Decreased control over right-sided body movements


18  Visual perception is a brain issue  The eye processes light and changes it to electronic impulses  The brain receives the impulses and changes them into an image  Visual understanding is a combination of the entry of light impulses to the brain and the brain’s ability to interpret those impulses.


20  Loss of half-field of vision in each eye  Characterized by bumping into things, visually missing door jams, etc.  Left side causes difficulty reading or noticing things on the left.

21  Treatment: Visual Field Awareness System (Dan Gottlieb)  Peli Lens  Training in scanning techniques

22  Most frequently person will neglect certain visual positions – usually on the left  Different from field losses  Tend to veer to the left when walking  Bump into things in the neglect area

23 Even visual memory may be missing the neglected area

24  Depth perception issues  Personal Boundary Issues – body space issues  Eyes functioning differently both in terms of movement and focal points  Complexity issues  Difficulty locating obvious objects – Kite in clear sky…

25  Learning to attend to areas of neglect  Scanning – perhaps with each step  Memory Issues – remembering to look

26  Saccadics (shifting gaze) Missing locations of items  Accommodative ability (inability to change focus)  Eye tracking (difficulty following movement)  Binocular abilities (Eye alignment/eye teaming)  Nystagmus – fairly common result of vision distruption from brain injury

27  Retraining/strengthening muscles for strabismus  Medicinal Options (Nystagmus – Xanex)  Rest – often worse when person is fatigued  Surgical Options

28  Eye strain can be related to dry eyes – caused by a number of things including lack of blink reflex  Confusion concerning content or recognizing words  Treatment: Frequent breaks, in some cases relearning reading, use of audio reading materials, artificial tears

29 fi uyo nca ared stih, uyo vhea a sgtraen nmdi too i dcnuotl lvbeiee tath I lcudo aulaclty seudnatndr awth I saw dranige. The hpaonmnale wpero of the mhuna nmdi, oaccdrgin to a srcheeahcr at mcabriged miuervtysi, it sden’to tmaert in wath eorrd the tlterse in a rwod are, the loyn piroamttn ithgn is atth the rfsti and slta tltere be in hte grhti cplea. hte srte can be a atolt smes and oyu can isllt arde it hwotuti a bpoerml. iths is cbuseea the uhanm nmid edos ont raed ervey lteter by sitlfe, ubt the rwod as a lwoeh. Zanmig huh? yaeh and I walysa tghuhto pslelign was ipmorattn!

30 Cna yuo raed tihs? fi yuo cna raed tihs, yuo hvae a sgtrane mnid too i cdnuolt blveiee taht I cluod aulaclty uesdnatnrd waht I was rdanieg. The phaonmneal pweor of the hmuan mnid, aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it dseno't mtaetr in waht oerdr the ltteres in a wrod are, the olny iproamtnt tihng is taht the frsit and lsat ltteer be in the rghit pclae. The rset can be a taotl mses and you can sitll raed it whotuit a pboerlm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Azanmig huh? yaeh and I awlyas tghuhot slpeling was ipmorantt!

31  Most frequent in the first year  Very real or awareness they are not real  Benign, threatening, traumatic  Charles Bonnet Syndrome

32  Increased sensitivity to light  Causes headaches, pain, anxiety  Photophobia  Treatment: Filters (amber, violet, brown with UV & BV protection)  wide brimmed hat

33  Inability to recognize faces, objects, letters  Concentration card game  Deficiencies are inclined to effect reading and spelling  Treatment: Developing  Memory Skills, Alternative strategies (50 First Dates)

34  Most common in children  blurred and double vision (lasts 6-12 months)  Can bring about the onset of vision related mannerisms (Blindisms)

35 What to expect post injury – the question everyone wants answered!

36  “There are three rules to be effective in helping someone with a severe brain injury become totally restored, but unfortunately no one knows what they are.”


38  Restoration – Life returns to what it was before. What they want. What they may believe.  Rehabilitation – Individual maintains some progress toward recovery, learns alternative strategies and develops a support system to meet needs where there will be no functional return. What they may get if they work hard and have appropriate support.  Status Quo – usually accompanied by depression and lack of personal, community or disability related resources. What often happens.

39  Neuroplasticity (also referred to as brain plasticity, cortical plasticity or cortical re- mapping) is the changing of neurons, the organization of their networks, and their function via new experiences....  Often thought of as the brain's ability, during infancy, to be altered by environmental stimulation as a child grows.  Now being applied to persons who have experienced injury to the brain and are relearning tasks and abilities they have always had.  Requires repetition, repetition, repetition.

40  The Rest Theory - Immediate to a year – rest, rest, rest. The brain needs to rebuild and reorganize. Rest. Do nothing.  The Active Theory – As soon as ICP is stable and the acute phases are over – get moving and get the blood flowing to the brain. Rest – exercise – rest – exercise…  Both – even early on in ICU, send as much nutrition to the brain as possible – ingest at least 2,000 calories per day.


42  TBI is a chronic disease process, one that fits the World Health Organization definition as having one or more of the following characteristics: it is permanent, caused by non-reversible pathological alterations, requires special training of the patient for rehabilitation, and/or may require a long period of observation, supervision, or care.  TBI is associated with increased incidences of seizures, sleep disorders, neurodegenerative diseases, neuroendocrine dysregulation, and psychiatric diseases, as well as physical symptoms that may arise and/or persist for months to years post-injury.

43  Brain injury rehabilitation involves two essential processes: 1.Restoration of functions that can be restored 2. Learning how to do things differently when functions cannot be restored to pre-injury level.

44  Current estimates state that at least 5.3 million Americans have a long-term or lifelong need for help to perform activities of daily living as a result of a TBI. In the Children's Health Act of 2000, Congress recognized that the estimated figure of 5.3 million Americans living with TBI-related disability is an under-count. This figure is based on the number of individuals discharged from a hospital following an overnight stay.

45  Strike these words from your vocabulary!  With brain injury comes insecurity, anxiety and sometimes an unwelcome dependency. If you don’t have someone to encourage and help you, you will likely not be able to be independent.  Grieving and depression are difficult to shake because of constant reminders of what you can no longer do.

46 What can be done to restore functioning and to find alternative methods of functioning?

47  Fatigue (insomnia)  Poor Time Management  Lack of ability to identify or solve problems  See self as pre-injury person. Difficulty self- regulating  Inappropriate social interactions (especially with frontal lobe injuries)  Easily distracted with difficulty returning to a task  Difficulty coping with noise, crowds, high stimulation environments and stress

48  Brain Injury Check List   Then, on a scale of 0 to 4 rate the effect of the impairment on you during the past 24 hours. For example: 0 = not present; 1 = minimal, present but does not interfere with activities; 2 = mild, some effect, interferes with activities but not disabling;3 = moderate, greatly interferes with activities; and a score of 4 = extremely disabling, unable to function.

49  Move person toward employability and independence.  Identify non-functional areas, and develop a plan to address those areas.  Coordinate resources – interact with a team including Certified Brain Injury Specialists

50  Evidence-based practice (EBP) "is the integration of best research evidence with clinical expertise and [consumer] values" (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000, p. 1). Clinical expertise refers to the use of practice skills and past experience to rapidly identify each [consumer's] unique circumstances and characteristics, "their individual risks and benefits of potential interventions, and their personal values and expectations" (p. 1).

51  Literature Review of Research Findings  Randomized Controlled Experimental Research  Unrandomized Controlled Experimental Research  Single Subject (Retrospective, Replicated)  Case Studies (Retrospective)  Expert Opinion

52  Article by Faydl, & McPherson: A Review of the Evidence  Systematic Literature Review  Goal 1 – To identify approaches most commonly used with persons with TBI  Goal 2 – To evaluate the evidence of prior research to determine effectiveness of various approaches

53  A Case Coordination Approach  Program-Based VR program based on the NYU Medical Center Head Trauma Model (Ben-Yishay, 1987)  Individualized Placement Model of Supportive Employment  Faydl, & McPherson rated findings as weak, moderate and strong evidence of effectiveness

54  Holistic approach based on individual assessments and implemented by a case manager  Focus on early intervention and continuity of care  Coordination of post-acute rehabilitation services with integration of VR services and appropriate and available community resources

55  Based on 9 research articles  Moderate evidence that it produces higher employment and productivity outcomes than previously reported.  80% in community based employment, 50% in paid competitive employment without any supports up to one year after placement.  Weak evidence that people who receive intervention in first year are placed in employment more quickly than those who did not receive intervention in the first 12 months.

56  Early and quick job placement with minimal pre-employment training. Training is primarily delivered in the context of the working environment.  Intervention is delivered almost entirely on- the-job by a job coach and continues until competency is reached.  Intervention time and depth are not limited or specified but evolve as needs arise.

57  Weak evidence that persons who were not employed post injury were able to become employed within the model.  Weak evidence that employment can last longer than 90 days  Outcome is competitive wage employment with on-going job coach support.

58  Based on NYU Medical Center Head Trauma Program model  Intensive individualized work skills rehabilitation and intervention in a structured environment (i.e. Center)  Guided work trials  Assisted job placement with transitional job support

59  Weak evidence that individuals have better vocational outcomes after completing a program  Weak evidence that people in this type program are more likely to gain competitive employment, work more hours and receive higher wages  Weak evidence that approximately half retain employment more than a year.


61  78 participants randomly selected from pool of 220 in Missouri.  Young, male, uneducated and relatively low intelligence with moderate and severe head injuries  Time from injury to VR referral approximately 9 years, number of jobs held in previous 3 years 2  1/3 had additional physical disabilities  1/5 had history of a learning disability  ¼ reported history of substance abuse  1/3 lived in rural areas – 1/2 in urban areas

62  Successful employment outcome for 17%  All but 2 in either industrial or service industry  10% unsuccessful,72% services interrupted  Reasons for unsuccessful closures (n=64) ◦ Client refused services 35 ◦ Failed to Cooperate11 ◦ Unable to contact client 4 ◦ Too severe a disability 4 ◦ Not severe enough 2 ◦ Unknown 8 ◦ This means 71% (n=64) of unsuccessful closures had some type of non-cooperation.

63  On-the-Job-Training  Counseling and Guidance

64  Providing VR services early in the rehabilitation process (question related to how early)  Create a supportive work environment  Provide cognitive skills training  Provide AT and train on its use  OJT helps (Johnstone, Vessell, Bounds et al, 2003)  Those with lowest rates of return to work (RTW) receive SSDI benefits


66  Behavioral Control must precede Cognitive and Physical Rehabilitation (Falconer)  Head Injured Individuals require tight structure in their daily lives to survive, grow and improve (Falconer).  The most effective rehabilitation following a head injury occurs in familiar settings. (Falconer)  To be effective, the entire family must be part of the rehabilitation process.

67  Avoid alcohol (for at least 2 years)  Keep your brain stimulated – keep learning new things.  Repetition, repetition, repetition – you are teaching your brain to think in different ways.  You will continue to improve, but you may not ever be exactly the same as before.  Self-examination is difficult, but it is the first step to improvement.  Find someone you trust to give you non- judgmental feedback

68  Initially, it is easier and more productive to modify the environment than the person.  At first, it is often difficult to reason with a person who has a severe head injury because they perceive themselves as functioning at their pre-injury levels and get frustrated when they cannot.  Repetition, Repetition, Repetition to improve brain plasticity. Patience is the key.  Always tell the Truth  Always be positive and encouraging.

69  Important to be able to: ◦ Identify areas that need work ◦ Plot progress and regressive areas ◦ Develop a plan  Brain Injury Self-Assessment Checklist In the last 24 hours have you noticed…  Three areas of functioning 1) intellect 2) emotionality 3) control  Rating scale 0 = not present, 1=minimal, 2=mild, 3 =moderate, 4 = extremely disabling

70  Memory  Easily distracted  Fear of loss of control  Mood swings  Easily fatigued  Trouble sleeping  Irresponsibility  Overly sensitive  Double vision  Blurred vision when fatigued

71  “Use metaphors frequently when trying to explain complex ideas.” (John Blyer)  Beware of “Cognitive Fatigue.” (John Byler)  “When you have a great success, be aware of the rebound of fatigue that often follows.” (John Byler)  “To speed up your recovery – go slow.” (Just Joe)  “Even a “mild” traumatic brain injury impacts your whole life.” (Fran Coleman – former CO legislator)

72  “Over stimulation is paralyzing. The more complex the situation, the more difficult it is to decide what to do - all input has equal value to you.” Gail Denton  “I thought I had a good attitude and I would get well – but, how many naps do you have to take?”  “People will tell you that you look great to encourage you, and if they are around you for short periods they will think you are fine – maybe even malingering. But you are not fine.”

73  “It is hard to realize that you can never live up to who you remember yourself being before the injury.” Lisa  “Failure and disrespect from colleagues is difficult to accept. Before my injury, I hardly ever experienced failure, now I fail all the time. But failure is not the opposite of success, it is part of success. You have to have the courage to keep trying through the pain… Support of family is critical.” Lisa

74  What can the person learn?  What strategies will enhance learning? ◦ Familiar settings ◦ Situational instruction ◦ At least daily, at time when the person is not fatigued. ◦ As much as possible, include a significant other  Brain Plasticity – In order to retrain the brain you must repeat, repeat, repeat.  Patience in the key for both the consumer and the instructor

75  Restructure the when’s, what’s, and where’s of instruction…  Old Lesson Plans will not work – small increments and repetition – work on generalizability  Need tangible reminders  Environment changes are more productive than trying to change people.

76 What every person wants ….

77 If you have worked with one person with a brain injury, you have met one person with a brain injury. Everyone is different. Rosa Schwarz Cifu, PhD

78 “You cannot reason with someone who has had a severe brain injury…” Nurse on Trauma Floor, UTMC – Knoxville, TN

79 It is often more productive to change environments rather than people (or bears)!


81  Ben-Yishay, Y., Silver, S.M., Piasetsky, E., and Ratok, J. (1987). Relationship Between Employability and Vocational Outcome after Intensive Holistic Cognitive Rehabilitation. Journal of Head Trauma Rehabilitation, 2(1), 35–48.  Brain Injury Association of America  Brainline  Defense and Brain Injury

82  Catalano, D., Pereira, A.P., Wu, M.Y., Ho, H., and Chan, F. (2006). Service patterns related to successful employment outcomes of persons with traumatic brain injury in Vocational Rehabilitation. NeuroRehabilitation, 21, 279–293.  Fadyl, J.K. and McPherson, K.M. (2009). Approaches to Vocational Rehabilitation after traumatic brain injury: A review of the evidence. Journal of Head Trauma Rehabilitation, 24, 195–212.

83  Falconer, Judith (2011) Recovering from Brain Injury: A continual process. Retrieved from  Johnstone, B., Vessel, R et al.(2003). Predictors of success for vocational rehabilitation clients with traumatic brain injury. Arch Phy Med, 84.

84  Masel, B. & Dewitt, D. (2010). Traumatic brain injury: A disease process not an event. Journal of NeuroTrauma 27,  Ownsworth, T. & McKenna, K. (2004). Investigation of factors related to employment outcome following traumatic brain injury. Disability and Rehabilitation, 26 (13)  Severe Brain Injury injury.comwww.severe-brain-

85  Traumatic Brain Injury Information Page  You look great!” – Inside a Traumatic Brain Injury, by John Byler Series of videos (1-6) dlI&feature=BFa&list=UU4rKJPrfkyM5g_mdnY HZe3A dlI&feature=BFa&list=UU4rKJPrfkyM5g_mdnY HZe3A  Just Joe Image  VR Research in Brief: Achieving Vocational Success after Traumatic Brain Injury. vrbriefs/vrbrief-success-after-tbi.pdf vrbriefs/vrbrief-success-after-tbi.pdf

86  “You look great!” – Inside a Traumatic Brain Injury, by John Byler Series of videos (1-6) ture=BFa&list=UU4rKJPrfkyM5g_mdnYHZe3A ture=BFa&list=UU4rKJPrfkyM5g_mdnYHZe3A  Don’t Give Up After Brain Injury eature=related eature=related  Understanding Traumatic Brain Injury nNOGJ0&feature=related nNOGJ0&feature=related

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