Clinic 5 Presentation
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Case Presentation:Robert, Hypoxic Brain
InjuryBy: Rachel Kennedy
11007281Clinical Placement 5
Summary of Presentation
Background to case: Client: RobertGender: Male Age: 34Presenting Condition: Hypoxic Brain Injury,
Secondary to Cardiac Arrest – Client has Fallot’s Tetralogy.
Brain Injury has caused a gradually recovering retrograde amnesia, anterograde amnesia and difficulties with aspects of short-term memory
History Chef Very supportive Parents, close
relationship with brother.Social Drinker. Smoker, x
10/day.Recreational illicit drug userLived with partner & younger
child at time of incident.
Record of Hospital Admittance: Chronological Cardiac Arrest, found 24-48 hours post
same, at home. Admitted to local hospital & intubated.
Transferred to the Mater. 1 x incidence aspiration pneumonia post extubation. No Issues with Dysphagia since. Trace dysphonia, spontaneously resolved
Referred to SLT days after admission, due to ? Issues with memory causing speech & language difficulties.
Stayed in Mater for approx. 35 days before returning home prior to admittance to NRH.
Description of Need for SLT at Initial AssessmentLanguage: Reduced output & non-retention of
verbal information at the level of conversation or with more complex language, generally
Dysarthria: hyponasality, monopitch and monotone
Current Client Profile (McCormack & Worrall, 1998)
Body Structures & Functions
Young Male, aged 34 Initial unsteadiness of balance and
gait at admission: since resolved with input from Physio during time here.
Language post-incident evidencing higher-level impairments secondary to hypoxic brain injury.
Memory loss, common outcome of type of injury (Geraghty & Torbey 2006, Mattiesen et al 2009).
Current Client Profile: ICFActivities & Participation
Environmental FactorsLived with partner and
younger child prior to admission. Worked full time.
Will live with parents between discharge from Mater and intake to National Rehabilitation Hospital.
Discussion of future limited & required sensitivity, due to client’s memory impairment.
Assessment Results Reduced output when patient asked to generate own
materials spontaneously…3-5 word sentences, telegraphic. Positive response to supporting cues with output
Pragmatic skills functionally intact, NAD. Functionally impaired retention of verbal and written
information - recalling 0-1 of 4 points from paragraphs heard or read some seconds previously.
Functional numeracy, literacy and written skillsDeemed an appropriate candidate for inpatient intensive
rehabilitative SLT (Constantinidou & Kennedy, 2013).
Patient Identified Difficulties: Remembering what people
had told him after a period of time had passed
Difficulty contributing as much at a conversational level as he had prior to admission
Occupational Therapist supplied patient with written diary to record activities day to day – memory aid.
DiagnosisIschemic Hypoxic Brain Injury (Powell, 2004)Primary Characteristic is Memory LossHigher Level Language Difficulties are related to
Memory LossDysarthria initially commented on by first
assessing SLT appeared to resolve without intervention across sessions - ? Effect of acute fatigue/loss of self-monitoring skills/acute medical condition earlier in admission.
7 Steps Case Management (Dodd, 1995)
Is Intervention Indicated?
Episode of Care
Clinical ObservationsIncreasing the cognitive effort required to produce
desired language output (via decrease in support or cueing) significantly decreased length and content of resultant expression
Robbie was initially able to recall information from a two paragraph passage heard less than a minute previously with maximal support and cueing only.
Robbie would intermittently draw on his general knowledge to assist in answering questions to comprehension tasks – useful mask for non-retention and at times a useful strategy too, but not always of best use to client, functionally
Mattiesen et al (2009), Shum et al (2013)
Long Term Goal One
Shum et al (2013), Kessels & DeHaan (2003), Dunlosky et al (2005)
Long Term Goal: Two
Rider et al (2008), Ehlhardt et al (2008), Das Nair & Lincoln (2013)
Direct TherapyUse of written and read
passages, based on Robbie’s interests … (Tottenham Hotspur, Thriller Novels, Electronica)
Discussion of topics, using a Semantic Features Therapy (modified use of this tool, to encourage longer sentences and more detail on specific topics, e.g. family, or work).
Critical Reflection: TherapyAdvantage that parents were very motivated
to help Robbie achieve this, and very in tune with his issues and challenges
Would every parent of an adult child be this motivated?
Increased practicality of tasks?May be prudent to consider family counseling
in the future (Schonberger et al, 2010).
Generalisation: how to achieve, how to measure? Robbie rehearsed strategies
on the wardParents used strategies Record of Robbie’s abilities
with activities taken every second session. Therapy used same tasks every day (Ylvisaker & Feeney, 1998).
Comparison of baseline & performance at final session (NB the effect of fatigue)
Outcome and Efficacy Outcomes: Ability with recall at
every session (Constantinidou & Kennedy, 2013).
Outcomes: Patient report of confidence in abilities
Efficacy: Comparison of performance at baseline and shortly before discharge from MMUH SLT.
Outcome Measures: So FarFrom 30% to 70% recall
(at best session) – Fatigue still impacting
Robbie reports he feels that the SLT sessions have helped him feel he can express more.
OT & Medical team note patient ‘more talkative,’ ‘participates more.’
Critical Reflections: generalisation, outcome & efficacyPatient still has a long road to travel – will undergo
further rehabilitation once admitted to NRH. Greatest improvements are made in the six
months post incident (Powell, 2004)
Recommendations & Future PlansOngoing input and potential review of status at NRHLink in with Headway/Acquired Brain Injury IrelandContinued vigilance on part of patient and family Counseling for family and partner – and for patient, if
he indicates need for same. Decision making around potential for return to work
and/or need for change in career or lifestyle will likely become possible during/post time in NRH.
What if problems remainIncrease proportion of focus on strategies to aid
memory and language use – written reference & clarification requests, for example
Consider change in career
DischargeFrom Mater, on parental request – felt it would be
better that Robbie could return to his natural environment
From SLT altogether? Ideally once client no longer has any needs; practically, once his needs are no longer considered significant enough to merit priority.
Prognosis – Chronic, or not?Ultimate deciding factor: time We’re not sure – yet!SLTs at NRH will take up work with Robert, and ongoing assessment may tell more
Thank you! Any Questions?
ReferencesConstantinidou, F. & Kennedy, M. (2013) Traumatic Brain Injury in Adults. In: Papathanasiou, I., Coppens, P. & Potagas, C. (2012) Aphasia and Related Neurogenic Communication Disorders. Massachusetts: Jonas & Bartlett. 365 – 387
Das Nair, R. & Lincoln, N. (2013) The effectiveness of memory rehabilitation following neurological disabilities: A qualitative inquiry of patient perspectives. Neuropsychological Rehabilitation, 23(4), 528 – 545 Dunlosky, J., Hertzog, C., Kennedy, M, & Thiede, K. (2005) The self-monitoring approach for effective learning. International Journal of Cognitive Technology, 10(1), 4 - 11
Ehlhardt, L., Sohlberg, M., Kennedy, M., Coelho, C., Turkstra, L., Ylvisaker, M. & Yorkston, K. (2008) Evidence-based practice guidelines for instructing individuals with acquired memory impairments: what have we learned in the past 20 years? Neuropsychological rehabilitation, 18, 300 -342
ReferencesGeraghty, M. & Torbey, M. (2006) Neuroimaging and serologic markers of neurological injury after cardiac arrest. Neurologic Clinics 24(1) 107 – 121
Kessels, R. & DeHaan, E. (2003) Implicit learning in memory rehabilitation: a meta-analysis on errorless learning and vanishing cues methods. Journal of clinical and experimental neuropsychology, 25, 805 – 814
Mattiesen, W., Tauber, S., Gerber, J., Bunkowski, S., Bruck. W. & Nau, R. (2009) Increased Neurogenesis after hypoxic-ischemic encephalopathy in humans is age related. Acta Neuropathalogica 117(5) 525 – 534
McCormack, J., and Worall, L (2008) ‘The ICF Body Functions and Structures related to speech-language pathology’ International Journal of Speech-Language Pathology :10,(1-2) 9-17
ReferencesPowell, T. (2004) Head Injury: A Practical Guide. Revised Edition. Milton Keynes: Speechmark. Rider, J., Wright, H., Marshall, R. & Page, J. (2008) Using Semantic Feature Analysis to Improve Contextual Discourse in Adults with Aphasia. American Journal of Speech-Language Pathology 17, 161 – 172
Schonberger, M., Ponsford, J., Olver, J. & Ponsford, M. (2010) A longitudinal study of family functioning after TBI and relatives’ emotional status. Neuropsychological Rehabilitation, 20(6), 813 – 829
Shum, D., Cahill, A., Hohaus, L., O’Gorman, J. & Chan, R. (2013) Effects of aging, planning and interruption on complex prospective memory. Neuropsychological rehabilitation, 23(1), 45 – 63
Ylvisaker, M. & Feeney, T. (1998) Collaborative Brain Injury Intervention: Positive everyday routines. San Diego, CA: Singular Publishing