• spatially distributed - "Gesault" - getting hte whole
• F0 processing; music & melody
• spatial temporal processing --> getting the full image
• deficits here are non-linear, spatially distributed arrays
• contemporary - collaboration of hemispheres; work together to achieve goals (produce & regulate behavior)

1. egocentric
2. social convetions - pragmatically incorrect
3. unaware of limitations - extremely impulsive
4. tangential/rambling of speech - not organized - talk a lot/say a lot w/ little or new info/content
5. no abstract/implied meaning - cannot reason or infer
6. cannot grasp significance of complex events

1. disturbed or incomplete mental representaion of external visuospatial relationships
• cab't analyze information & integrate to whole - seeng parts, no composite
2. impaired attention - hard to keep on taks (highly distractable)

**perceptual deficits will be 1 or combination of both**

1. neglect
2. denial of illness
3. constructional impairment
4. topographical impairment
5. geographic disorientation
6. visuoperceptual impairments
7. facial recognition deficits

Perceptual impairment:

1) hemispatial neglect

• hemispatial neglect - failure to respond to stimuli of 1 side opposite side of brain injury
• common/severe in RIGHT PARIETAL INJURY (supramarginal & angular gyrus)
• may co-occur with partial or complete visual field blidness
• if it does not resolve/improve in days/weeks must address in Treatment (Tx)

symptoms of hemispatial neglect (left)

**never their fault, always someone else's/something else's fault**

• failure to respond to people, sound, objects, etc. - left of midline
• attend to only right side in grooming/self-care
• bump into walls on left side
• read only right side of printed materias
• displace writing to right side
• diminished awareness of language - simliar to Wernicke's  - does not manage output

Perceptual Impairments

What are the 4 proposed theories on neglect?

1. representational theories - neglect caused by disturbed mental representation of external space (udnerlying perceptual deficit)
2. arousal theories - perceptual systems are less responsive to stimuli
3. attention engagement theories - difficulty directing attn. to neglected side
4. attentional disengagement theories - not attending to stimuli

Perceptual Impairments:

2) denial of illness - agnosogia

• common with right parietal injury
• ranges in difficulty:
• acknowledges, but indifferent
• underestimate effects & severity
• disavows existence of disability
• denies ownership of limbs
• claims to perform activites beyond abilites
• may ignore errors, confabulate, argue, & justify when confronted

Perceptual Impairments:

3) Constructional Impairments

• visuospatial, perceptual, organization impairements
• **parietal-occipital dmaage**
• responds quickly or impulsively
• proportions are inaccurate - lines are distorted - problems w/ drawing/reproducting

Percetpual Impairments:

3) Constructional Impairments - Frequency of Errors

• leave details out on left side
• add lines, rotate, and fragment drawings when copying
• 3D becomes a 2D drawing
• displaced to right side, disorganized & crowded (clock drawing)

Perceptual Impairments:

4) Topographic Impairment

• distorted internal representaitons of external space - don't see/understand external space
• difficulty orientating to extra-personal space
• following familiar routes - lost easily
• reading maps
• giving directions
• failure to attend to visual cues
• fail to recognize landmarks or learn new ones

Perceptual Impairments:

5) Geographic Disorientation - less common than topographic, but can co-occur

• disoriented to:
• where they are - confused
• familar people
• location
• *distinct to time and place*
• recognize general nature of surroundings, but mistaken as to locality
• distinct from oritentation to time & speech
• due to difficulty inferring location from cues surrounding

Perceptual Impairments:

6) Visuosperceptual Impairments

• difficulty identifying objects, picutres, or drawings in unusual formats - because of orientation/relationship is different
• formats: incomplete, degraded/distorted
• superimposed line drawings of objects
• fragmetned object forms in unusual orientation and/or size
• can describe, but cannot identify
• poor organization of information into coherent rep. of stimulus

Perceptual Impairments:

7) facial recognition deficits - prosopagnosia

• failure to recognize familiar people by facial features
• may affect perception of cartoons, line-drawn faces & photographs
• posterior RHD  - if persistent may be bilateral

1. appreciation of prosodic cues - don't appreciate inflection
2. facial expression & interpreting
3. emotinal tones related to sterotypical emotional situations - don't appreciate affects (laugh @ funerals)

**don't convey their own emotion (vocal or facial)**

• focusing, maintaining, and shifting attention = difficult
• impairments have varied effects:
• highly distractable in Tx activities
• intereferes w/ ADLs - grooming, cooking, et. - get caught up in irrelevant details
• difficult to determine overall meaning of situations/events

• difficult to spearate relevant vs. irrelevant
• inability to maintain app. interaction patterns with conversational partners - important - difficulty carrying on a conversation; can't shift quickly
• decreased maintence of coherence in speech & writing - lack of organization & sequencing

1. arousal
2. vigilance
3. orientation
4. sustained attentinon
5. selective attention
6. alternating attention
7. divided attention

1. diminished speech prosody
2. anomalous content & organization connected speech
3. impaired comprehension of narratives & conversations
4. pragmatic impairments

Communicative Impairment:

1) Diminished speech prosody - robot like

• reduced stress in phrases & sentennces
• influction is restricted - diminished pitch
• slower rate
• failure to distinguish between questions & assertions

Communicative Impairments:

2) Anamoalous content & organization of connected speech

• confabulated & sometimes inappropriate speech (repetitive, irrelevant, tangential, disgressive)
• use more words, but produce less info - lacks content in terms of information
• apparent in narrative production - cookie theft picture

Communicative Impairments:

3) impaired comprehension of narratives & conversations

• no cause/effect
• premature assumptions, cannot reject/revise - impulsive
• fails to judge appropriateness of event
• does not appreciate implied meaning
• performance depends upon context

1. Suppression deficit hypothesis - cannot suppress initially activated assumptions or inferences
2. Theory of Mind -inability to appreciate content of other people's minds

Communicative Impairment:

4) Pragmatic Impairments - common ** work on**

• literal interpretation
• will not establish relationship of events
• difficulty interpreting emotional/body posture
• affect social & itneractional aspects of language
• turntaking, topic maintentance, social conventions (Saying hello), eye contact, repairs
• shift topic --<perservate on previous topic

1. Standardize Procedures
2. Non-standardized procedures
3. pragmatic assessments
4. visual & spatial perception, organization, & attention

Assessing Adults w/ RHD:

Standardized Procedures

1. RH Lang Battery
2. mini inventory of RBI - clock drawing - can be used to identify RHD; strengths/weakness; guide treatment & document progress ** BEST SCREENING TEST **
3. RICE-R - rating scale; 4 tests of visual scanning & tracking; metaphoric language test
4. BICC - assessing cognition comm. dysfunction in RHD adults
5. Evanston Northwestern Healthcare - RH screen - only screen selected items (long test)

Assessing adults with RHD:

Non-Standardized Procedures

1. Gordon & associates protocol - visual scanning & attention; ADLs skills; sensorimotor integration; visual integration; higher cog & percept functions; linguistic & cognitive flexibility, affective state

Assessing Adults with RHD:

Pragmatic Assessments

1. rating scales
2. RHLB - supportive routines; assertive routines; formality - lang & behavior; turn-taking - rules of conv
3. RICE-R (rating scale)L nonverbal comm; conversational skills, use of ling. context; referencing skills
4. Test of pragmatic abilities - not designed exclusively for RHD

Assessing Adults with RHD:

visual & spatial perception, attention, & organization

• cancellation tasks
• line bisection tests - mark the middle of the line
• copying & drawing tests
• drawing from memory test - clock
• scanning test
• identify incomplete/fragmented visual stimuli
• figure-ground discrimination - airplane w/ lines or bike behind fence

Treating Adults w/ RHD - they have more diffuse comm. impairments that are less amenable to quantification (when compared to LHD)

Cognitive Behavioral Abnormalities (treatment) 4 target areas

1. indifference & denial
2. attention impairments and distractabilities
3. impulsivity
4. impaired reasoning and problem solving

Cognitive Behavioral Abnormalities:

1) Indifference & denial

Cognitive Behavioral Abnormalities

2) attention impairments & distractabilities

• paper & pencil tasks (concrete-no denying errors)
• targets:
• sustained attention, selective attention, alternating attention or divided attention
• must add variations and make more applicable to daily living situations

Cognitive Behavioral Abnormalities

3) impulsivity

• stop and go signals (external) progressively treated/shaped to patient - generated self-cues
• reasoning & problem solving
• give possible solutions (2) & reasons why not correct

Cognitive Behavioral Abnormalities

4) impaired resoning & problem solving

• role play problem solving - must rehearse alternatives to making decisions & acting
• they do not recognize own erros but quick to point out others
• mimic behvior to help point out/identify their errors

Treatment: Communicative Impairments (4)

1. affective communication & prosody
2. reading impairments
3. pragmatic impairments
4. inferencing failures

Treatment: Communicative Impairments

1) affective communication & prosody

• need to discriminate/recognize emotion
• imitate --> produce
• on command
• need to watch video tapes; see people itneracting, what are the people talking about? - emotions - how would you know?
• patients don't understand facial expressions or body language
• **work on ability to comprehend & express**

Treatment: Communicative Impairments

2) Reading impairments

• visual neglect - common target treatment - because neglect impacts reading & comprehend printed material
• treated w/ external cues to shift to the left side of printed materials
• heightens pt's awareness of left space or by activities that enhance gen. attn process
• games - life, candyland, bingo, dominos, checkers (atn, spatial process, reasoning), "I Spy"
• tray with fake food - What are you having for lunch today?  - get them to shift their focus to other portions of plate

Treatment: Communicative Impairments

3) Pragmatic Impairments

• preserved verbal skills -build upon
• Tx include coaching & structured practice with compensatory skills
• eye contact, turn-taking, and topic maintenance
• "where should your eyes be?"

Treatment: Communicative Impairments:

4) inference failure - impairment making inferences

• Tx should focus on making inferences
• appropriate acitivites:
• appreciate humor - punchline
• app. implied meaning, metaphors, idioms
• verbal and picturoal absurdities- not much time spent on
• **compr. of implied information in discourse
• **retelling stories (seq. & org) prefer writing **
• **perceiving relationships**

• tend ot no spontaneously generalize responses or strategies from 1 context ot another
• progress through sucessive levels of Tx may be slowed because of failure to apply skills

• can be enhanced by making task source resemble the target task
• loose-traning - prevents Pt from beomcing too tightly bound to a restricted set of conditions - allows for variations

**use a wide range of reinforcement**

• need to practice mroe than a couple of times; need to exhibit appropriate behaviors over 3 consecutive sessions
• incorparte aspects of target evironment to Tx activities
• train self-instruction & verbal mediation
• invlove family members, caregivers, friends, etc. in Tx

• look left
• create pattern behavios; make associations (allows for generalizations)
• always try to take to a natural context
• diminish exact conditions (generalize)
• self-talk, think through - self-correct, work through: "what is the first thing I do?"
• always give HW  related to Tx goals - make sure they can do it in therapy before sending it home
• orientaiton problems: calendar (mark days off) guest registry

• substance abuse
• school adjustment (poor) & social history (rebels)
• low SES
• personality types - impulsive
• history of TBIs (3x greater)
• high risk

1. Pepetrating
2. non-penetrating

Types of TBIs

Penetrating Injuries

• missles & blunt instruments (club); high velocity (90% fatal) low velocity (40%) fatal
• skull is perforated & meninges are usually torn
• **foreign matter w/ missle affects nervous system**
• brainstem penetrating - significant problems if the pt lives - typically fatal or paralysis (loss of function)
• those who survive = focal physical and cognitive and linguistic deficits reflecting site of injury

TBI types:

2) Non pepenetrating - what are the types (3)

meninges intact, no forgein substance in the brain

1. non-acceleration
2. acceleration injuries
3. traumatic injuries

TBI type: Non-penetrating:

non-acceleration - struck in the head with an object

3 types of non acceleration

1. impression trauma
2. elliposidal deformation
3. skull fracture

TBI: non-penetrating: non-accelerating:

Impression trauma

TBI: non-penetrating: non-accelerating:

elliposidal deformation

• skull forced from usual shape (oval) --> circular
• increase the volume, which leads to increased pressure & expands the structures
• causes tissu shearing (ripping, pullin, stretching), bleeding & swelling
• the swelling is what leads to death (secondary consequence to bleeding)

TBI: non-penetrating: non-accelerating:

skull fracture

• crack, not complete break (at base of skull) - damage to cranial nerves or carotid arteries
• dangerous because if meninges are torn because of bleeding of vessel, it could lead to potential infection by bacteria penetrating damaged meninges

TBI: non-penetrating: acceleration injuries:

What is it? What are the types of acceleration injuries?

• move quickly and suddenly stop - the sudden acceleration or deceleration of head (whiplash)
• brain & brainstem suffer diffused damage caused by movement in the skull due to intertial forces

1. linear acceleration
2. angular acceleration

TBI: non-penetrating: acceleration injuries:

linear acceleration

• head suddenly accelerated by outside force - moving along a linear path aligned with central axis of head
• bruises/abrasions on brain surface
• mismatch in deceleration compresses brain against inner surface of skull opposite point of initial impact

TBI: non-penetrating: acceleration injuries:

linear acceleration

coup, contre coup, inertial lag, translational trauma

• inertial lag - of the brain causes it to be compressed against skull at point of impact
• coup injuries - damage at point of impact
• contre coup - localized damage in another area -- more diffused damage
• translational trauma - focal damage to meninges, brain, cortex, and underlying subcortical tissue ** front or back of the head**

TBI: non-penetrating: acceleration injuries:

2) angular acceleration

• blunt force applied at an angle causing the skull and its contents to rotate away from the point of impact
• lag of intertia of skull mvm, generating twisting & shearing forces
• wertebrae & neck muscles stop mvmt, causing rebound in opposite direct
• **tissue damages = more midline structures**
• produce more sever brain injuries than linear
• the brain's inertia causes it to continue to rotate its original direction for a few milisec & causes second episode of twisting & shearing forces in axial structures

TBI: non-penetrating:

acceleration injuries

(4)

• cranial nerve damage
• diffuse axonal injury (attention, perception, behavioral problems w/ TBI)
• vegetative state
• axonal degeneration

TBI: non-penetrating: acceleration injuries

Vegetative State

• caused by widespread diffused axonal injury
• patient has sleep/wake cylce, but makes no purposeful movements
• results from severe, diffuse damage to cortical & subcortical regions with relative preservation of the brainstem
• **inertial force, rather than tearing of axons cause vegetative state**

TBI: non-penetrating: acceleration injuries

axonal degeneration

• 1-2 days post, the stretched axons swell, separate from cell bodies & then the dendrite
• affectts some axons in region while leaving others untouched
• deafferentaiton - spotty pattern of loss of input to a neuron from others

TBI: non-penetrating: acceleration injuries

What happens - 2 things ?

1. brain tries to recover, build new pathways to damaged areas = collateral sprouting or dendritic proliferation (send intact axon terminals into regions of deafferentation) 
2. repair process may partially account for physiologic recovery in patients w/ mild-moderate TBI

TBI: non-penetrating: traumatic injuries

4 types

• cuts & bruises on the brain surface, twisting, and shearing within brain causes bleeding (hemorrhage) and accumlulation of blood (hematoma)
• epidural hematoma
• subdural hematoma
• subarachnoid hematoma
• intracranial hematoma

TBI: non-penetrating: traumatic injuries

epidural hematoma

subdural hematoma

1. epidural hematoma - blood accumulates between dura & skull
2. subdural hematoma - accumulation of blood between dura & arachnoid
• MVAs most common cause: lacerations of cortical blood vessels by abrasions & contusions on brain

TBI: non-penetrating: traumatic injuries

subarachnoid hematoma

intracerebral hematoma

**can die quickly with these 2**

1. subarachnoid hematoma - in a non-vascular area - blood vessels from pia rupture
2. intracerebral hematoma - rupture of blood vessels within the brain
1. usually occur/develop in subcortical white matter, B.G., & brainstem

What are some secondary consequences of TBI? - represents the brain's response to trauma (more devestating)

6 types

1. cerebral edema
2. traumatic hyrocephalus
3. elevated intracranial pressure
4. ischemic brain damage
5. cerebral vasopasm
6. alterations in blood-brain-barrier

Secondary Consequences of TBI:

cerebral edema

traumatic hyrocephalus

1. cerebral edema- accumluation of fluid due to trauma --> causes tissue to swell
• increased intracranial pressure - occurs around the primary site of injury
2. traumatic hyrocephalus - tissue compresses passage of CSF (swelling) - ventricles & subarachnoid
• accumulate CSD -->enlargement of ventricles --> takes up more space

Secondary Consequences of TBI:

elevated intracranial pressure

ischemic brain damage

cerebral vasopasm

1. elevated intracranial pressure - most frequent cause of TBI death; build up of pressure w/in cranial vault
• elevated pressure compresses & displaces tissue
• reults in herniation
• prolonged intracranial pressure --> irreversible brain damage, coma, & death
2. ischemic brain damage - insufficent O2 to brain tissues
3. cerebral vasopasm - walls around blood vessels have contractions & spasm; corical arteries from subarachnoid hemorrhage are affected most frequently
   

Secondary Consequences of TBI:

alternations in blood-brain barrier

• protective barrier - keeps foreign matter out - allow substances to normally exclude from blood to brain, into the brain (now)
• causes cerebral edema (swelling)

**primary & secondary phsyical consequences of TBI are important determinants of eventual level of recall**

What are the 4 prognostic indicators?

1. duration of coma
2. duration of post-traumatic amnesia
3. patient related variables
4. behavior & cognitive recover

Prognostic Indicator:

1) duration of coma

2) duration of post-traumatic amnesia

1. duration of coma - deeper & longer lasting comas associated with poor recovery
• Glasgow - simple & quick - used most often; used immediately post injury; rating eye opening, verbal responses, and motor responses
• Com. Level Conciousness Scale - broader range of responses & is more sensitive than Glasgow
2. duration of Post traumatic amnesia -time post coma during which pt is unable to store new information & experiences in memor
• GOAT; Rancho Los Amigos Scale of Cog. Levels; Disability Rating Scale

Prognostic Indicator:

Patient related variables

behavioral and cognitive recover

1. patient related variables:
• age - younger, the better recovery - system can regenerate (heal quicker)
• substance abuse (prior) - negative effect; longer coma & hospitalization
• premorbid intelligence - release of inhibition - persisting changes of personality
• SES
2. behavioral & cognitive recovery
• step wise fashion; little to no "rapid" mvmt

1. level of consciousness & responsiveness to stimulation
2. orientation
3. cognitive & comm. abilities
• tonic alertness & phasic alertness
• attention: sustained, selective, alternating, divided
• memory: pre-traumatic & post-traumatic
• visual processing
4. executive function
5. language & communication

Assessing Adults w/ TBIs

1. level of consciousness & responsiveness to stimulation

• alertness & responses to stimuli
• Glasgow - general estimate
• sleep/wake cycles & ease of arousal from sleep
• responses to environmental stimuli (tv/radio)
• responsiveness to speech & commands
• visual & tactile stimulation
• response to olfactory & taste stimul
• **use scales & augment ratings w/ observations
• **frequency & nature of responses to stimuli (multimodality)
• **TBIs are most responsive in the mornings

Assessing Adults w/ TBIs

2. orientation

• person, place, time
• awareness of self & appreciation of how one is related to others and environment
• place - immediate environment - where are you now? city, state, country, etc.
• time - "how long do you think I have been here?"
• screenings - mini mental or GOAT

Assessing Adults w/ TBIs

3. cognitive & communication abilities

Alertness & Attention

• Alertness:
• tonic - ongoing/continuing receptively to stimulation
• phasic-  momentary rapidly occurring changes in receptivity to stimulation
• Attention - UNIVERSAL CONSQUENCE OF TBI
• sustained - over time maintaining
• selective - maintain attn/focus on stiulus despite competing or distracting stimuli
• alternating - shifting to stimuli according to changes in task requirements
• divided - performing more than 1 activity concurrently (multitasking)

Assessing Adults w/ TBIs

3. cognitive & communication abilities

Memory

**impairment in retrospective memory - persistent area of loss - especially declarative (world knowledge) more impaired than procedural**

• Memory
• pre-traumatic - hard to gage what they remember vs. what they have been told
• loss of memory for events preceding injury
• before traumatic event - not encoded to LTM
• loss usually shrinks w/ recovery of all but lost few seconds to minutes
• post-traumatic - loss for memory/events immediately following injury
• inability to retain new info min --> wks after injury
• lasts longer & has more lasting effects ADLs
• duration related to coma duration & helps predict recovery

Assessing Adults w/ TBIs

3. cognitive & communication abilities

Visual processing - simialar to RHD

• similar to RHD
• posterior damage will have persisting deficits
• will perform poorly on:
• identifying incomplete, partially, fragmeted stimuli - analyzing spatial relationships
• discrimination of figures from backgrounds in drawings or photos

Assessing Adults w/ TBIs

3. cognitive & communication abilities

Executive function

• **when there are poor results look @ memory, att, visuospatial processing deficits - are they underlying the impact??**

• Executive function - not impt for those below level IV - must work on attn & orientation (reduct confusion & agitation
• abstract thinking, reasoning, & problem solving
• Language & Communicaiton - depends upon severity & pattern
• look @ language output & auditory comp/receptive vocab
• reading vocab & comp
• generative naming
• connected & conversational speech sample (pragmatics) carrying on a convo - content, orga, coherence, pragmatics, topic maintences & shifts

1. functionally oriented approach
2. behavioral management
3. pharmacological management
4. cognitive communication rehabilitation

Intervention of TBIs (4 steps/processes)

Functionally oriented approach

• improving/being able to carry out ADLs
• planning/organizing
• teach to budget, shop, what is a good option/could be better?
• Sensory stimulation
• Orientation training

Intervention of TBIs (4 steps/processes)

Functionally oriented approach

sensory stimulation

orientation training

• sensory stimulation - coma stimulation
• responses to differential stimuli, what to build consistency
• facilitate alertness/arousal; increase responsiveness to environment, prevent sensory deprivation, facilitate responsiveness changes --> all 5 senses
• orientation training - use to anticipate upcoming events
• passive orientation drills - lower level - asking them to repeat, verbalize cues give, taught to tell time & where they are
• active orientation drills - carry out ADLs to person, place & time - more indept - follow schedule (appts, meals, monitor passage of time)
• depends upon internalized concepts of person place and time

Intervention of TBIs (4 steps/processes)

Functionally oriented approach

environmental control

• environment control - increase coping skills, want to reduct agitation & confusing situations
• label possessions/locationgs
• photographs of bathroom

Intervention of TBIs (4 steps/processes)

Behavioral Management - consistently delivered - enhanced desired behaviors by manipulating stimuli & response contingencies

4 types of reinforcement

1. positive reinforcement - pleasurable stimuli contingent upon desired response - consequence
2. negative reinforcement - terminate activity - aversive stimuli removed contigent on desired response
3. punishment - limited role - aversive stimuli delivered contingent on undesired respones
4. extincting - no reinforcement - selected respones elicit neither pleasurable nor aversive stimuli

**verbal praises does not mean much in early stages - want something tangible**

Intervention of TBIs (4 steps/processes)

3) pharmacological management

• medication can be prescribed to:
• control agitation & restlesness
• improve alertness & attn - stimulants
• manage depression (later stages)
• fiminish psychotic symptoms - reduce paranoia, hallucinations & dillusional behaviors

**must have proper dosage & combination - look at schedule**