CBIS EXAM LATEST PRACTISE QUESTION 2024 SOLVED 100% VERSION 2 (V2) 200 QUESTION AND ANSWER 1. Nuerocognitive Issues Assoicated with Frontal Lobe Emotional control, behavioral control, verbal expression, problem solving, decision making, social control, attention, motivation 2. Acquired BI An injury to the brain that is not hereditary, congenital or degenerative or induced by birth trauma 3. TBI An alteration in brain function or other evidence of brain pathology, casused by an external force 4. 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 5. 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 6. Severe TBI Characteristics Loss of consciousness >24 hours, 3-8 on the GCS 7. Likelihood of Additional Injury 1 BI increases risk of 2nd by 3x and 2nd BI increases risk of 3rd by 8x! 8. Most Frequent Cause of TBI Falls 9. How many people sustain a BI per year? 2.5 million. 81% visit ED, 16% hsopitalized, 3% result in death 10. How many people are living with effects of a TBI? 13.5 million 11. Likelihood of BI by gender Men are 1.4x more likely than women 12. Most common cause of TBI and death by age - 75+ Falls! 13. Most common cause of TBI and death by age - 0-3 AHT! 14. Most common cause of TBI and death by age - 20-24 MVAs and Firearms 15. Most common cause of TBI and death by age - 16-19 MVAs! 16. 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 17. Joint Commission Accreditation agency for hospital based programs, may accompany CARF accreditation, ensures quality of services through requirements for accreditation and surveys 18. 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 19. 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 20. 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 21. Early Treatment for Mild TBI Relaxation techniques, rest, slow return to normal activity, and reduction of normal activity if symptoms recur 22. Peristent Post Concussive Symptoms (PPCS) Symptoms of Mild TBI last >1 month, occurs 10% of the time in Mild TBI cases 23. 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 24. Define Skull Bony shell that protects the brain, has bony prominences inside which can worsen brain injury 25. 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 Dura Mater - hard plastic, top layer 26. Nuerons vs Glial Cells Nuerons communicate electrical impulses throughout brain while Glial cells support and nourish Nuerons 27. Synapse A junction between the axon of one neuron and the dendrite of another, allows for passing of communication fro, nueron to neuron 28. Functions of the Parietal Lobe Sense of touch; differentiation of size, color, and shape; visual perception; spatial perception 29. Functions of the Occipital Lobe Visual functions 30. Functions of the Frontal Lobe Planning; organizing; problem solving; working memory; impulse control; decision making; personality; behavior; initiation; anticipation; self-monitoring; motor planning; emotions; awareness of abilities; attention; concentration; mental flexibility; speaking - all executive functions 31. Functions of the Temporal Lobe Hearing functions, memory, understanding language, organization and sequencing 32. Functions of the Brain Stem Breathing, HR, arousal, consciousness, sleep/wake functions, attention, concentration Transmits all sensory information from body to brain and movement signals from the brain to the body Contains sensory centers for hearing, touch, taste, and balance Even if the cerebral cortex is gravelly damaged, the brain stem can keep someone alive - or in a vegetative state 33. Functions of the Cerebellum Balance, coordination, skilled motor activity Reticular Activating System (RAS) Part of the brain stem - collection of nerve fibers that modulate changed in arousal, alertness, concentration, and biological rhythms Can be turned down or up much like a light dimmer switch - i.e during a coma, it is turned down - if turned down too much, can result in death Medulla Part of the brain stem- responsible for basic living functions such as breathing, HR, BP, swallowing, and vomiting Pons Part of the brain stem- responsible for facial movements, facial sensation, hearing and coordinating eye movements Serves as a bridge between the cerebral cortex (thinking part of brain) and cerebellum (moving part of brain) Damage can cause decreased coordination and poor control of body movements Midbrain Part of the brain stem - responsible for elementary forms of seeing and hearing, alertness, arousal Thalamus Part of the diencephalon - major relay station for incoming and outgoing sensory information except for smell Hypothalamus Part of the diencephalon - control center for hunger, thirst, sexual responses, endocrine levels, temperature regulation, hormone release "The conductor of the emotional orchestra" Functions of the Limbic System Drives basic instincts, "animal-like" aspects of a human - if damaged can cause emotional responses that can become uncontrollable Amygdala Part of the limbic system - responsible for emotional memories, closely tied to sense of smell "Fight of flight structure" Hippocampus Part of the limbic system - responsible for the organization of memories Described at the pole in a closet - without pole, all clothing falls - without hippocampus memories become disorganized Basal Ganglia Part of the limbic system - relays information from cerebral cortex to brain stem and cerebellum for movement, the checking system that comes to attention when things are not working as they should be i.e. restoring equilibrium Cerebellum Governs a person's movements by controlling rate, direction, force and steadiness of movements Cerebral Cortex Made up of right and left hemisphere and corpus collosum Functions of the Right Hemisphere Holistic, visual spatial and , intuitive in nature Associated with art, shapes, music, and faces Functions of Left Hemipshere Linear, verbal-analytic, logical in nature Associated with speaking, reading, and calculating 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 Acute vs. Chronic Headaches Short vs lasting atleast 15 days out of a month for atleast 3 months, cannot be linked to withdrawal of medication and must have occurred within 14 days of TBI to be considered post traumatic head ache Tension Headache Described as bilateral head pain, "clamping", caused by head or neck muscle strain. Not associated with any other symptoms and does not worsen with PA. Craniomandibular Headache Associated with temporal-madibular joint, often causes difficulty with eating and talking Cervicogenic Headache Generated from the cervical spine, clinical diagnosis in made with the use of nerve block Migraines Located on one side of head or the other; lasts 4-72 hours; worsens with heat, light and exercises 4 phases: Prodrome (pre-headache symptoms), Aura, Headache, Postdrome (symptoms following headache) Can be treated with caffeine, NSAIDS, bata blockers, environmental changes, and narcotics (last resort) COLDER Acronym used to help diagnose and assist in treating headaches Character Onset Location Duration and frequency Exacerbation Relief Percentage of physical complications existing >2 years post TBI 30%! Spasticity Increase in muscle tone, tendon reflexes, and involuntary velocity of movements Treated multimodally with with meds (i.e. baclofen, diazepam, etc.) OT and PT services Heterotrophic Ossification (HO) Formation of new bone around joints due to trauma or immobility Can cause severe pain, decreased ROM, and increased spasticity Treated with NSAIDS, PT, and sometimes surgery Contractures Shortening of tendons and muscles causing decreased ROM Treated with combination of meds, splinting, casting, PT, OT, etc. Hyperreflexia Bladder emptying that is triggered easily, overactive and overresponsive reflexes Pressure Sores Occur most often near bony prominences due to decreased mobility and lack of sensation Can be avoided by keeping skin clean and dry, turning schedules (every 2 hours), specialty cushion/mattress, and tilt in space W/Cs Stage 1 (non blanchable redness) Stage 2 (shallow open ulcer with red or pink wound bed or blister) Stage 3 (subcutaneous fat visible, may have undermining or tunneling) Stage 4 (exposed bone, muscle, or tendon) Unstageable (colorful wound bed) Deep Tissue Injury Purple, maroon localized area caused by damage of underlying soft tissue Agnosia Perceptual defecit associated with BI Inability to recognize Anosagnosia Perceptual defecit associated with BI Inability to recognize own defecits or disabling condtion Somatoagnosia Perceptual defecit associated with BI Inability to recognize body part of structure Apraxia Perceptual defecit associated with BI Absence of Spatial Relations Disorder Perceptual defecit associated with BI Inability to perceive space between objects Form Discrimination Disorder Perceptual defecit associated with BI Challenge with orientation and similar shapes Vertical Disorientation Perceptual defecit associated with BI 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 Can last up to 10 days Management of Coma-Emergent Agitation Use consistent and familiar staff, environmental alteration to decrease triggers, provide familiar objects, reduce stimuli, establish predictable routines Stability Triangle Model that suggests you must establish medical stability, develop stable activity plan and promote stable behavior in order to achieve stability ABA Method of behavior change - discovers variables that predict behavior to modify antecedents to illicit behavior change 3 components - the environment, the individual, and the target behavior Behavior Change Process Assess behavior -> define target behavior -> collect data -> change behavior Operation Any that variable that temporarily alters effectiveness of some stimulus of event as a reinforcer Example of Intermittent Reinforcement Slot Machine Example of Continous Reinforcement Soda Machine Positive Reinforcement A stimulus is added, likelihood of behavior increases I.e. student gets As on report card and earns $20 Positive Punishment A stimulus is added, likelihood of behavior decreases I.e. driver speeds, officer gives $100 ticket Negative Reinforcement A stimulus is removed, likelihood of behvaior increases I.e. child puts toy away, avoids being nagged by parent Negative Punishment A stimulus is removed, likelihood of behavior decreases I.e. siblings fight over toy, parent takes away toy Functionally Equivalent Altneratives to Behavior Modification Prompting, Cuing, Shaping, Fading, Generalization and Discrimination Nueropsychology Assessment Process Medical record review -> clinical review -> standardized testing -> report and feedback Assessment short in acute settings but more in depth when post acute Cognitive Rehab Process Cognitive Education (awareness of defecits) -> Cognitive Training (restoring cognitive/psych defecits) -> Strategy Training (compensatory approaches) -> Functional Training (real-world application) Areas of the Brain Associated with Increased Psychiatric Co-morbidity Left frontal gray matter reduction, lateral and medial frontal lobe lesions, amygdaloid and hippocampus lesions, basal ganglia lesions, changes in balance and production of nuerotransmitters. (Dopamine, glutamate, serotonin) Depression and TBI Symptoms: changes in appetite, weight gain, suicidal ideations, depressed mood, tiredness Risk Factors: change in socioeconomic status , preinury pathologies MOST COMMON co-morbid psychiatric illness Organic Personality Disorder and TBI Symptoms: Depression, emotional instability, irritability, impulsivity, changes in behavior prior to injury due to an organic impairment or disease of CNS 23% of people with TBI experience OPD Pseudo Bulbar Affect and TBI Symptoms: Uncontrollable episodes of laughing or crying, catastrophic reactions A result of TBI or other nueroglogical disorder Substance Use Disorder (SUD) and TBI Involves continued use of substance despite health, psychological or social consequences Exacerbates effects of TBI including memory, judgment, behavior, and generalization impairments 12% of people 16 and older with TBI used a month prior to injury Use of substances before injury increase risk of reusing x10 As many as 50% of users will use again after injury Screening Tools for SUD ASSIST, CAGE, AUDIT, CRAFFT 4 Quadrant Treament for SUD and TBI Co-Committance Quadrant 1 - low severity TBI and SUD - receive treatment in acute medical setting - brief intervention 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 nonjudgmental 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 Family Systems Theory Families are considered to be the experts, every family has their own way of communication and functioning that will influence reception of rehab Assumes that families have the strength and capacity to solve problems and be successful Family Centered Services The survivor, family and provider are partners in healthcare. Care should be tailored to individuals and family strengths and values. Cognitive Behavioral Family Theory A - Activating Event - family has no control (medical deicisions and the accident itself) B- Belief - family has control over (i.e. "this will be the end of our family" vs "we can do this") C- Consequence of Belief - family has control over (feeling hopeless vs seeing progress and feeling encouraged) Brain Injury Family Interventions (BIFI) 90-120 minute sessions focused on familial support for families of individuals with BI Session focuses may include what's normal after BI, coping strategies and loss etc. Primary Blast Inury vs. Secondary Blast Injury Caused by direct impact from over-pressure wave, compresses air filled organ or catapults body backwards vs energized debris and explosive fragments that impact on head or body Tertiary Blast Injury Body impacts the wall, ground, or object Quarternary Blast Inury Inhalation of toxic gases or substances Mild TBI and PTSD This severity of TBI has highest rate of co-mittal PTSD at 44% Components of Return to Military Duty Medical Evaluation Board - physician informally determines if a soldier can meet medical retention standards Physical Evaluation Board - a formal fitness for duty and disability determination and eligibility for compensation Screening and Testing for Military Related TBI Military Acute Concussion Evaluation, Nuerobehavior Symptom Inventory, State Strait Axiety Inventory, The ANAM Simple Reaction Time and Continuous Performance Subtests, Repeatable Battery for the Assessment of Nueropsychological Status Patients' Bill Of Rights Written guarantee of basic rights for individuals in treatment programs. Staff are accountable to adhere to rights by law. Power of Attorney A document where a competent person appoints other person to act for him or her in legal and fincancial situations Guardianship A legally-enforceable arrangement in which the guardian has the right and duty to care for another - can be a guardian or the person and estate Plenary Guardianship- accounted by the court for person and estate Exploitation The process of making bad, or improper use of, violating, injuring, or taking bad advantage of. Using for one's own profit or selfish purposes Neglect The failure to provide necessary care, assistance, or guidance that causes or is likely to cause physical, mental, or emotional harm or damage to/loss of assets. Legal Use of Restraint Restraint must be used as a last resort after all other non-restrictive strategies prove unsuccessful and person is putting self- or other in immediate danger i.e. using prescribed medications, bed rails, W/C seatbelts Misuse of restraint is a violation of constitutional rights Care Management Process Assess -> Plan -> Faciliate/Implement -> Coorindate -> Monitor -> Evaluate Focuses on resource utilization, management, psychosocial and economic supports, rehab, outcomes, and ethical/legal processes Life Care Plan Plans written to encompass full understanding of injuries and resultant disabilties, considers all possible complications and co-morbities - from time of injury to death. Focuses on short term and long term needs and is individualized. A "road map" for services Reliability Measures consistently when applied to different individuals, at different times and in different situations - refers to the repeatability and consistency of a measure Validity The degree to which an instrument actually measures what it is intended to measure i.e. the FIM is a valid measure of level of A and functional ability but not of quality of life Widely Accepted Instruments that have withstood substantial rigor in the scientific community and are endorsed for use without being subject to question Popular Measures Early After Injury Glasgow Coma Scale (GCS) - scored 3-15, measures eye opening, verbal response, and motor response Ranchos Los Amigos - scored 1-10, based on intent and appropriateness of responses and level of A. Used to assess cognitive functioning of people with BI post coma 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