4 Traumatic Brain Injury

Question 1

Leading cause of TBIs

Answer 1

• falls 40.5%- age >65 y/o
• unknown/other 19%
• struck by/against 15.5%
• MVA 14.3%- age 5-24 y/o
• assault 10.7%- age 0-4 y/o

Question 2

Epidural hematoma

Answer 2

-blood between dura and skull, rapid increase in ICP- start lucid, then rapidly decline

Question 3

Subdural hematoma

Answer 3

• between dura and arachnoid layers

- blunt trauma without skull fracture

Question 4

Normal vs increased ICP

Answer 4

• normal 0-10 mmHg
• increased >20 mmHg
• signs of increased- headache, papilledema, vomiting, drowsiness, altered consciousness

Question 5

Normal vs decreased cerebral perfusion pressure

Answer 5

• Normal >70 mmHg

- CPP <40-50 mmHg causes ischemia

Question 6

Glasgow coma scale

Answer 6

• mild TBI 13-15
• moderate 9-12
• severe 3-8

Question 7

Westmead post-traumatic amnesia scale

Answer 7

• mild 5-60 minutes
• moderate 1-24 hours
• severe 1-7 days
• very severe 1-4 weeks
• extremely severe >4 weeks

Question 8

Rancho Level I

Answer 8

-no response, complete absence of observable change in behavior to any stimuli

Question 9

Rancho Level II

Answer 9

-generalized response- non-specific, inconsistent and non-purposeful manner with stereotypical and limited responses

Question 10

Rancho Level III

Answer 10

• localized response- specifically and inconsistent response with delays to stimuli
• turn toward or away from auditory stimuli
• follows object in visual field
• may follow simple commands

Question 11

Rancho Level IV

Answer 11

• confused/agitated
• altert, heightened state of activity
• restless, aggressive, abusive
• absent STM
• performance of motor activities without purpose
• lack of deficit awareness

Question 12

Rancho Level V

Answer 12

• confused/inappropriate/non-agitated
• altert, non-agitated
• not oriented
• gross attention to environment but highly distractible
• severely impaired recent memory and unable to learn new information
• absence of goal-directed, problem solving, self-monitoring behavior
• appropriate responses to simple commands with external cues (without cues, inappropriate and non-purposeful)

Question 13

Rancho Level VI

Answer 13

• confused/appropriate
• inconsistently oriented
• emerging awareness of appropriate response to self, family, basic needs
• goal-directed behavior but dependent on external cues
• remote memory better than recent
• demonstrates carryover for some re-learned familiar tasks like self-care
• consistently follows simple directions

Question 14

Rancho Level VII

Answer 14

• automatic/appropriate
• appropriate behavior in familiar settings
• daily routines automatic
• carryover of new learning
• unrealistic planning for future and overestimates abilities
• initiates social interactions, but judgment remains impaired

Question 15

Rancho Level VIII

Answer 15

• purposeful/appropriate (stand-by assistance)
• consistently oriented
• independent for familiar tasks in distracting environments
• aware of impairments but difficulty taking corrective action when completing tasks
• difficulty with abstract reasoning, stress tolerance, judgment

Question 16

Rancho Level IX

Answer 16

• purposeful/appropriate (stand-by on request)
• independently shifts between tasks for two hours
• requires some assistance to adjust to life demands
• emotional and behavioral issues possible

Question 17

Rancho Level X

Answer 17

• purposeful/appropriate (mod I)
• goal-directed and able to handle multiple tasks independently with strategies
• may continue to have decreased attention and require additional time to complete tasks

Question 18

Baclofen

Answer 18

• GABA receptor agonist

- orally or intrathecally

Question 19

Diazepam (Valium)

Answer 19

• benzodiazepine

- typically for anxiety

Question 20

Dantrolene

Answer 20

-muscle relaxant

Question 21

Botulinum toxin

Answer 21

• neurotoxic protein

- injections last 3-4 months

Question 22

Coma caused by

Answer 22

• diffuse bilateral hemisphere damage and/or failure of ascending reticular activating system
• brainstem infarction or hemorrhage
• drugs and metabolic disease by depression of both cortex and ascending reticular activating system

Question 23

Oculocephalic response

Answer 23

-doll’s eyes- eyes should move opposite direction of passive L/R rotation of head

Question 24

PT’s role in rehab of executive functions

Answer 24

• ask patients to predict their performance before beginning a task
• ask patients to provide post-task feedback about performance
• use systematic cueing strategy to maximize patient recognition of errors and improve ability to generate solutions

Question 25

Highly recommended outcome measures for acute care

Answer 25

• agitated behavior scale
• coma recovery scale- revised
• moss attention rating scale
• rancho levels of cognitive functioning

Question 26

Agitated behavior scale

Answer 26

• 14 items- distractibility, unpredictable anger, repetitive behaviors, self-abusiveness, etc.
• total scores 14-56, items scored 0-4 (absent to present to extreme degree)
• WNL <21
• mild agitation 22-28
• moderate 29-35
• severe >35

Question 27

Coma recovery scale- revised

Answer 27

• 23 items in 6 sub scales (auditory, visual, motor, oromotor, communication, arousal)
• scored 0-23, higher scores = better function
• for disorders of consciousness

Question 28

Moss attention rating scale

Answer 28

• observational tool for attention-related behaviors after TBI
• 22 items reflecting both good and impaired attention
• 1 (definitely false) to 5 (definitely true) for each item
• total scores 22-110 (higher scores = better attention)

Question 29

Ten meter walk

Answer 29

• <0.4 m/s = household ambulator
• 0.4-0.8 m/s = limited community ambulator
• > 0.8 m/s = community ambulator

Question 30

Community balance and mobility scale

Answer 30

• high level balance and mobility in the community
• allowed to wear orthotic but can’t use ambulation aides
• 13 tasks with total score of 96 (most able)

Question 31

Disability rating scale

Answer 31

• monitors recovery from coma to community in mod to severe TBI
• 30-point scale that determines function in 8 areas including consciousness, cognitive ability, dependence on others, and employability
• 0 (without disability) to 29 (extreme vegetative state)

Question 32

Functional assessment measure

Answer 32

• 12 items added to 18-item FIM for brain injury
• 30 item scale = FIM+FAM
• same scoring as FIM (0-7)
• includes swelling, car transfer, community access, reading, writing, speech intelligibility, emotional status, adjustability to limitations, employability, orientation, attention, and safety judgment
• <65 (FAM only) = individuals at risk for long-term unemployment

Question 33

High level mobility assessment tool

Answer 33

• 13 items performed at max safe speed (running, skipping, hopping, etc) score 0-4
• 0-54 (higher scores = better performance)
• norm for 18-25 y/o = 50-54 males, 44-54 females
• can use orthotics
• must be able to ambulated independently over 20 meters without AD

Question 34

Patient health questionnaire

Answer 34

• self-report to assess depressive symptoms over previous 2-weeks
• 0 (not at all) to 3 (nearly every day)
• 9 items, max score 27
• > 12 = possible major depressive disorder

Question 35

Quality of life after brain injury

Answer 35

• health-related QOL
• 37 self-rated items
• 0 (worst QOL) to 100 (best QOL)