Chapter 11: Prognosis and Treatment Planning

Case Timmy, paralyzed from the waist down + concussion (minor closed head injury) Verbal consent over the phone from his parents for surgery, bc Timmy = minor Was also given anticonvulsant meds Alcohol may have been a factor in the accident (dived headlong into a rock) CNS factors are not uncommon in his family, dad is an alcoholic Never be able to walk again, possibly postconcussion syndrome They needed professional help to take care of him even once he was at home Lack of sig cog + mem deficits (which is consistent w/ most cases of concussion). But, less impairing transient deficits are often evident Trouble inhibiting emotions, attn + concn difficulties They suggesting counselling and aids like note takers/permission to tape his classes Since many things change within the first year posttrauma, a reeval was recommended One difficulty is that school and family tend to focus on physical, not mental needs The prognosis for the npsy issues is generally dependent upon type + quality of intervention normal for depression to occur in these cases Also, prone to self-esteem difficulties, particularly when theyre comparing their premorbid fxning to their current one (his gf broke up w/ him, and to prevent self-esteem issues, counselling should address this event too) Prognosis is poor for spinal cord injury, good for mild TBI Introduction Cnpsy had to corroborate the info from the doctors, Timmys life circumstances, etc. They have to comment on prognosis (based on data from research lit + Timmys specific circumstances) and provide input in treatment planning, i.e. goals + means to attain those goals for each deficit that the npsy eval uncovered Prognosis = estimate of persons ability to return to premorbid lvl of fxn (expected date/amount of time reqd for recovery of fxn is often requested by pts) Some ppl are not capable of returning to this lvl therefore an estimate of relative strengths and weaknesses is a more appropriate rep of prognosis Prognosis estimates begin as early as the very beginning of any type of rehab Each CNS disorder has its own timeline and any pt/sitn variables may extend/decrease this Treatment plan = all the services which will be provided for the client An appropriate eval is reqd for successful treatment. The assessment tool must answer qs related to prognosis. Examples of assessment tools = o Record viewing, interview, behv obvs, psychometrics ~ usually includes protocols dependent upon outcome of eval and pts strengths/weaknesses

Also goals, strategies to attain these goals The actual form will have insurance #, treatment dates completed, DSM diag (Axis V for current and past year), specific data to verify current diag i.e.intake summary, psych/substance history, immediate treatment plan including behv specific goals, objective crit for discharge, type of treatment (individ or group), meds, prescribing physician, termination date, clinic contact ~ is often administered by a case manager = coordinates services delivered by multiple disciplines (sometimes a cnpsy can serve as a ~, though its usually a social worker) Premorbid Pt Factors

~ = all the abilities/disabilities pt has prior to injury that will help/detract from rehab progress ~ factors into prognosis and estimate of strengths/weaknesses

Intellectual Abilities Defn of intelligence is related to the construct in the type of test being used to measure Premorbid estimates may come from school, work, military, etc. records Certain types of intelligence tend to remain intact (or decline at a slower rate during aging) Parallels are often drawn to abilities which usually decline less w/ accidents/illness to ones that decline in aging. Often these are Cattells crystallized intelligence = skills, general info, related to work, hobbies, talents. Rehearsed, practiced, related to formal edu and life exp According to Wechsler scales, crystallized declines very little in normal aging the subtests that measure overlearned skills like Vocab, Info, Comp, Arithmetic show the leas t decline out of all the subtests high crystallizd may be a protective factor/cog resource against dementia Fluid (=novel reasoning, efficiency in solving new problems, responding to abstract ideas (related to adaptability, not edu/exp) declines w/ aging o Digit Symbol, Block Design tend to decline across lifespan DS is not in the WAIS-IV All of the other subtests have been retained though but they load on different composite indices (Info + Vocab are core on Verbal Comp Index Scale w/ Comp being a supplemental. And Block Design is core on Percep Reasoning Scale) Brain size is another factor potentially, but is controversial o When measured by MRI, modestly corrs (0.35) w/ summed test scores. o So, this is not proof that nature is stronger in nature/nurture. Bc enviro can interact Mental abilities and social skills to some extent determine amount of cog loss + dementia o These are diminished bc amount and connectivity of brain tissue reduces it Satz theorized that BRC (= brain reserve capacity) reps structural/physio brain advs (size, redundancy of interconnections) or disadvs. That link to higher edu, higher test scores both pre and post morbidly, better lvl of fxning after injury More years of edu also means better scores on npsy, even w/ brain imp o Also greater control over processing, conceptualization ability (which are related to BRC)

o Though, brighter individuals tend to be the ones who go to uni in the first place Illiteracy can affect cog dev, processing strategies, processing pathways, fxnl brain org o Illiterate/ppl w/ very low edu lvls are frequently not included in normative data o If they are included, they are grouped into the subcategory of <10yrs edu o This may be misleading though and some say we need to dev more norms for them Ppl w/ lower premorbid intelligence/edu are actually more likely to place themselves in sitns where brain imp is more likely Also, ppl w/ higher premorbid intelligence/edu are more likely to understand rehab goals and have motivation to achieve these o But, tend to complain more about their disability and how it affects their QoL Being very close to graduating from high school may help Timmy bc he may be more motivated to grad in the same year as the rest of his class

Personality Factors Affects coping, quality of adjustment to their sitn/handicaps, ability to benefit from rehab, lvl of expectation about their return to fxn Also brain injury tends to exaggerate premorbid personality o i.e. short-tempered more short-tempered if frontal injury the effects of this may not become apparent until pt needs E/social support outside hostpital/rehab setting (if premorbidly E-stable, more likely to have social support networks than those who display antisocial traits, so more likely to be helpful if CNS injury)

Social Support ~ = info from others that one is loved, cared for, esteemed, valued, and part of a network of comm. and mutual obligation Necessary to have ~ to have a recovery that is as positive as possible Pets, ppl w/ same CNS injury included in this High ~ means less stress when confronted w/ stressful exp and more successful coping o Caveat = ~ needs to be of a positive nature o The quality of ~, not the # of ppl is the important factor here o You want someone w/ a truly +ve attitude, not someone defeatist in their analysis of pts ability to recover Reduces physio/neuroendocrine stress response (especially if oxytocin release) Even believing that social support is avail/thinking about the sources can be beneficial

Age

3 ways ~ is imp: 1)Age at which injury is sustained (worst if from birth -5 y.o or >65 (arbitrary later years #))

Though, evidence that CNS is still deving into the 20s (corpus callosum is still thickening which causes improved info processing, cerebral cortex is still maturing until 18-25. But amygdala matures earlier, which is why adolescents exp strong Es but have difficulty controlling their Es Also the enviro is stll imp. Corpus callosum thickens and more brain conns form when adolescents resist peer pressure successfully So, early life injuries can be problematic bc dev is incomplete. BUT, plasticity = behv/neural ability to reorg after injury (healthy brain tissue takes on the roles of impaired tissue o Children show less behv effects after injury and recover faster 2)Certain ages when ppl are more at risk for certain CNS issues, making prevention important i.e. 15-24 sustain more closed head injuries than any other group. o tend to engage in more risky behvs, substance abuse o also, a sense of invulnerability, perhaps bc of their lvl of CNS dev (frontal lobes) very young and then the elderly are the next groups that get closed head injuries the most, but most often bc of falls 3)Normal course of aging can be compared to factors which may be CNS issue-related Not normal to dev dementia w/ age, however more common in older popns o Though, more tech increases life expectancy and so its hard to tell which behvs are bc of aging vs those that have a diff etiology. Major decline is evidence of CNS injury tho Normal: abilities slow (so any timed task will show a deficit), decline in brain volume, cortical atrophy w/ wider sulci, narrowed gyri, thinning of cortical mantle, increasing ventricle dilation, changes in temporal lobes, changes in basilar-subcortical regions. Bc neuronal loss mostly o Also decreased cerebral blood flow in these areas o None of these are evidence for significant behvl sequelae Crystallized remains intact for longer than fluid abilities Also, the idea of BCR is pretty well supported by some large studies (i.e. nun study) These studies also suggested that BCR begins early in life and is aided by an active lifestyle (wich is actually more common in those who are more intelligent too) Recovery of soldiers from head injuries is greater in the 17-20 group than 21-25

Gender Controversial. Kimura found men are better in motor skills like target throwing, catching, spatial analysis, spatial nav, geographical knowledge, math reasoning. Females are better at fine motor skills, spatial memory, math computation, sensitivity to sensory stimuli, perceptual speed, sensitivity to facial and body expressions, visual recog mem, verbal fluency, verbal mem Kimura said was unable to find any enviro reasons for these results Physio: male brains are larger, even when you account for differences in body size. They have more neurons, more gray matter, and its organized differently Lateral asymmetry (left larger than right) is more pronounced in men , especially in the Sylvian fissure, planum temporale which may evidence sex diffs in org of lang-fxns o Thus, womens brains can reorg better after injury to compensate

o Left-handed ppl also have this adv Women have more interhemispheric cons in corpus callosum, anterior commisure The posterior part of callosum is larger in women Also larger anterior commisure in women prob bc of # of neuronal fibres, which is due to way the 2 hemis interact The ridges on fingertips are more asymmetrical for women and this pattern is corrd w/ performance on certain cog tests Types of Difficulties Expressed by Pt

Nature and Extent of Changes Diffuse: affects many brain areas, but usually unequally. Widespread, typically bc infection, anoxia, degen disorder, closed head injury. mem issues, attn, concn, higher lvl and complex reasoning, and response slowing Also may involve E flattening (Es re not expd w/ any degree of excitement) or E lability (Es fluctuate quite dramatically). Symptoms tend to occur early on and may worsen as time goes on vs. focal: a very circumscribed area is affected. Caused by infection, tumor, lesion, trauma (including Timmys concussion and spinal cord injury) the area determines type of dmg. However, very few pts just have that areas dmg often symptoms thought to accompany diffuse will occur (which can make diag difficult) the cause of dmg is imp in prognosis and treatment planning a clean wound/clear pattern of tissue involvement will give cnpsyist more concrete info than injury that affects multiple areas depth and extent to which a cortical lesion involves subcotrtical tissue makes the symptom picture more complex bc of the possibility of more disrupted pathways, damaged integrative centres, impairment of verbal skills diaschisis, first described by Von Monakov, = form of shock to nervous sys due to disruptions in neural network connected to are dmgd by lesion w/ fxnlly related areas that may be a distance away or even in the opposite hemi o = nonpermanent phenomenon that improves spontaneously according to most o But some use term to describe permanent changes not directly assocd w/ lesion site o Chronic ~ may appear similar to disconnection syndrome bc both appear as loss of fxn surrounded by an area of of brain that is intact, away from lesion o But some researchers say there is a diff in causality. Lesions that extend to white matter or dont can cause ~ But, for disconn syndrome, it only results from dmg to white matter that cuts cortical pathways, disconning cortical area from comm. network of brain Regardless of nature of lesion, severity = most imp var in determining lvl of imp Etiology also plays some role (TBI recover more arm/leg motion + speech than stroke o Though, this interacts w/ age as TBI victims tend to be younger

Degenerative difficulties also have a much diff type of prognosis and treatment planning o Most often dementia. Also, Alzheimers leaves behind dead/diseased tissue (tau plaques, neurofib tangles) which occupy extra space and make prognosis unclear

Course of Illness/Injury Related to whether there is a standard pattern of progression/recovery due to etiological factors or whether the course is more individualistic depending on pt factors Alzheimers, for x, has a standard pattern of decline which makes it easier for cnpsy to predict Though progressive, the stage in which the individual is in may affect prognosis Early assessment may allow for treatment that keeps person in stage 1 longer Relapse-remitting disorders like MS are more individualistic and include periods of acceleration of symptoms/decline and also slower progression periods Another variable is at which point the cnpsyist is first involved (i.e. early/late diag, early/late referral to cnpys for treatment to begin) Standard to npsy assess right after diag, then at 6 months, 1 yr, and 2yr intervals from then. Recovery tends to progress in spurts, w/ periods of improvement/decline for the same ability Improvements are also morst prominent at 6months and 1yr o Ie. For TBI, mem, processing speed, lang, construction skills improve substantially o Also gains in community integration, but not in driving ability In most cases, pts make the most rapid gains in the first weeks/months following medical stabilization (and in this time frame, other factors soon after diag are imp bc CNS has not had a chance to recover on its own w/o assistance at this stage) Spinal cord injury is static (will not get better or worse) CNS cannot control the progression of muscle atrophy though, which will happen Postconcussion syndrome = new diag in DSM-V = aftereffects of a med documented concussion including npsy assessment of difficulties w/ attn, mem. can aslo include easy fatigue, disordered sleep, headache, dizziness, anxiety, depression, personality change, lack of spontaneity Ways to Enhance Recovery 4 ways in which it can be enhanced These are discussed not as a critique of treatment programs but as a way to look at how diff lvls of evidence may affect prognosis/treatment plans

Spont Recovery ~ implies any +ve change/movement toward premorbid fxn w/o intervention. Just by time. Many fxns that improve w/ ~ were already only temporary (therefore reversible) ~ is often the reasons ome pts show very rapid recovery soon after a brain injury ~ does not occur in degen difficulties Edema (swelling of brain that may follow many types of trauma, similar to the swelling when an area is bruised/bone is broken) is one of the main reversible events in brain injury

In the brain, swelling occurs within confines of skull Dependent on the extent of ~, there may also be increase in pressure which in turn may damage various cells or cause a blood vessel to be blocked/ruptured Temporary loss of blood flow to brain cells is another reversible event o Actual cause may be occlusion by emboli within brain, thrombi from other areas, or blood flow loss caused by hemorrhage (= escape of blood from the vessel) o Similar to edema, if the loss of blood flow is only partial or lasts a short time, brain cells will be dmgd but not dead and so they can spont recover Trauma may have a lasting effect or may shock but not permanently impair Diaschisis may also occur Drugs, dehydration, metabolic imbalance, bio deficiencies may also cause nonpermanent dmg o However in each of these, there is potential for more serious difficulties Ex. of spont recovery = coping w/ spinal cord injury (Timmy)

o o

Recovery of Old Fxnl Systems Behv may be regulated by diff areas of brain In early dev, a task may have been performed by one area, but as dev progresses, other areas may replace the original sites in reging these fxns w/ CNS issue, it is natural for brain to revert to a developmentally earlier sys that may be present but has not been used for extended period of time if all fo the conns within the older sys are still intact, earlier system can do the fxn in many cases, it is easier for a person to have an injury that permanently affects a fxnl sys bc itll trigger the natural attempt to revert to earlier dev stage also, we may be able to either regroup cells from other areas or actually dev new cells to replace dmgd cells (research in this area is growing exponentially) issue of stem cell research has recently been addressed at federal lvl (theyve allowed use of stem cells within federally funded research. This was previously forbidden) many times, injury will affect white matter that conns and supports neurons, instead of impacting only the neurons themselves. Axons that link cells are able to sprout after injury ex. Timmy = using his arms to help propel wheelchair when his legs were immobile

Dev of New Fxnl Systems spont recovery and use of old fxnl systems are easier ways for CNS to recover but, when the loss is permanent and/or the two other ways are not possible, it is necessary to form new links which fxn as a replacement for the injured sys. Or, to dev a new sys entirely. New sys can be formed through substation of one brain area for another More common scenario = tasks that involve both hemis, but one hemi is impaired (i.e. the corresponding area in other hemi can compensate, i.e. occipital lobes if vision imp in one lobe)

But, at the optic chiasm, the optic nerves decussate so that if one hemi is lost, the other cannot completely fill in all of the visual field. So a new sys is clearly a substitute and may not bring pt completely back to their premrbid lvl of fxn Or, one could try to complete a task in a diff way. I.e. each individ has a preferred learning style. But, if visual is impaired, person may have to learn w/ auditory learning Or, the task itself can be changed to make it easier (i.e. use a letter board for pt to talk if stroke has impaired their speech). Or, making a task more complex can even help, i..e Luria: pt who is unable to walk but if lines were placed on the floor, he could do it Ex. Timmy = using other means to try to move and do other tasks

Changing the Enviro If none of the above methods are enough for pt, this last method = ~ The possibilities for this method are endless, limited only by imagination of client/OT i.e. making home wheelchair accessible, altering a vehicle for handicap driving Forensic Issues in Prognosis and Treatment Planning many CNS issues occur under circumstances where there is a deg of fault/blame attached malpractice, liability manufacturer for defective product/service, negligence, etc. Also if injured at site of employment, workers comp. Also just disability claims in general. Cnpsyists participate in litigation as impartial objective assessors when hired by court, or as an expert witness when hired by either side in a litigation Forensic npsy = term for when cnpsyist provides npsy evidence/opinions for court on issues involving cog status (becoming a bigger part of cnpsyists jobs, since 1980s) o Several reasons for this = more ppl getting TBIs, dev of advocacy orgs, advent of neurolaw, increasing supply of cnpsyists, response to legal sys Majority of cnpysists are employed in private practice and #1 referral source = attorneys Particularly salient are issues of workers comp and social security disability payments

Litigation Issues Diff philosophies and codes of conduct within law and psy, which cnpsyist must understand Sci-practitioner model is particularly imp in forensic arena bc of standards for admissibility of evidence (cnpy is grounded in empirical research but validity of assessment tools must be proven for forensic purposes) Frye standard = from Frye v. U.S.A, 1923. Was the prevailing standard for admissibility of expert testimony = the evidence must be generally accepted within the field from which derived Recently, the Daubert standard has been used instead. From Daubert v. Merrel Dow Pharma Inc, 1995. = judges have the task of determining if the methodology used by expert is sound. So, it has become more difficult for some ppl to be accepted as experts in their field but, cnpsyists whose judgements are based on sound science tend to applaud this decision

Worker Compensation Issues many ways and types of work CNS issues can occur in workplace worker comp = benefit, previously called workmens comp, dates to 1902, Maryland first federal law = 1906. Was initially designed to reduce litigation and speed up delivery of benefits. Person must agree they would not file a lawsuit against employer (tort/negligence) so, workers comp = form of disability insurance, health insurance, life insurance(bc of the no lawsuit part, bc pays med bills, bc premiums to dependants in case of death, respectively) comes into play when person claims injury happened at workplace and some implied responsibility of employer to take care of employee majority of employed individuals get it, even those who are self-employed or work for a very small org bc it is not a benefit in the strict sense of the word o so, they can get it even if no health insurance, no social security deductions but, it varies by state, even though it is supposed to follow certain federal guidelines o varies in terms of how employer liability is decided and amount to reimburse steps = worker files an incident report, then an application. Then a contracted agency responds and makes a determination of extent of disability + negligence of employer In many cases, they receive less salary than normally would. Relinquished legal right to sue Role of cnpyist varies depending on referral source and whether they are asked ot evak the claimant to deliver expert witness (court recogs them as an expert based on training and exp and will use thir testimony to render a decision) testimony Must be impartial, objective, rest on the most empirically verifiable tools avail One difficulty = cnpyists person they are assessing may be malingering/secondary gain o Tests are avail to screen for this though

Social Security Disability Person can get this in addition to workers comp. SSA = Social Security Administration = admins 2 programs for disability benefits = o SSDI (SS Disability insurance, Title II of the SS Act) Title II = payment to those who are insured under the act by having contributed to the SS tax by wage deductions as well as some dependents of insured ppl) o SSI (Suplemental Security Income, Title XVI of the SS act) For ppl under 18, those who have limited income/resources Most disability claims are processed through a network of local SS field officers and state agencies. = DDSs= Disability Determination Services Appeals may be made to these offices. They are funded by fed govt and state agencies are responsible for deving med evidence and rendering initial determination of whether claimant is disabled or not or blind They get evidence from claimants own med source first. If insufficient, CE = consultative exam) judgement of diability is made by a two-person team = med/psy consultant + disability examiner

cnpsyist ay be the treating professional in which case DDS may request info regarding claimant and his/her prognosis/treatment plan they may also be requested to perform, for a fee, npsy tests or, they may be involved to testify at admin law judge hearings or respond to written interrogratories from admin law judge