This is a slide presentation that provides informaton on taumatic brain injuries and the PREP program at the Shepherd Center. This is an edited version of a presentation and is NOT the full slide presented by deckto deal with specific issues our family is facing and is not an official Shepherd publication.

1. Shepherd Center
Acquired Brain Injury Program

2. Introduction
 What is Neuropsychology?
 What happened to your loved one?
 Part 1:
 Basics of the Brain
 What happens with a brain injury
 Part 2:
 2 Tracks at Shepherd: all patient-specific
 PREP (Pre-rehabilitation Education Program)
 Rehab Program
 Discharge- What happens when you leave here?

3. Brain Anatomy
 Brain is soft, and has consistency of a Jello mold
 Fits relatively snuggly in the skull
 Attached to skull by small veins and meninges
 Floats in cerebral spinal fluid
 Provides cushion, “shock absorber”
 Enclosed environment
 Other than veins and arteries, there is only one
exit—where brain stem exits the base of the skull to
become the spinal cord
 This is why we have the pressure problem

4. Brain Anatomy
 Surface of the brain is wrinkled
with deep folds
 Increase the surface area of the
brain in a small space
 Compact, efficient
 Allows for more connections
 Cortical structures on surface
 Subcortical structures deeper in
brain

5. Brain Anatomy
 Neo-cortex or Cortical
Structures
 Each hemisphere divided into 4 lobes
 Frontal, temporal, occipital, parietal
 “Thinking” portion of the brain
 Subcortical Structures
 Life sustaining structures/functions
 White matter – communication
between different brain regions
 Brain stem controls heart
rate, breathing, temperature, arousal/
wakefulness
 May be affected by focal damage or
generalized mechanisms
(swelling, compression, diffuse/shear
injury, anoxia)

6. Anatomical Relationships
 Grey-white distinction
 Grey = cell body
 White = axons
 Axons carry information
to/from outside world
 Converge in brainstem

7. Fulcrum Biomechanics
 Top heavy cortical regions
 Rotational forces centered on brainstem

8. Neuropathology of Brain Injury
 Acquired Brain Injury (ABI):
 Any injury that happens within the brain itself at
the cellular level
 Traumatic Brain Injury (TBI)
 Non-Traumatic Brain Injury (TBI)

9. Neuropathology of Brain Injury
Traumatic Brain Injury (TBI):
 Outside force impacts head hard enough to cause
brain to move within the skull or the force directly
hurts the brain
 Examples: motor vehicle
collisions, falls, firearms, sports, physical violence, etc.
 Closed Head Injury vs. Open Head Injury

10. Neuropathology of Brain Injury
Non-Traumatic Brain Injury (TBI):
 Does not involve external mechanical force
 Examples: stroke, aneurysm, insufficient oxygen
(anoxia/hypoxia) or blood supply
(ischemia), infectious disease, AVM, etc.

11. Neuropathology of TBI
 Contusions: Bruising
 blood vessels in or around
brain are damaged or
broken
 Hemorrhage
 bleeding from blood vessel
leakage rupture
 Hematoma
 Localized pooling of blood
that occurs from
hemorrhaging.
 Can be large or small

12. Neuropathology in TBI
 Edema
 Swelling in brain tissue
 Or influx of fluid
 Causes increased intracranial
pressure (ICP)
 Enclosed space: Increased
pressure on all brain tissue,
can put pressure on stem
 Treatments:
 Medically induced coma
 Brain diuretic (reduce
fluid/water)
 Placement of shunt (drain)
 Craniectomy (remove portion of
skull bone to allow extra space for
swelling)

13. Diffuse Axonal Injury in TBI
(What Grace Has)
• “Shear injury”
• Results from sudden stopping, rotating, twisting and tearing of
axons of neurons
• Capillaries, blood vessels also tear
• Doesn’t always show up immediately on CT scans
• Usually present in TBI, especially MVA
• Axons/neurons don’t repair, per se, and leads to cell death
• Some neuroplasticity can compensate

14. Anoxia/Hypoxia
 Anoxic Brain Injury
 Brain does not receive any oxygen. Cells in the brain need
oxygen to survive
 Anoxic Anoxia: no oxygen supplied to the brain
 Anemic Anoxia: blood that does not carry enough
oxygen
 Toxic Anoxia: toxins that block oxygen in the blood
 Hypoxic Brain Injury
 Brain receives some, but not enough oxygen
 Common causes:
 Cardiovascular disease or trauma, asphyxia (e.g., drowning),
chest trauma, electrocution, severe asthma attack, poisoning,
substance overdose

15. Chemical Changes
 Brain is very efficient—produces at the cellular level
only what it needs and needs everything it produces
 Brain injury may cause neurochemical imbalance
 Neurotransmitters:
 E.g., Serotonin  mood
 Medications may be given:
 Parlodel for arousal
 Ritalin for focused attention & arousal
 Mood stabilizers, antidepressants may be beneficial
 Damage to pituitary gland can effect hormone
disruptions, sleep/wake cycles can be affected

16. STORMING
 Hypothalamic Instability
 ANS poorly regulated by
central brain mechanisms
 Elevated blood pressure
 Fever
 Tachycardia
 Rapid respirations
 Sweating
 May or may not be stimulated
 Not a sign of improvement
 Can be very difficult to watch

18. Two Tracks at Shepherd Center
 PREP Program (Pre-Rehabilitation Education
Program)
 Rancho Levels 1-3, passive therapies to keep body
conditioned, and ready for progression to full rehab
 Stimulation for coma emergence
 Rehabilitation Program
 Full Rehabilitation Program
 Dual diagnosis SCI patients
 Patient has both a spinal cord injury and brain injury
 They frequently co-occur (e.g., car accidents, falls, etc)

19. Overview: Pre-Rehabilitation
Education Program
 Reflexive & generalized responses without purposeful or
goal-directed behaviors
 Goal: Provide best possible environment for emergence
 1.5 hours daily of passive therapies
 Minimize complications of immobility
 Increase quality and quantity of responses to stimuli
 Recovery is not dependent on amount of stimulation—
more is not necessarily better
 Neurostimulants - medications to promote arousal
 Establish and maintain medical stability
 Family training, home modifications, preparation for
discharge

20. Levels of Arousal
 Severity of Initial Injury
 Glasgow Coma Scale (GCS 3-15)
 Length of reduced arousal
 Rancho Scale Levels
 Only for TBI
 Range from 1-10
 Levels 1-3 are low-level consciousness (Prep Program)
 Level 4-10 full Rehab program
 Traditional arousal terminology
 Assessing functional abilities

21. PREP Program (cont.)
 JFK Coma Recovery Scale (Speech Therapy)
 Useful in documenting even slight improvements
 Visual: Startle, localization, pursuit, tracking, object
recognition
 Auditory: Startle, localization, consistency
 Oromotor: Oral movement, vocalization, verbalization,
 Communication: Accuracy, consistency
 Arousal
 Neurobehavioral Examination (Neuropsychology)
 Family Education and feedback

22. LEVEL 1
 Rancho 1: No Responses : Total Assistance
 Arousal Level: Coma
 Functional Abilities
 Eyes closed
 No response to any stimuli

23. LEVEL 2
 Rancho 2: Generalized Responses
 Arousal Level: Vegetative State
 Functional Abilities
 Eyes open
 Generalized responses
 Reflexive behaviors (grasping)
 Non-purposeful movements
 Fragments of coordinated movement
 Vocalization but not verbalization

24. LEVEL 3 (Grace’s Current Level)
 Rancho 3: Localized Responses
 Arousal Level: Minimally Conscious
 Functional Abilities
 Localized responses
 Intelligible verbalization
 Purposeful behavior
 Responses still inconsistent

25. PREP Program (cont.)
 Emergence criteria
 Interactive communication to simple, concrete
questions or requests
 Following commands
 Yes/no responses
 Allow time
 OR functional use of 2 objects
 Reliable: With all staff, not reflexive
 Consistent: 85% of the time
 Motor and language impairments can interfere

26. Neural Recovery
 Everyone is DIFFERENT
 Time & Biology
 Types of recovery
 Recovery from secondary effects
 Cortical reorganization
 Nearby cells may take on additional work
 Limitations
 We do not make new brain cells
 Limited capacity for reorganization

27. PREP Program (cont.)
 Speak in a comforting, positive, and familiar way. Be
mindful of delayed response time.
 We cannot be sure how much cognitive processing is
occurring.
 When visitors are present, focus on the patient.
 Limit the number of visitors. Keep visits short – rest
is essential
 Provide the patient with pictures, music, and
personal items that are comforting and familiar.
 There are opportunities to assist with patient care as
directed by nurses.

28. PREP - Going Home…
 Each patient’s recovery rate is unique
 Recovery continues after discharge
 For some patients, familiar environment can be
stimulation for emergence
 We want you to feel competent to go home
 Family Training Day
 Marcus Bridge Program, telehealth
 Continued support
 Return for rehabilitation if
appropriate

29. Factors That Can Affect Recovery
 Age
 Prior brain injury
 Previous health status
 Length of PTA
 Time since injury
 How much tissue was damaged
 Focal injuries are more resistant to recovery
 Language, executive functions, ataxia are more resistant
 Substance abuse, smoking tobacco
 Adaptive functioning before injury
 Family involvement
 More therapy hours are not related to amount of recovery

30. Family
 You know your loved one better than we do
 Your knowledge about their emotional and physical
needs is valuable to us and to their recovery
 Your participation and involvement is helpful
 Feelings of loss, sadness, anger, guilt, and frustration
are common and normal
 You do not have to go through this alone- help is
available

31. Stages of Family Adjustment
1. DENIAL 1. TRUST
 Just listen
 Encourage hope
 Self-care advice
 One foot in front of other
2. BEWILDERMENT 2. OBJECTIVITY
3. DESPAIR 3. LONG-TERM PLAN
4. INSIGHT 4. IN DEPTH FEEDBACK
5. MOURNING 5. PERMISSION
6. ACCEPTANCE
6. RESOURCES

32. Self Care is Essential
 You have to be healthy in order to be able
to take care of someone else
 Break the stress response cycle
 Rest, eat well, get some exercise
 Practice whatever gives you strength, peace, hope
 Manage your physical & emotional energy
 Asking for help is a valuable skill, not a weakness
 Find people who will help you and then let them
 Share your feelings with trusted others
 This is your chance for a break before your loved one is
discharged