Download - The Healthy Brain and Effects of Traumatic Brain …...The Healthy Brain and Effects of Traumatic Brain Injury Samantha Backhaus, Ph.D., HSPP January 19, 2007 GENERAL OVERVIEW The

The Healthy Brain and Effects The Healthy Brain and Effects of Traumatic Brain Injuryof Traumatic Brain Injury

Samantha Backhaus, Ph.D., HSPPSamantha Backhaus, Ph.D., HSPPJanuary 19, 2007January 19, 2007

GENERAL OVERVIEWGENERAL OVERVIEW

The Healthy BrainThe Healthy BrainCNSCNSBrain stemBrain stemSubcortexSubcortexCortexCortex

TBI and TBI EffectsTBI and TBI EffectsRole of the FamilyRole of the Family

Central Nervous System (CNS)Central Nervous System (CNS)

CSN:CSN: brain and spinal cordbrain and spinal cordBrain: (a) brain stem; (b) Brain: (a) brain stem; (b) subcortexsubcortex; (c) ; (c) cerebral cortexcerebral cortexSpinal cord: mediator b/t spinal nerves Spinal cord: mediator b/t spinal nerves and brain possessing nerve fibers that and brain possessing nerve fibers that relay sensory information to brain and relay sensory information to brain and motor information from brain to rest of motor information from brain to rest of body.body.

Brain StemBrain StemLocated at top of spinal cord forming three major Located at top of spinal cord forming three major componentscomponentsMedulaMedula, , ponspons, midbrain, midbrainReticular formationReticular formation: runs through entire brain stem : runs through entire brain stem creating a network of fibers that mediates creating a network of fibers that mediates communication among spinal cord, cerebellum, communication among spinal cord, cerebellum, cerebral cortex, and other brain structurescerebral cortex, and other brain structuresReticular activating system (RAS):Reticular activating system (RAS): allow alertness allow alertness to meaningful sights, sounds, or touches in to meaningful sights, sounds, or touches in environment. Crucial in maintenance of wakefulness, environment. Crucial in maintenance of wakefulness, consciousness, and attention.consciousness, and attention.

Brain Stem: MidbrainBrain Stem: Midbrain

Visual information is initially relayed to Visual information is initially relayed to midbrain (where visual reflexes midbrain (where visual reflexes originate). Blinking, dilation, originate). Blinking, dilation, constriction of pupil, and certain eye constriction of pupil, and certain eye mvtsmvts..Hearing reflexes: being startled by loud Hearing reflexes: being startled by loud noisenoiseBasic Basic mvtmvt patterns: walking and patterns: walking and runningrunning

Brain Stem: Brain Stem: PonsPons

Lies just below midbrainLies just below midbrainRegulation of sleepRegulation of sleep--wake cyclewake cycleUpper portion: wakefulnessUpper portion: wakefulnessLower: permits one to fall asleepLower: permits one to fall asleepVital inhibition of motor activity that Vital inhibition of motor activity that accompanies certain stages of sleepaccompanies certain stages of sleep

Brain Stem: MedullaBrain Stem: Medulla

Lowest structure in brain stemLowest structure in brain stemRegulation of cardiovascular system, Regulation of cardiovascular system, breathing, and maintenance of muscular breathing, and maintenance of muscular tone in skeletal musclestone in skeletal musclesImplicated as mechanism that assist in Implicated as mechanism that assist in reducing body’s sensitivity to painreducing body’s sensitivity to pain

SUBCORTEXSUBCORTEX

Includes cerebellum, hypothalamus, Includes cerebellum, hypothalamus, thalamus, basal ganglia, and limbic system thalamus, basal ganglia, and limbic system viewed as resident to the viewed as resident to the subcortexsubcortexArousal, initial filtering of and orientation to Arousal, initial filtering of and orientation to sensory stimuli, coordinated stereotypic sensory stimuli, coordinated stereotypic response patterns (fight or flight), and response patterns (fight or flight), and execution of complex behaviors (including execution of complex behaviors (including instinctive responses)instinctive responses)

SUBCORTEX: CerebellumSUBCORTEX: Cerebellum

Not technically Not technically subcorticalsubcorticalLies behind medulla and lower portion of cerebral Lies behind medulla and lower portion of cerebral cortexcortexDiverse motor skills depending on region of Diverse motor skills depending on region of cerebellumcerebellumVermisVermis (middle): postural disturbances and cognitive (middle): postural disturbances and cognitive deficits (learning and memory, executive control, deficits (learning and memory, executive control, visuoperceptionvisuoperception).).Lateral lesions result in difficulty coordination rapid Lateral lesions result in difficulty coordination rapid alternating alternating mvtsmvts..Vertigo and disturbance of eye movementsVertigo and disturbance of eye movements

SUBCORTEX: HypothalamusSUBCORTEX: Hypothalamus

Basic regulatory functions: thirst appetite, Basic regulatory functions: thirst appetite, sexual arousalsexual arousalLesions: diminished drive states, obesity, and Lesions: diminished drive states, obesity, and loss of decreased temp. regulationloss of decreased temp. regulation

SUBCORTEX: ThalamusSUBCORTEX: Thalamus

Lies near middle of brain and composed of two Lies near middle of brain and composed of two halveshalvesStation for most sensory pathways to the cerebral Station for most sensory pathways to the cerebral cortex, contributing significantly to conscious cortex, contributing significantly to conscious experience of sensationexperience of sensationHigher cortical functions such as language (Higher cortical functions such as language (decrdecrverbal fluency, spontaneity of speech, and reduced verbal fluency, spontaneity of speech, and reduced tone) and memory (retrotone) and memory (retro--and and anterogradeanterograde))Emotional alterations such as reduced spontaneity, Emotional alterations such as reduced spontaneity, apathy, or lowered initiative in thalamic lesionsapathy, or lowered initiative in thalamic lesions

SUBCORTEX: Basal GangliaSUBCORTEX: Basal Ganglia

Lies at base of cerebral hemispheresLies at base of cerebral hemispheresContains 3 structures: Contains 3 structures: putamenputamen, , globusglobuspalliduspallidus, and caudate, and caudateMotoricMotoric control and voluntary and control and voluntary and automatic automatic mvtsmvtsTranslates cognition into actionTranslates cognition into actionContributes to learning, memory, Contributes to learning, memory, receptive, and expressive language.receptive, and expressive language.

SUBCORTEX: Limbic SystemSUBCORTEX: Limbic System

Several structures that add to regulation of emotionsSeveral structures that add to regulation of emotionsIncludes hypothalamus, Includes hypothalamus, cingulatecingulate, , septalseptal region, region, hippocampus, hippocampus, fornixfornix, and , and amygdalaamygdalaRegulate and adjust emotional tone that Regulate and adjust emotional tone that accompanies behavior and contributes to accompanies behavior and contributes to motivational aspects of behavior and learning and motivational aspects of behavior and learning and memorymemoryCingulateCingulate lesionslesions: : amotivationalamotivational or or akineticakineticsyndrome: no initiation of behavior and will at times syndrome: no initiation of behavior and will at times simply sit for hourssimply sit for hours

SUBCORTEX: Limbic SystemSUBCORTEX: Limbic System

SeptalSeptal regionsregions: expression of intense anger or rage: expression of intense anger or rageHippocampus:Hippocampus: learning and memory. Consolidates learning and memory. Consolidates new info and contributes to transition of ST to LT new info and contributes to transition of ST to LT memory formationmemory formationFornixFornix:: originates in hippocampus and is critical originates in hippocampus and is critical interconnection for interconnection for neurocircuitryneurocircuitry w/in systemw/in systemAmygdalaAmygdala: expression of emotional responses and : expression of emotional responses and participates in laying down of new learning, participates in laying down of new learning, especially those with emotional component.especially those with emotional component.

CEREBRAL CORTEXCEREBRAL CORTEX

Newest and most developed portionNewest and most developed portionParticipates in highest level of cognitive Participates in highest level of cognitive processingprocessingContributes to aspects of personality and Contributes to aspects of personality and social interactionsocial interaction2 hemispheres and 4 lobes 2 hemispheres and 4 lobes –– occipital, occipital, parietal, temporal, and frontalparietal, temporal, and frontal

CORTEX CORTEX -- HemispheresHemispheres

Left (in most rightLeft (in most right--handed):handed):Language abilitiesLanguage abilitiesVerbal MemoryVerbal MemorySeeing the detailsSeeing the detailsRightRight--sided sensory / motor movementssided sensory / motor movements

CORTEX CORTEX -- HemispheresHemispheres

Right: Right: Visual Spatial AbilitiesVisual Spatial AbilitiesControl of left side of bodyControl of left side of bodyMemory for visual objectsMemory for visual objectsAttentionAttentionAwarenessAwarenessSeeing the Big PictureSeeing the Big PictureUnderstanding subtleties of speechUnderstanding subtleties of speech

CORTEX CORTEX –– Occipital LobeOccipital Lobe

Location in back of brainLocation in back of brainIntegration of visual stimuliIntegration of visual stimuliVisual info travels from retina Visual info travels from retina ––thalamusthalamus--OLOLInfo then passes to parietal lobe : plays role Info then passes to parietal lobe : plays role in in visuospatialvisuospatial location or object positionlocation or object positionInfo passes to temporal lobe: provides object Info passes to temporal lobe: provides object recognition and analysis of form and shaperecognition and analysis of form and shapeLesions:Lesions: deficits in object location, doubledeficits in object location, double--vision, blurred vision, vision, blurred vision,

CORTEX CORTEX –– Parietal LobeParietal Lobe

Located on top and in posterior part of brainLocated on top and in posterior part of brain1. 1. VisuospatialVisuospatial location or object positionlocation or object position

2. Processes sensory and tactile information2. Processes sensory and tactile information

3. Some aspects of language (3 R’s)3. Some aspects of language (3 R’s)

CORTEX CORTEX –– Parietal LobeParietal Lobe

Lesions:Lesions:Deficits in body sense, touch, pressure, painDeficits in body sense, touch, pressure, painAnomiaAnomiaAlexiaAlexiaAgraphiaAgraphiaAcalculiaAcalculiaAttentionalAttentional problems of opposite side (problems of opposite side (espesp w/rightw/right--sided lesions) sided lesions) Visual spatial neglect or inattentionVisual spatial neglect or inattention

CORTEX CORTEX –– Temporal LobeTemporal Lobe

Located near the templesLocated near the temples1. Processing auditory information1. Processing auditory information

Heschyl’sHeschyl’s gyrusgyrus: primary auditory area where : primary auditory area where info is initially integrationinfo is initially integration

2.2. Comprehension of speech with Comprehension of speech with unawareness of deficit (unawareness of deficit (Wernicke’sWernicke’s aphasia)aphasia)

3.3. Memory. Transforms shortMemory. Transforms short--term info into term info into longlong--term storage. Located within term storage. Located within hippocampus / dentate hippocampus / dentate gyrusgyrus

CORTEX CORTEX –– Temporal LobeTemporal Lobe

LesionsLesionsDifficulties with audition or hearingDifficulties with audition or hearingLearning new information or recalling Learning new information or recalling previously learned information previously learned information (retrograde (retrograde vsvs anterogradeanterograde amnesia)amnesia)Problems understand what others are Problems understand what others are asking and responding as if you asking and responding as if you understoodunderstood

CORTEX CORTEX –– Frontal LobeFrontal Lobe

Executor of the brain: highest level of cognitionExecutor of the brain: highest level of cognitionJudgmentJudgmentPlanningPlanningInhibitionInhibitionProblemProblem--solvingsolvingInitiationInitiationImpulsivityImpulsivityCognitive flexibility vs. perseverationCognitive flexibility vs. perseverationConfabulationConfabulationorganizationorganization


4 major anatomical areas including 4 major anatomical areas including primary motor cortexprimary motor cortex: motor functioning,: motor functioning,dorsolateraldorsolateral prefrontal cortexprefrontal cortex: executive : executive function deficits, perseveration, stimulusfunction deficits, perseveration, stimulus--bound bound behavior, diminished verbal fluency behavior, diminished verbal fluency lateral orbital cortexlateral orbital cortex: : disinhibitiondisinhibition, , inappropriate affect, impaired judgment and inappropriate affect, impaired judgment and insight, distractibilityinsight, distractibilityanterior anterior cingulatecingulate cortexcortex: apathy, : apathy, mutismmutism, , lower extremity paresis, incontinencelower extremity paresis, incontinence


Lesions Lesions Solving problems and planning appropriatelySolving problems and planning appropriatelyAbstract reasoning: Seeing the big picture Abstract reasoning: Seeing the big picture Initiation: Getting tasks started and keeping them goingInitiation: Getting tasks started and keeping them goingMaking proper decisions and using good judgmentMaking proper decisions and using good judgmentBeing able to stop from “acting without thinking”Being able to stop from “acting without thinking”Having awareness of our actions and consequences of Having awareness of our actions and consequences of themthemMental flexibility: Being able to be flexible in our thinking Mental flexibility: Being able to be flexible in our thinking and not “stuck” on one ideaand not “stuck” on one idea


Frontal lobes also responsible for:Frontal lobes also responsible for:Movement of certain body partsMovement of certain body parts

Lesions:Lesions: paralysis or weakness on one paralysis or weakness on one sideside

Controls expressive speechControls expressive speechLesions:Lesions: ability to speak fluently or ability to speak fluently or Broca’sBroca’s aphasia (aphasia (paraphasiasparaphasias, , dysnomiadysnomia, , semantic aphasias)semantic aphasias)


Frontal lobes also responsible for:Frontal lobes also responsible for:Aspects of AttentionAspects of Attention

Lesions:Lesions: Paying attention for a long Paying attention for a long time and doing several things at oncetime and doing several things at once

Controls emotional responses and Controls emotional responses and personalitypersonality

Lesions:Lesions: May experience more May experience more emotional “ups” and “downs”emotional “ups” and “downs”

Traumatic Brain InjuryTraumatic Brain Injury

Occurs when a sudden trauma causes Occurs when a sudden trauma causes damage to the brain.damage to the brain.

Can result when the head suddenly and Can result when the head suddenly and violently hits an object, or when an violently hits an object, or when an object pierces the skull and enters brain object pierces the skull and enters brain tissue. tissue.


Leading causes of TBI are motor vehicle Leading causes of TBI are motor vehicle accidents, acts of violence, falls, sports and accidents, acts of violence, falls, sports and recreational injuries, lightening strikes, recreational injuries, lightening strikes, electric shocks, and blows to the head.electric shocks, and blows to the head.

Symptoms of a TBI can be mild, moderate, or Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of the severe, depending on the extent of the damage to the brain. damage to the brain.


Closed Head Injury: Closed Head Injury: Occurs when brain is injured without opening Occurs when brain is injured without opening of the skull. of the skull. Damage to the brain is caused by Damage to the brain is caused by

bruising and bleeding within the brain (contusions, bruising and bleeding within the brain (contusions, hematomashematomas, hemorrhages), hemorrhages)tearing and stretching of nerve cells tearing and stretching of nerve cells swelling of the brain (edema)swelling of the brain (edema)Fluid build up causing pressure on the brain Fluid build up causing pressure on the brain tissuetissue


Penetrating (Open) Injury: Penetrating (Open) Injury: occurs when brain is injured by a sharp occurs when brain is injured by a sharp object entering the skull and going through object entering the skull and going through the brain tissue.the brain tissue.Bullets, foreign objects, swords, knives, etcBullets, foreign objects, swords, knives, etc

Primary Factors in TBIPrimary Factors in TBI

Acceleration injuriesAcceleration injuriesLinear and rotational inertia of brain in Linear and rotational inertia of brain in relation to skullrelation to skull

Pt turns reflexively from impact Pt turns reflexively from impact Skull stops, brain rotates Skull stops, brain rotates Areas next to ridges most vulnerable Areas next to ridges most vulnerable

Anterior and inferior temporal lobeAnterior and inferior temporal lobeOrbitofrontalOrbitofrontal, , ventromedialventromedial prefrontalprefrontalMedial temporal (limbic) Medial temporal (limbic)

Primary Factors in TBIPrimary Factors in TBI

Diffuse Axonal InjuryDiffuse Axonal Injury

Bony structures carry surface brain tissue Bony structures carry surface brain tissue forward while deeper brain remains forward while deeper brain remains momentarily stationary because of inertiamomentarily stationary because of inertia

Axons are torn, twisted, or brokenAxons are torn, twisted, or broken

Cognitive Effects of TBICognitive Effects of TBI

Processing speed: Speed of thinking Processing speed: Speed of thinking slowed, takes longer to do thingsslowed, takes longer to do thingsAttention: Difficulties focusing and paying Attention: Difficulties focusing and paying attentionattentionExecutive abilities: Problems with those Executive abilities: Problems with those “higher“higher--level” thinking abilitieslevel” thinking abilitiesMemory: Difficulty learning and Memory: Difficulty learning and remembering new informationremembering new information

Behavioral Effects of TBIBehavioral Effects of TBI

•• Difficulty getting started on tasksDifficulty getting started on tasks

•• More mood swingsMore mood swings

•• Act before thinkingAct before thinking

•• Being aware of one’s actions/ strengths/ Being aware of one’s actions/ strengths/ weaknessesweaknesses

•• Irritability or aggressionIrritability or aggression

Behavioral Effects of TBIBehavioral Effects of TBI

•• More of less sleep than usualMore of less sleep than usual

•• Increased or decreased interest in sexual Increased or decreased interest in sexual activitiesactivities

•• Feeling more tired than usualFeeling more tired than usual

Emotional Effects of TBIEmotional Effects of TBI

•• Feelings of being “on edge”Feelings of being “on edge”

•• Feeling down and sadFeeling down and sad

•• Feeling nervous and anxious Feeling nervous and anxious

•• Hitting, yelling, or punchingHitting, yelling, or punching

•• Appearing as if one “doesn’t care about things”Appearing as if one “doesn’t care about things”

•• Feeling more frustrated and helplessFeeling more frustrated and helpless

•• Not wanting to live anymoreNot wanting to live anymore

ImportantImportant

The brain is a system, each area heavily The brain is a system, each area heavily connected with other areasconnected with other areasDamage to any one area usually causes a Damage to any one area usually causes a variety of difficultiesvariety of difficultiesMost common problems are memory, attention, Most common problems are memory, attention, and higher level thought functionsand higher level thought functionsIf a person had problems before with thinking, If a person had problems before with thinking, memory, behavior, etc., it is likely to become memory, behavior, etc., it is likely to become worse after an injuryworse after an injury

Importance of FamilyImportance of Family

•• In the hospitalIn the hospital:: Emotional Support, Emotional Support, treatment decisions, discharge planningtreatment decisions, discharge planning

•• Out of the hospitalOut of the hospital:: supervision, supervision, emotional support, assistance with emotional support, assistance with transitioning back into the community, transitioning back into the community, assistance with selfassistance with self--care activities, care activities, becoming a chauffer, financial supportbecoming a chauffer, financial support


•• How a family member copes can also How a family member copes can also depend on the characteristics of the depend on the characteristics of the survivor:survivor:

•• personality changespersonality changes

•• behavior changesbehavior changes

•• emotional statusemotional status

•• physical disabilityphysical disability

•• cognitive statuscognitive status


•• Research has demonstrated that families’ Research has demonstrated that families’ reports of the greatest amount of reports of the greatest amount of caregiver distress are related to caregiver distress are related to personality, emotional, and behavior personality, emotional, and behavior changes in the patient with TBI (and changes in the patient with TBI (and cognitive changes), rather than severity cognitive changes), rather than severity of injury or physical disability.of injury or physical disability.

Emotional Reactions of FamiliesEmotional Reactions of Families

•• ShockShock

•• AnxietyAnxiety

•• Denial Denial

•• DepressionDepression

•• AngerAnger

Emotional Reactions of FamiliesEmotional Reactions of Families

•• FatigueFatigue

•• MourningMourning

•• FrustrationFrustration

•• Concerns about being in a new roleConcerns about being in a new role

Changes in RolesChanges in RolesConsider how the follow scenarios from the Consider how the follow scenarios from the

perspectives of both the family member and the perspectives of both the family member and the survivor.survivor.

•• A spouse becoming a caretaker and sometimes a A spouse becoming a caretaker and sometimes a parental figure. parental figure.

•• An adult child is now providing care and supervision for An adult child is now providing care and supervision for his / her parenthis / her parent

•• Empty nesters are having to ask children to live with Empty nesters are having to ask children to live with them once againthem once again

•• The primary “breadwinner” is now dependent on his / The primary “breadwinner” is now dependent on his / her spouse for financial supporther spouse for financial support

Changes in RolesChanges in RolesResponding to changes in roles:Responding to changes in roles:

•• It is normal to feel uncomfortable with changes in rolesIt is normal to feel uncomfortable with changes in roles

•• Consider looking at the situation from your loved one’s Consider looking at the situation from your loved one’s perspectiveperspective

•• Individuals often report that they adjust better to these Individuals often report that they adjust better to these roles changes with support of everyone involved and roles changes with support of everyone involved and with good communication.with good communication.

•• Consider involving the survivor in important family Consider involving the survivor in important family decisions and everyday routines, as they still play a decisions and everyday routines, as they still play a significant role and contribution to the overall family significant role and contribution to the overall family functioning. functioning.

Common StatementsCommon Statements

•• I should not take any time for rest. I should not take any time for rest. •• It should have been meIt should have been me•• I could have done something to prevent itI could have done something to prevent it•• There is nothing I can do to improve this There is nothing I can do to improve this

situationsituation•• My loved one just isn’t the same anymoreMy loved one just isn’t the same anymore•• I’ve lost the person I once knewI’ve lost the person I once knew•• I know it may not be their fault, but I can’t help I know it may not be their fault, but I can’t help

but get frustrated.but get frustrated.

Common StatementsCommon Statements

•• Reactions of guilt and sadness after a loved one Reactions of guilt and sadness after a loved one experiences a brain injury are very common experiences a brain injury are very common and normal.and normal.

•• However, if these concerns become severe and However, if these concerns become severe and are not addressed they can impede recovery. are not addressed they can impede recovery. •• Try seeking support from other family members or Try seeking support from other family members or

friends.friends.•• Try seeking professional support from a counselor or Try seeking professional support from a counselor or

spiritual leader.spiritual leader.•• Try participating in local support groups or access Try participating in local support groups or access

internet websites to identify more ways of obtaining internet websites to identify more ways of obtaining support.support.

Family ConcernsFamily Concerns

•• Reactions of guilt and sadness after a loved one Reactions of guilt and sadness after a loved one experiences a brain injury are very common experiences a brain injury are very common and normal.and normal.

•• However, if these concerns become severe and However, if these concerns become severe and are not addressed they can impede recovery. are not addressed they can impede recovery. •• Try seeking support from other family members or Try seeking support from other family members or

friends.friends.•• Try seeking professional support from a counselor or Try seeking professional support from a counselor or

spiritual leader.spiritual leader.•• Try participating in local support groups or access Try participating in local support groups or access

internet websites to identify more ways of obtaining internet websites to identify more ways of obtaining support.support.

Download - The Healthy Brain and Effects of Traumatic Brain …...The Healthy Brain and Effects of Traumatic Brain Injury Samantha Backhaus, Ph.D., HSPP January 19, 2007 GENERAL OVERVIEW The

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