Severe Brain Injury and Vision Loss: What’s it all

about? BJ LeJeune, CRC, CVRT

Mississippi State University

Part 1: Review of Medical Aspects of Traumatic and

Acquired Brain InjuryWhat is it all about??

`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.’

TBIAdopted by the Brain Injury Association Board of Directors, February 22, 1986.

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.

ABIAdopted by the Brain Injury Association Board of Directors, March 14, 1997.

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

Types of Primary Traumatic Brain Injuries

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

Types of Secondary Injuries

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.

Severity Measures of Brain Injury

Range of high of 15 to low of 3◦ Higher the score the lower the degree of

impairment.◦ Mild Injury – 13-15◦ Moderate injury 9-12◦ Severe – less than 8

Motor response (1-6)+ eye opening (1-4)+ verbal response (1-5)

Glascow Coma Scale

Severity of Brain Injuries (Michigan Brain Injury Certification training program)

Mild Brain Injury

Severe Brain Injury

Loss of consciousness for less than 30 minutes

Glasgow Coma Scale 13-15

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)

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

Factors that may help Predict Outcomes following a Brain Injury

Brain MappingWhere is the injury and what is the impact?

Cerebrum Lobes

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

Major Brain Functions

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

Major Brain Functions

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

Possible Impairments to the Right Side of the Brain

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

Possible Impairments Related to the Left Side of the Brain

Most Common Types of Vision Problems related to Brain Injury

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.

Vision and the Brain

The brain interprets the visual environment…face or vase?

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.

Loss of Visual Field(Hemianopsia)

Treatment: Visual Field Awareness System (Dan Gottlieb)

Peli Lens Training in scanning techniques

Hemianopsia

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

Visual Neglect

Left side NeglectEven visual memory may be missing the neglected area

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…

Visual Spatial Disorders

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

Visual Spatial Disorders/NeglectTreatment Strategies

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

Impaired Eye Movements

Retraining/strengthening muscles for strabismus

Medicinal Options (Nystagmus – Xanex) Rest – often worse when person is fatigued Surgical Options

Treatment for Impaired Eye Movements

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

Eye Strain, Brain Strain and Difficulty Reading

fi uyo nca ared stih, uyo vhea a sgtraen nmdi tooi 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!

Can you read this?

Cna yuo raed tihs?fi yuo cna raed tihs, yuo hvae a sgtrane mnid tooi 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!

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

Visual Hallucinations

Increased sensitivity to light Causes headaches, pain, anxiety Photophobia

Treatment: Filters (amber, violet, brown with UV & BV protection) wide brimmed hat

Light Sensitivity

Inability to recognize faces, objects, letters Concentration card game Deficiencies are inclined to effect reading

and spelling

Treatment: Developing Memory Skills, Alternativestrategies (50 First Dates)

Impaired Visual Memory

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

mannerisms (Blindisms)

Post Traumatic Vision Syndrome

Severe Head Injury: Restoration, Rehabilitation

or Status QuoWhat to expect post injury – the question everyone wants answered!

“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.”

Misquoting Sommerset Maugham

My Case Study of one…Bobby

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.

Restoration, Rehab or Status Quo

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.

Brain Plasticity (neuroplasticity)

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.

Two Approaches to Brain Recovery

Perspective

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.

Traumatic Brain Injury: A disease process, not an event. (Masel, & Dewitt, 2010).

Brain injury rehabilitation involves two essential processes: 1. Restoration of functions that can be restored2. Learning how to do things differently when functions cannot be restored to pre-injury level.

Brain Injury Rehab (www.headinjury.com/rehabcognitive.html)

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.

Number One Complication in Recovery: Access to Appropriate Services

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.

Melingering and Co-Dependency

What is the Prognosis for Employment?

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

functioning?

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

Complicating Behavioral Issues

Brain Injury Check List http://www.headinjury.com/checktbi.htm 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.

Self-Assessment Self-Regulation

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

Vocational Rehabilitation Role

Evidence-Based Practice 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).

Levels of Best Research Evidence(Boothroyd,2006) Literature Review of Research Findings Randomized Controlled Experimental

Research Unrandomized Controlled Experimental

Research Single Subject (Retrospective, Replicated) Case Studies (Retrospective) Expert Opinion

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

Approaches of Vocational Rehabilitation after TBI

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

Three Primary Approaches

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

Case Coordination Approach

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.

Effectiveness

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.

Supportive Employment Model

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.

Effectiveness

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

Program Based VR Model

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.

Effectiveness

Other Levels of EB Research

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

Other Disabilities and Factors (Johnstone, Vessell, et al, 2003)

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 Cooperate 11◦ 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.

Employment Outcomes (Johnstone, et al study)

On-the-Job-Training Counseling and Guidance

Predictors of Success (Johnstone,

et al, 2003)

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

Evidence Based Suggestions to Enhance employability (VR Research Brief, 2008)

What strategies are important to enhance overall success?

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.

Case Study and Expert Opinion Levels of EB from Neuro-Psych Professionals

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

Tips from Varied Professionals….

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.

Expert Opinion Tips Con’t…

Important to be able to:◦ Identify areas that need work◦ Plot progress and regressive areas◦ Develop a plan

Brain Injury Self-Assessment Checklistwww.headinjury.com/checktbi.htm 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

Self-Assessment is Key

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

BI Self-Assessment sample items

“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)

Expert Opinion Tips from Consumers

“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.”

From Consumers…

“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

Lisa made it

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

Instructional Challenges: What do Job Coaches and Instructors need to know

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 aremore productive than trying to change people.

Instructional Tips

Provide a safe and comfortable environment of acceptance and value.

What every person wants ….

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

“You cannot reason with someone who has had a severe brain injury…”

Nurse on Trauma Floor, UTMC – Knoxville, TN

(early on...)

It is often moreproductive to change environments

rather than people (or bears)!

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 www.biausa.org

Brainline www.Brainline.org Defense and Brain Injury www.dvbic.org

Resources and References (R&R)

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.

R & R continued

Falconer, Judith (2011) Recovering from Brain Injury: A continual process. Retrieved from http://www.brain-train.com/articles/recoveri.htm

Johnstone, B., Vessel, R et al.(2003). Predictors of success for vocational rehabilitation clients with traumatic brain injury. Arch Phy Med, 84.

R & R Continued

Masel, B. & Dewitt, D. (2010). Traumatic brain injury: A disease process not an event. Journal of NeuroTrauma 27, 1529-1540.

Ownsworth, T. & McKenna, K. (2004). Investigation of factors related to employment outcome following traumatic brain injury. Disability and Rehabilitation, 26 (13) 765-784.

Severe Brain Injury www.severe-brain-injury.com

R & R Continued

Traumatic Brain Injury Information Page www.ninds.nih.gov

You look great!” – Inside a Traumatic Brain Injury, by John Byler Series of videos (1-6) http://www.youtube.com/watch?v=x9Xso4qGdlI&feature=BFa&list=UU4rKJPrfkyM5g_mdnYHZe3A

Just Joe Image www.justjoeimage.com VR Research in Brief: Achieving Vocational

Success after Traumatic Brain Injury . http://www2.ed.gov/rschstat/research/pubs/vrbriefs/vrbrief-success-after-tbi.pdf

R & R Continued

“You look great!” – Inside a Traumatic Brain Injury, by John Byler Series of videos (1-6) www.youtube.com/watch?v=x9Xso4qGdlI&feature=BFa&list=UU4rKJPrfkyM5g_mdnYHZe3A

Don’t Give Up After Brain Injury www.youtube.com/watch?v=R76RMK4EXUc&feature=related

Understanding Traumatic Brain Injury www.youtube.com/watch?v=9Wl4-nNOGJ0&feature=related

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