FRONTAL LOBE INJURIES

SEAN O’LEARY OTS

OVERVIEW

 Brief Introduction of Frontal lobe

 WHO Classification
 Case Study
 Research
 Handout
FUNCTIONS OF THE FRONTAL LOBE

 Speech and language production: Broca's area, helps put thoughts into words.
Damage to this area can undermine the ability to speak, to understand language, or
to produce speech that makes sense.
 Some motor skills: The frontal lobe houses the primary motor cortex, which
helps coordinate voluntary movements, including walking and running.
 Comparing objects: The frontal lobe helps categorize and classify objects, in
addition to distinguishing one item from another.
 Forming memories: Research suggests it plays a key role in forming long-term
memories.
Chayer & Freedman (2001)
Collins & Koechlin (2012)
FUNCTIONS CONTINUED

 Understanding and reacting to the feelings of others: The frontal lobe is vital
for empathy.
 Forming personality: The complex interplay of impulse control, memory, and other
tasks helps form a person's key characteristics. Damage to the frontal lobe can
radically alter personality.
 Reward-seeking behavior and motivation: Most of the brain's dopamine-
sensitive neurons are in the frontal lobe. Dopamine is a brain chemical that helps
support feelings of reward and motivation.
 Managing attention, including selective attention: When the frontal lobe
cannot properly manage attention, then conditions, such as attention deficit disorder
(ADHD), may develop. Chayer & Freedman (2001)
Collins & Koechlin (2012)
AREAS OF THE FRONTAL LOBE AND FUNCTION

 Frontal-subcortical circuits allow living organisms to act on their surroundings

 Mesial frontal and anterior cingulate cortex are linked to apathy
 Dorsolateral prefrontal cortex is involved in executive functioning
 Anterior cingulate circuit is involved in motivated behavior
 Dorsolateral prefrontal circuit in response to information
 Orbitofrontal circuit is involved in the integration of emotional information into
behavioral responses.
 Right prefrontal cortex is one of the main areas involved in self-awareness
Bonellie & Cummings (2007)
OLIGODENDROGLIOMAS ARE DIVIDED INTO TWO WHO GRADES

 Oligodendrogliomas are often 'diffuse’ tumors which do not have clear edges.
 Grade 2 (low grade) oligodendrogliomas are very slow growing
 Many patients with a grade 2 oligodendroglioma will remain in remission (i.e. no signs of the
tumor growing) for several years after surgery.
 Grade 3 (high grade) anaplastic oligodendrogliomas are a faster growing and malignant
type
 Grade 3 Oligodendrogliomas are slightly more common in men than in women.

https://www.thebraintumourcharity.org/understanding-brain-tumours/types-of-brain-tumour-adult/oligodendroglioma/
CASE STUDY

 30 y/o Male
 PMH: depression and chronic headaches
 Presented with severe headaches bifrontal and holocephalic, as well as visual
obscuration.
 Dx: Right Frontal Oligodendroglimoa (WHO grade II)
 VP shunt placement on 3/26
 Right Frontal Craniotomy performed 5/1 for subtotal debulking
 5/14 Concern for shunt infection, pt. reports picking at wound prior to wound
leaking.
CASE STUDY

 Nursing expectations
 Multiple occasions where nursing warned us that pt. is not participating and
disengaged. Opportunity for education about the frontal lobe and ways to
facilitate the pt.
 Presentation
 Often flat affect, monotone voice, required cues to attend, and lethargic requiring
additional time to process command and respond.
 Easily distracted (eliminate outside stimuli: close door, close curtain, tv off, one
person speaking at a time, and mother would wait in lobby.
CASE STUDY TREATMENTS

 Bed mobility, functional t/f’s and functional mobility

 Frequent verbal and tactile cues for hand placement on RW, short basic 1 step
commands and tactile cues to initiate task.
 Poor safety awareness (constantly itching around EVD’s)
 ADLs
 Decreased self awareness and motivation for hygiene. Required command such as
“start brushing your teeth” and a tactile cue to initiate the task.
 MOCA
 16/30 (24/30 indicates cognitive impairment). Visuospatial: 1/5. Language: stated 4
words starting with F in 1 minute. Delayed recall: 0/5, Attention: 1/3 only able to
count back from 100 subtracting 7 one time.
CASE STUDY

 Incorporate easily attainable goals at the beginning of session

 Today you’re going to walk to the chair.
 Today you’re going to wash your face.
 Today you’re going to sit in the chair for 30 minutes.

 Mindful of how you phrase commands

 Do you want to brush your teeth? Pt. responds, “no, I am okay.”
 Pt. lacks awareness that he needs to brush his teeth or how to initiate the task.

 Brush your teeth in the bathroom. Pt. responds, “Okay.”

 Provide cues necessary to initiate task
CASE STUDY D/C REC.

 Initial d/c home with 24 hour supervision at mothers house

 Current d/c recommendation: IPR with TBI/CHI focus
 Requires cueing for initiating task and demonstrates poor safety awareness
 Not safe to return home currently
RESEARCH- RISK TAKING

 An increase in impulsivity, risk taking or both is often seen in individuals following

frontal lobe damage.
 The two related terms differ in that impulsivity is a response disinhibition, while risk
taking is related to the reward-based aspects of decision-making.
 An impulsive person will make a decision quickly, without considering the
consequences, leading ultimately to a lack of self-control.
 Risk takers will look at the consequences but not weigh them; they will jump at the
opportunity of a reward even if the likelihood of receiving that reward is slim.

Fecteau, Levasseur-Moreau, García-Molina, Kumru,Vergara, Bernabeu, Tormos, (2013)

RESEARCH- GOAL MANAGEMENT TRAINING (GMT)

 The primary objective of GMT is to train patients to stop ongoing behavior in order to define
goal hierarchies and monitor performance. This is achieved through instructional material,
interactive tasks, discussion of patients’ real-life deficits, and homework assignments (Levine,
Schweizer, O'Connor,Turner, Gillingham, Stuss, Robertson, 2011).

 Studies of GMT for patients with brain injuries have reported improved sustained and
executive attention (error reduction, planning and time allocation) (Levine et al., 2011).
 Imaging studies have suggested that GMT results in functional changes in brain networks
supporting sustained attention, which in turn may lead to functional improvements that
generalize to broader domains of goal-directed behaviors (Tornås, Løvstad, Solbakk, Evans, Endestad, Hol, Stubberud,
2016).
RESEARCH-GMT

 Mindfulness meditation is incorporated toward developing a skill of

repetitively bringing one's mind to the present to monitor ongoing behavior,
goal states, and the correspondence between them.
 The intervention also includes real-life examples provided by the therapist and
the patient to illustrate goal attainment failures and successes, promoting
awareness of alterations in goal states, and in session practice on complex
tasks that mimic real-life tasks that are problematic for patients with executive
deficits (e.g., planning a party) (Tornås et al., 2016).
 RESEARCH- GMT TREATMENT SESSIONS

 Session 1 Devoted to defining the concept of absentmindedness and raising awareness of

absentminded errors in daily life.
 Session 2. Absentminded errors were identified as inappropriate expressions of habit
(i.e., the “automatic pilot”).
 Session 3. Frequent checking (i.e., stopping) is required secondary to sensitivity of
working memory to distraction. Mindfulness-based meditation was introduced to
enhance awareness toward current behavior, feelings, and goal states.
 Session 4. Emphasized stating the goal as a method to activate goal representations
following stopping and bringing one's mind to the present.
Tornås et al., (2016)
RESEARCH-GMT CONTINUED

 Session 5. Dealt with decision making in the context of competing goals and the use
of to-do lists.
 Session 6. Participants practiced splitting large goals into sub-goals.
 In this study of patients with stable brain lesions and self-reported executive deficits,
GMT was associated with reduced attentional lapses, increased behavioral
consistency, and improved problem-solving performance.
 There was a tendency toward improved performance on attention demanding tasks
for GMT, with error reduction indicating improved executive attention. The overall
pattern of results confirmed that GMT had a more favorable effect on cognitive
executive functioning than an active psycho-educative control condition.

Tornås et al., (2016)

 RESEARCH- OCCUPATION BASED STRATEGY TRAINING

 Sessions involved reviewing and applying the meta-cognitive strategy (Goal-Plan-Do-

Check) to the goals that were being trained.
 Through guided discovery (a technique in which the participant was facilitated to problem
solve through an iterative process with the facilitator), participants developed sub-goals
and plans to move them toward a larger goal.
 Outcomes of the plan were reviewed (“checked”) with the facilitator to determine
whether the plan had worked or a new or revised plan was needed.
 Occupation-based strategy training is a feasible approach to providing strategy training
for persons with executive dysfunction post brain injury.

Dawson, Binns, Hunt, Lemsky, & Polatajko, (2013)

HANDOUT
QUESTIONS?
REFERENCES

Bonelli, M. & Cummings, J. (2007). Frontal-subcortical circuitry and behavior. Dialogues in clinical neuroscience, 9, p. 141-151.
Chayer, C., & Freedman, M. (2001, November). Frontal lobe functions [Abstract]. Current Neurology and Neuroscience Reports, 1(6), 547-552.
Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11898568
Collins, A., & Koechlin, E. (2012, March 27). Reasoning, learning, and creativity: Frontal lobe function and human decision- making. PLOS Biology, 10(3).
Retrieved from http://journals.plos.org/plosbiology/article?id=10.1371/journal.pbio.1001293
Dawson, Deirdre R., PhD, OT Reg (ON), A. Binns, M., PhD, Hunt, Anne, PhD (ABD), OT Reg (ON), Lemsky, Carolyn, PhD, CPsych, &
Grace, J., Stout, J. C., & Malloy, P. F. (1999). Assessing frontal lobe behavioral syndromes with the frontal lobe personality scale. Assessment, 6(3), 269-
284. doi:10.1177/107319119900600307
Knight, R. T., Stuss, D. T., & ProQuest (Firm). (2002). Principles of frontal lobe function. New York;Oxford;: Oxford University Press.
Levine, B., Schweizer, T., O'Connor, C., Turner, G., Gillingham, S., Stuss, D., Robertson, I. (2011). Rehabilitation of executive functioning in patients with
frontal lobe brain damage with goal management training. Frontiers in Human Neuroscience, 5, 9. doi:10.3389/fnhum.2011.00009
Polatajko, Helene J., PhD, OT Reg (ON), OT(C), FCAOT. (2013). Occupation-based strategy training for adults with traumatic brain injury: A pilot
study. Archives of Physical Medicine and Rehabilitation, 94(10), 1959-1963. doi:10.1016/j.apmr.2013.05.021
Tornås, S., Løvstad, M., Solbakk, A., Evans, J., Endestad, T., Hol, P. K., Stubberud, J. (2016). Rehabilitation of executive functions in patients with chronic
acquired brain injury with goal management training, external cuing, and emotional regulation: A randomized controlled trial. Journal of the International
Neuropsychological Society : JINS, 22(4), 436. doi:10.1017/S1355617715001344