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

1. Severe Brain Injury and Vision Loss: What’s it all about? BJ LeJeune, CRC, CVRT Mississippi State University

2. Part 1: Review of Medical Aspects of Traumatic and Acquired Brain Injury What is it all about??

3. TBIAdopted by the Brain Injury Association Board of Directors, February 22, 1986. `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. ABIAdopted by the Brain Injury Association Board of Directors, March 14, 1997. • 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. Types of Primary Traumatic Brain Injuries • Diffuse Axonal Injury • Concussion (mildest and most common) • Contusion (bruising) • Coup-ContrecoupInjury (two part blow) • Second Impact Syndrome "Recurrent Traumatic Brain Injury“ • Skull Fracture • Penetration Injury • Shaken Baby Syndrome

6. Types of Secondary 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

7. Severity Measures of Brain Injury • 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. Glascow Coma Scale • 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)

9. Severity of Brain Injuries (Michigan Brain Injury Certification training program) • 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) • 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 Mild Brain Injury Moderate Brain Injury Severe Brain Injury

10. Factors that may help Predict Outcomes following a Brain Injury • 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. Brain Mapping Where is the injury and what is the impact?

12. Cerebrum Lobes

13. Major Brain Functions • 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. 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

15. Possible Impairments to the Right Side of the Brain • 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. Possible Impairments Related to the Left 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

17. Most Common Types of Vision Problems related to Brain Injury

18. Vision and the Brain • 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.

19. The brain interprets the visual environment…face or vase?

20. Loss of Visual Field(Hemianopsia) • 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. Hemianopsia • Treatment: Visual Field Awareness System (Dan Gottlieb) • Peli Lens • Training in scanning techniques

22. Visual Neglect • 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. Left side Neglect Even visual memory may be missing the neglected area

24. Visual Spatial Disorders • 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. Visual Spatial Disorders/NeglectTreatment Strategies • Learning to attend to areas of neglect • Scanning – perhaps with each step • Memory Issues – remembering to look

26. Impaired Eye Movements • 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. Treatment for Impaired Eye Movements • Retraining/strengthening muscles for strabismus • Medicinal Options (Nystagmus – Xanex) • Rest – often worse when person is fatigued • Surgical Options

28. Eye Strain, Brain Strain and Difficulty Reading • 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

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

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

33. Impaired Visual Memory • 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. Post Traumatic Vision Syndrome • Most common in children • blurred and double vision (lasts 6-12 months) • Can bring about the onset of vision related mannerisms (Blindisms)

35. Severe Head Injury: Restoration, Rehabilitation or Status Quo What to expect post injury – the question everyone wants answered!

36. Misquoting Sommerset Maugham • “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.”

37. My Case Study of one…Bobby

38. Restoration, Rehab or Status Quo • 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. Brain Plasticity (neuroplasticity) • 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. Two Approaches to Brain Recovery • 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.

41. Perspective

42. Traumatic Brain Injury: A disease process, not an event. (Masel, & Dewitt, 2010). • 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 Rehab (www.headinjury.com/rehabcognitive.html) • Brain injury rehabilitation involves two essential processes: • Restoration of functions that can be restored 2. Learning how to do things differently when functions cannot be restored to pre-injury level.

44. Number One Complication in Recovery: Access to Appropriate Services • 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. Melingering and Co-Dependency • 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 is the Prognosis for Employment? What can be done to restore functioning and to find alternative methods of functioning?

47. Complicating Behavioral Issues • 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. Self-Assessment Self-Regulation • 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.

49. Vocational Rehabilitation Role • 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 • 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).