Transcript Week-4x

WEEK 4: FEDERAL & STATE
REHABILITATION LAWS, RULES,
REGULATIONS & GUIDELINES AS THEY
APPLY TO WORKING AS A VRC IN THE
VA SYSTEM.
Special Topics in Rehabilitation: REH 6560
Assignment 4


Assignment 4 has been posted to the Course
Website
Reading Assignment for Week 4 has been posted to
the Course Website
Amputations

Acquired condition
that results in the loss
of a limb
3
Amputations: Causes
4
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Trauma: Severance of a body part due to sudden
severe trauma
Severe open fractures with arterial and nerve damage
can be treated; however, treatment is at a high cost,
and multiple surgeries are required
The result is often a limb that is painful, nonfunctional,
and less efficient than a prosthesis
Amputation: Location
5
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Below-Knee Amputation (B/K): This is an amputation
above the ankle, but below the knee
Full knee use is retained, but it is hard for these
amputees to put weight on the stump
Amputation: Location
6
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Above Knee Amputation (A/K): This is an
amputation in the thigh
The whole body weight can't be held on the stump,
but a person is able to sit with this amputation
Amputation: Location
7
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Hip Disarticulation (H/D): This involves removing the
entire leg bone, but surgeons like to leave the upper
femur for stability and a place or a prosthetic
device
Amputation: Location
8
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Wrist Disarticulation (W/D): This is a removal of the
hand, but at the wrist joint
Plastic sockets are now made to serve as wrists
Amputation: Location
9
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Elbow Disarticulation (E/D): This is the removal of
the whole forearm at the elbow
This amputation creates a bulb shaped stump that
can hold weight
Amputation: Possible Functional Limitations
10
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Upper Extremity:
 Grasping
 Pinching
 Bimanual
 Carrying
 Lifting
 Holding
 Pushing
activities
11
Amputation: Possible Functional Limitations
12
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Lower Extremity:
 Balancing
 Climbing
 Walking
 Stooping
 Pushing
 Lifting
 Jumping
/ Pulling
13
Prosthetics
14
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Fit
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Training

Comfort

Stump Care
Things To Ask About…
15
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Frontal Lobe Injury
 Alterations in personality
Occipital Lobe Injury
 Visual disturbances
Things To Ask About…
16
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Cortical Disruption
 Reduce mental status or Amnesia
Retrograde
Unable to recall events before injury
Antegrade
Unable to recall events after trauma
“Repetitive Questioning”
The Effects of a TBI Depend on:
17
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Number of injuries
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Severity of injuries
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Time since injury(s)
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Areas of injury
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Age the injury(s) occurs
The Effects of a TBI Depend on:
18
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Status of the person before injury
What happens after the injury to re-establish
previous abilities
Effects of Injury
19
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The effects of the injury will not be uniform or
necessarily stable.

Impaired skills in one area does not necessarily
mean impaired skills in another area.

Strengths and weaknesses may change over
time, especially with more recent injuries.
Simplified Brain Behavior Relationships
Frontal Lobe
• Initiation
• Problem solving
• Judgment
• Inhibition of behavior
• Planning/anticipation
• Self-monitoring
• Motor planning
• Personality/emotions
• Awareness of
abilities/limitations
• Organization
•
Attention/concentration
• Mental flexibility
• Speaking
(expressive language)
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Parietal
Lobe
Frontal
Lobe
Occipital
Lobe
Temporal
Lobe
Parietal Lobe
• Sense of touch
• Differentiation:
size, shape, color
• Spatial perception
• Visual perception
Occipital Lobe
• Vision
Cerebellum
Brain
Stem
Temporal Lobe
Brain Stem
• Memory
• Hearing
• Understanding language
(receptive language)
• Organization and sequencing
• Breathing
• Heart rate
• Arousal/consciousness
• Sleep/wake functions
• Attention/concentration
Cerebellum
• Balance
• Coordination
• Skilled motor activity
Types of TBI: Open
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Skull
compromised
and brain
exposed
Head Trauma - 21
Types of TBI: Closed
22
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Skull not
compromised
and brain not
exposed
Head Trauma - 22
Brain Injury
23

As defined by the National Head Injury
Foundation
 “a traumatic insult to the brain capable of
producing physical, intellectual, emotional,
social and vocational changes.”
Brain’s Response to Injury

Swelling of brain
Vasodilatation
Increased
24
with increased blood volume
ICP
Head Trauma - 24
Brain’s Response to Injury
25

Decreased blood flow to brain
Perfusion
decreases
Cerebral
ischemia (hypoxia)
Signs & Symptoms of Brain Injury: Altered
Mental Status
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Altered orientation
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Alteration in personality
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Amnesia
 Retrograde
 Antegrade
Signs & Symptoms of Brain Injury
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Cushing’s Reflex
 Increased
BP
 Bradycardia
 Erratic
respirations
Signs & Symptoms of Brain Injury
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Vomiting
 Without
nausea
 Projectile
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Body temperature changes

Changes in pupil reactivity
Direct VS. Indirect Brain Injuries
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Direct
 Primary injury caused by forces of trauma
Indirect
 Secondary injury caused by factors resulting
from the primary injury
Brain Injury: Direct Brain Injury
30
o
Immediate damage
due to force
o
Coup and contracoup
o
Fixed at time of injury
Head Trauma - 30
Direct Brain Injury Types
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
Coup
 Injury

at site of impact
Contrecoup
 Injury
on opposite side from impact
32
Coup
Contrecoup
Indirect Brain Injury
33
o
o
o
Results from hypoxia
or decreased perfusion
Response to primary
injury
Develops over hours
Head Trauma - 33
Blast Injuries
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Secondary blast injury (caused by flying debris and
fragments)
Tertiary blast injury (caused by being thrown by
blast wind) from penetrating and blunt trauma that
is not unlike head injuries from causes other than
explosions
Blast Injuries
35
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There is some controversy whether the brain is
vulnerable to primary blast injury (caused by the
overpressurization wave), animal models suggest
that it is.
Shear and stress waves from the overpressurization
could potentially cause TBI directly (e.g., concussion,
hemorrhage, edema, diffuse axonal injury).
PTSD
36


Post-traumatic stress disorder (PTSD) is a mental
health condition that's triggered by a terrifying
event
Symptoms may include flashbacks, nightmares and
severe anxiety, as well as uncontrollable thoughts
about the event
Summary
37
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The frontal lobe of the brain is most commonly
injured.
Therefore, deficits in executive functioning and
self-regulation are frequently observed after
TBI
Summary
38
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Self-regulation is at the core of who we are, how
we respond to different situations, and how well we
are able to move toward the completion of our
long-term goals.
Summary
39
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
Self-regulation deficits can interfere with the
effective provision of treatment and other
services
Many individuals with TBI have additional
disorders associated with impaired selfregulation. The effects of such co-occurring
disorders are not yet well-understood
Secondary Effects of Impaired Executive
Functioning/Self-Regulation
40
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Decreased automatic responses
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Slowed processing
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More effort required to learn and respond
Self-Regulation
41
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Using the cognitively-based executive functions to
manage one’s own responses to different situations
Being able to make decisions based on long-term
goals rather than immediate desires
Impulsivity/Disinhibition
42

Performing a response without considering the longterm consequences of that action
Lack of Initiation
43
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
Problems with “starting”--cannot initiate behaviors
consistent with the achievement of one’s goals
How would this impact looking for a job?
Deficits in Self-Regulation are also Observed in
Persons with:
44

Substance use disorders
Attention deficit disorder
Various psychiatric disorders

And all are more prone to having a TBI.

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TBI: POSSIBLE FUNCTIONAL LIMITATIONS
45
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Balancing, lifting, walking
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Strength, coordination
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Vision, hearing, communication skills
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Pain and headaches
Possible Functional Limitations: TBI
46
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Memory, organizational and planning ability,
concrete thinking
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Attention span/distractibility
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Writing skills, reading skills, visual-spatial skills
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Lack of initiative, inflexibility, irritability
TBI: Psychosocial Considerations
47
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Social judgment, maturity
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Social awkwardness
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Feelings of isolation, impulsiveness,
aggressiveness
Anger, depression, anxiety, low self-esteem
Noise-Induced Hearing Loss (NIHL)
48


Sound is measured in units called decibels.
The humming of a refrigerator is 45 decibels,
normal conversation is approximately 60 decibels,
and the noise from heavy city traffic can reach 85
decibels.
Noise-Induced Hearing Loss (NIHL)
49


Long or repeated exposure to sounds at or above
85 decibels can cause hearing loss.
People usually experience pain at about 130 dB
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51
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Stats
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1.6 million troops deployed to OEF/OIF to date
Approximately 40% have accessed VA care
Three most common presenting problems:
Musculoskeletal Ailments
Mental Disorders (PTSD, SA/D, Depressive)
“Symptoms, Signs, and Ill Defined Cond.”
PTSD and Mild Traumatic Brain Injury (TBI)
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Slightly more than half of combat injuries early in OIF
came from explosions
29% evacuated from combat theater to WRAMC had
evidence of TBI (Jan 2003-Feb 2007)
Approximately 15% of all wounded vets have
suffered TBI (4,471 cases diagnosed between
October 2001 and September 2007)
TBI



Physical damage by external blunt or penetrating trauma
Acceleration-Deceleration Movement (whiplash) resulting in
tearing or nerve fibers, bruising/contusion of brain
Scraping of brain across bony base of skull leading to
olfactory, oculomotor, acoustic nerve damage.
 Loss of sense of smell and reduction of taste (anosmia),
double and/or blurred vision, dizziness or vertigo
 Usually remit after several days or weeks (nerves recover or
regenerate)
Levels of TBI

Mild
 LOC
for less then 30 minutes w/normal CT and/or MRI
 Altered mental state: “dazed,” “confused,” “seeing
stars”
 PTA less then 24 hours (unable to store or retrieve new
information)
 Glasgow Coma Scale (GCS): 13-15
Levels of TBI
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Moderate
LOC less than six hours w/abnormal CT and/or MRI
 PTA less than seven days
 GCS: 9-12
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Severe
LOC greater than six hours w/abnormal CT and/or MRI
 PTA greater than seven days
 GCS: 1-8

Post-Concussion Syndrome (PCS)

Symptoms immediately post-injury may include:
Memory, attention, concentration deficits
 Fatigues, poor sleep, dizziness, headaches
 Irritability, depression
 Anxiety



Most common: free-floating anxiety, fearfulness, intense worry,
generalized uneasiness, social withdrawal, heightened sensitivity,
related dreams
Recovery (mild TBI) expected within 4-12 weeks;
however, some symptoms may linger for months to
years
Assessment

Post concussion Syndrome
(PCS)

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
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
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
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

Insomnia
Memory Deficits
Poor Concentration
Depressed Mood
Anxiety
Irritability
Headache
Dizziness
Fatigue
Noise/Light Intolerance
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PTSD










Insomnia
Memory Deficits
Poor Concentration
Depressed Mood
Anxiety
Irritability
Intrusive symptoms
Emotional Numbing
Hyperarousal
Avoidance behavior
Mild TBI among OIF Returnees
(Hoge et al., 2008)

2,525 soldiers included in study (assessed 3-4
months post-deployment)
 5%
(124) reported injury with LOC (up to several
minutes)
 10% (260) reported injury with altered mental status
w/out LOC
 Four soldiers reported LOC longer than 30 minutes
 17% (435) reported other injuries
TBI Among OIF Returnees
(Hoge et al., 2008)
Of those who reported LOC, 44% met
criteria for PTSD, as compared to:
-27% of those with altered mental
state
-16% of those with other injuries
-9% of those with no injuries
Blast Injuries
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Over 50% of combat injuries result from bombs,
grenades, land mines, missles, mortar/artillery shells
Account for majority of brain injury in theater with
GSWs, falls, and MVAs close behind
TBI among service members as high as 22%
2003-2008: over 6,600 TBI
 Four major polytrauma centers (MN, CA, FL, VA): 923
OEF/OIF patients with TBI

Blast Injury


Blast injuries results from pressure generated from
an explosion which causes in overpressurization
Air-filled organs (ears, lung, GI tract) and organs
surrounded by fluid filled cavities (brain, spinal
cord) susceptible
Hoge et al. (2006)

01 May 2003 – 30 April 2004:
OEF (Afghanistan)
 OIF (Iraq, Kuwait, Qatar)
 Other (Bosnia, Kosovo, etc.)


N = 303,905 Marines and Soldiers
OEF: 11.3% of 16,318
 OIF: 19.1% of 222,620
 Other: 8.5% of 64,967

Hoge at al. (2006)

Combat Experiences:
OEF
OIF OTHER
Any
46.0% 65.1% 7.4%
Witnessed
38.1% 49.5% 5.3%
Discharged
6.2% 17.8% 0.4%
Felt in Danger 24.6% 50.3% 3.2%
Suicidality and PTSD
PTSD patients are 6 times more likely to
attempt suicide than the general
population
PTSD has greater risk of increased
number of suicide attempts than all other
anxiety disorders
Kessler R et al. Arch Gen Psychiatry 1999;56:617-626.
Therapeutic Intervention
Teach patients that PTSD


Represent psychobiologic reaction to overwhelming stress
Not character flaw or sign of weakness



Fear that will be seen as “damaged” or emotionally unstable
May lose right to carry weapon
May be viewed as unstable
 Traumatized patients
 Notoriously reluctant to seek help

Particularly from mental health professionals
Therapeutic Intervention
PTSD symptom relief

Usually requires specialized techniques

help patient confront fears and emotional responses to
trauma in more structured format

Without becoming overwhelmed
Treatment involves



Reducing level of distress associated with
memories of event
Quelling resultant physiological reactions
Focus on behavioral outcomes rather than
biomedical indices
Therapeutic Intervention
Effective

Exposure Therapy


Cognitive-Behavioral Therapy


Helping confront painful thoughts and feelings
Helping process thoughts and feelings
Interpersonal therapies

Understanding ways in which traumatic event continues
to affect relationships and other aspects of their lives
Group Therapy

May also help reduce isolation and stigma
Pharmacotherapy
In PTSD, randomized trials have shown
effectiveness of

SSRIs

TCAs

MAOIs
SSRIs

1st-line treatment

safer and better tolerated
Only FDA-approved drugs

Sertraline (Zoloft)

Paroxetine (Paxil)
Pharmacotherapy
-blockers

May reduce peripheral sympathetic tone

Perhaps, potential to worsen depression
Beneficial effects of drug therapy

May not be evident for 8 weeks or more
Once drug a drug seems effective

Continue for at least 12 months
Summary
 Most people will gradually recover from
psychological effects of traumatic event
 PTSD will develop in a substantial portion of
subjects exposed to trauma
 PTSD


Failure to recover from nearly universal set of emotions
and reactions
Typically manifested by



Distressing memories or nightmares related to trauma
Attempts to avoid reminders of trauma
Heightened state of physiological arousal
Summary
Biologic mechanisms of PTSD
Changes in brain regions

Amygdala and hippocampus

Associated with fear and memory
Changes in systems involved
in coordinating body’s
response to stress



Hormonal
Neurochemical
Physiological
Summary
Treatment
Educate patient about nature of disorder
Provide safe and supportive environment

Discuss trauma and impact
Relieve distress associated with

Memories

reminders of events
Treatment strategies with variable success


Exposure therapy
Pharmacotherapy

cognitive therapy
Summary
Pharmacotherapy
SSRIs

Effective and well tolerated
Many with PTSD do not respond to drugs

Need to better study this subset
Pilot studies with propranolol

Need confirmation