Chapter 5, 6, 7, 9 Flashcards
Autonomic Storming
AKA dystonia
failure of sympathetic or parasympathetic components of the autonomic nervous system to regulate body functions
-characterized by disruptions in heart and respiratory rates, BP, temperature, perspiration, muscle overactivity, posturing, dystonia, rigidity, and spasticity
Deep vein thrombosis
blood clot in and deep venous part of the circulatory system
common in TBI
Pulmonary Embolism
blockage of a main artery in the lung frequently caused by a blood clot that has traveled from elsewhere in the body (often a DVT)
Urinary Tract Infection
- occur early and late post-BI
- may be detected through cognitive or behavior changes
is bladder or bowel incontinence behavioral or intentional
no, typically not. There is great shame and embarrassment in not being able to control these functions
Treatments for incontinence
foley catheter suprapubic catheter timed-voiding schedule anti-cholinergic drugs bowel routine
aspiration
material/bolus passing level of vocal folds into airway
The Congress of Neurological Surgeons states that in the acute phase following a head injury, a person will require at least ___% more calories than he or she needed prior to the injury
40%
BI present in ___% of SCI cases
60%
Effect on BI co-occurring with SCI on LOS and motor outcomes
People with paraplegia and co-occurring severe TBI had worse motor outcomes and longer acute rehab LOS than individuals with only paraplegia and no TBI
Complete SCI
no motor or sensory function below level of injury
incomplete SCI
functioning of sensory and possibly motor below the level of injury
decubitus ulcers
pressure injury/sores from prolonged pressure on any area due to positioning and increased spasticity or tone
important principles to prevent decubitus ulcers
Use bracing (immobilization, external fixation, orthotics)and proper wheelchair/bed positioning
Stage I Pressure Injury
red and warm to the touch
may itch or burn
timely identification may help reverse and minimalize further damage
Stage IV Pressure Injury
- most severe
- may lead to potentially serious infection, which may be life threatening
- result in large open areas of tissue destruction down to and including muscles, bones, tendons, and joints
How to prevent pressure sores
- keep skin clean and dry
- change position every 2 hours
- pressure-relieving devices: specialty mattress, specialty cushions, tilt in space w/c
MRSA (stands for, cause, treatment)
Methicillin-Resistant Staphylocuccus Aureus
- typically a product of poor hygiene, including poor hand washing by care providers and repeated use of soiled clothing
- requires antibiotics to treat
3 Categories of seizures after a TBI
(classified by time of appearance after initial impact)
- Immediate post-traumatic convulsions (IPTC)
- within seconds of impact - Early post-traumatic seizure (EPTS)
- within first week - Late post-traumatic seizures (LPTS)
- >1 week after BI
Immediate post-traumatic convulsions (IPTC)
involve loss of consciousness and involuntary movement within seconds of impact
Early post-traumatic seizures (EPTS)
- occur up to 7 days after initial impact
- result of primary direct effects of the trauma
- approx 50% occur within 24 hrs of impact
- strong risk factor of late post traumatic seizures
Late Post-Traumatic seizures (LPTS)
- greater than 1 week after initial head trauma
- generally within first 18-24 months after BI
- also known as post-traumatic epilepsy
- presence of seizure disorder associated with increased mortality
- individuals with post-traumatic epilepsy die at a younger age than those that do not. Worse with advanced age at time of injury and presence of SDH
tonic posturing
back arching, eyes roll back in head
clonic/myoclonic jerks
muscle spasms causing a jerking in limbs less than 2-3 min in duration
Postictal period
short period of time following a seizure where there is an altered state of consciousness
decerebration
loss of cerebral brain function
hippocampal atrophy
shrinkage of the hippocampus
status epilepticus
more than 30 min of continuous seizure activity or two or more sequential seizures without full recovery of consciousness
Causes of pain after BI
orthopedic pain muscular pain headache spasticity/contracture HO myofascial pain neuropathic pain
nociceptive pain
pain related to peripheral nerve fibers
neuropathic pain
associated wtih primary lesion dysfunction of nervous system
pain management strategies
NSAIDs OTC pain meds (acetaminophen) topical agents antispasticity meds opoids nerve blocks steroids ice heat ROM stretching ultrasound therapy TENS
post-traumatic headache (PTH)
- headache that commences within 14 days of LOC
- may spontaneously resolve within 6 months or symptoms may persist and become chronic
Percentage of people who get PTH after mTBI vs moderate-severe TBI
95% after mTBI
22% after moderate-severe
primary headache
headache with no specific cause
secondary headache
headache that may have identifiable cause that can be determined
chronic headache
occurs at least 15 days per month for at least 3 months
primary nocioceptive afferent nerves involved with post-traumatic headache
CN V (Trigeminal) CN IX (Glossopharyngeal) CN X (Vagus) Greater Occipital Nerve (from C2 root) Lesser Occipital Nerve (from C3 root)
Spasticity
motor disorder characterized by a velocity-dependent increase in tonic strength with exaggerated tendon reflexes resulting from excitability of the stretch reflex caused by upper motor neuron damage
What medication is standard of care for spasticity management
baclofen
hyperreflexia
involuntary increase in muscle tone and exaggerated deep tendon reflexes
contractures
abnormal, usually permanent condition of joints charaterized by decreased ROM, often in a flexed position, and fixation due to wasting awat and shortening of muscle fibers and loss of skin elasticity
signs of heterotropic ossification
- decrease in joint ROM
- increased spasticity & pain
- joint may become red and swollen
- swelling in lower leg that mimics DVT
- usually occurs on same side of body where spasticity is worst
- hip is most common, followed by shoulder and elbow.
- knee is least common place
- surgery warranted in some cases after individual reaches maximum motor recovery (usually 1.5 years)
Stage II pressure ulcer
- partial thickness
- loss of dermis
- shallow open ulcer
Stage III pressure ulcer
- full thickness tissues loss
- fat may be visible but not bone, tendon, or muscle exposed
Stage IV pressure ulcer
full thickness tissue loss with exposed bone, tendon, or muscle
Unstagable pressure ulcer
full thickness tissue loss in which actual depth of ulcer is complete obscured by slough and/or eschar in the wound bed
Deep tissue injury
purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear
predominant disabling factors 5-10 years after BI
cognitive
behavioral
personality changes
Alzheimer’s disease
most common form of dementia
- progressively worsens
- most common early symptom is short term memory loss
Older adults with hx of TBI vs age-matched controls without TBI on attention, verbal memory, relative cognitive decline over 2-5 year period
- no difference in relative cognitive decline
- TBI group had lower scores on attention and verbal memory
10 elements of successful aging after BI
- Exercise
- Brain Health
- Heart Health
- Advovate
- Nutrition
- Mental Health
- Protect the Brain
- Socialize
- Avoid Drugs & alcohol
- the brain is capable of making billions of connections; make more (neuroplasticity)
fatigue
awareness of decreased capacity for physical and/or mental activity due to an imbalance in the availability, utilization, and/or restoration of resources (physiological or psychological) needed to perform the activity
physiological fatigue
casued by depletion of energy, hormones, neurotransmitters, or reduced number of neural connections due to brain injury
-direct result of injury or dysfunction in the brain; may be associated with muscle weakness or other changes or injuries in the PNS
Psychological fatigue
a state of weariness related to reduced motivation, prolonged mental activity, or boredom that occurs in situations such as chronic stress, anxiety, or depression
Secondary fatigue
can be caused by a number of factors such as pain, sleep disturbance, or stress
Measures used to assess fatigue in BI
- Visual analog scale for fatigue (VAS-F)
- Fatigue Severity Scale (FSS)
- Barrow Neurological Institute Fatigue Scale (BNI Fatigue Scale)
- Global Fatigue Index (GFI)
- Multidimensional Assessment of Fatigue (MAF)
- Causes of Fatigue Questionnaire (COF)
Treatment of fatigue
- assess for anxiety, depression, and pain
- lifestyle modifications
- sleep hygiene techniques
- Modafinil (wake-promoting drug)
- non-pharmacological interventions (light therapy- enhancing vigilance and mood)
Sleep disruptions following BI
- insomnia
- hypersomnia
- escessive daytime sleepiness (EDS)
- changes in sleep-wake cycle
- changes in REM sleep
Causes of sleep disturbance after BI
- injury to brain regions or pathways
- presence of depression
- disrupted circadian regulation of melatonin production
Prevalence of Minimally conscious State
280,000
Prevalence of Vegetative state
35,000
Prevalence of individuals with DOC total
315,000
Minimally Conscious State
severely altered consciousness in which minimal but definite behavioral evidence of self or environmental awareness is demonstrated
emergence from DOC evidenced by
functional communication as evidenced by verbal or gestural yes/no
OR
functional use of 2 or more objects
No Response
no discernable reflexive or volitional response noted to stimuli
Generalized Response
Response to stimuli is automatic, reflexive, or non-purposeful, and is non-specific
Localized Response
Response to stimuli reflects person’s ability to regulate incoming sensory information and voluntarily control the response to the stimulation
-localized responses are NOT reflexes and can occur in relationship to the area stimulated
Goals of medical management of DOC
- Maintain physical stability to allow participation as fully as possible in daily routines and therapy
- Prevent medical complications
- Provide opportunities for stimulation to the brain through environmental manipulation and pharmacological intervention
Common medical challenges associated with DOC
skin breakdown
respiratory
bowel/bladder dysfunction
autonomic dysfunction syndrome
Autonomic dysfunction syndrome (ADS)
a problem with the autonomic nervous system (located in medulla and lower brainstem) that controls processes such as digestion, heart rate, the immune system, respiratory rate, etc
Symptoms of Autonomic Dysfunction syndrome (ADS)
- dystonia
- agitation
- tachycardia
- diaphoresis
- hyperthermia
- hypertension
- tachypnea
How to treat Autonomic Dysfunction Syndrome (ADS)
- environmental control (determining provoking factors such as bright lights, noise, specific movement patterns) and minimizing or eliminating
- medications- propranolol, gabapentin, clonidine, bromocriptine, dantrolene, morphine
Neuralgia
pain caused by damage to a nerve of structural change to a nerve
Neuroma
when a nerve becomes entrapped in scar tissue
Syndrome of the Trephined
- specific to patients who have had had a craniectomy following TBI
- related to surgical site
- characterized as headache, dizziness, cognitive changes,
- involves shrinking of the skin flap after craniectomy due to positional changes
- typically have good improvement after cranioplasty
Stability Triangle components (for stability to be established and maintained)
- medical stability
- behavior stability
- stable activity plan
medical stability
control of medical complications such as pain, sleep disturbance, incontinence, seizures, etc)
behavior stability
requires team to assess problematic behavior such as resistance or refusal, mood instability, threatening or demanding behaviors, verbal and physical aggression, property destruction, elopement, self-harm, and substance abuse or misuse
stable activity plan
team must explore individual’s abilities, interests, and need for support associated with specific activities and settings, and work to minimize all related risks
functionally equivalent alternatives
behavior that serves the same function as the target behavior, but is safer, more appropriate, and thus is more useful for the individual
operational definition
outlines what exactly will be counted as an occurrence or episode of the behavior; must be observable or measurable, definition must be specific enough such that multiple observers can agree upon what would count as an occurrence
focus of neuropsych evaluation
determines how different areas and systems of the brain are working
neuropsych assessment process
record review
clinical interview
standardized testing
report and feedback
neuropsych evaluation provides
detailed description of individual’s abilities, strengths, adn weaknesses in various areas of functioning
neuropsych evaluation achieved through
administration of tests that measure behavioral constructs of specific human abilities such as attention and memory, in a standardized fashion
neuropsych findings can be used to
determine nature and extent of cog deficits, presence of a neurologically based disorder, understand how cog deficits may contribute to problems in daily life, determine nature and degree of change in cog performance on re-assessment, assist in treatment planning, determine appropriateness of a surgical intervention, and make recommendations for modifications or accommodations in the community
ACRM definition of cognitive rehabilitation
systematic, functionally oriented service of therapeutic cognitive activities, based on an assessment and understanding of the person’s brain-behavior deficits. Services are directed to achieve functional changes by:
- reinforcing, strengthening, or reestablishing previously learned patterns of behavior
- establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems
2 fundamental principles of cognitive rehab
neuroplasticity
adaptability
neuroplasticity
ability of nervous system to regenerate and reorganize its structure, functions, and connections
restorative cognitive tx goals
aims to reestablish lost functions or develop new functions
restorative treatment consists of
repetitive, targeted, consistently challenging exercise thought to facilitate recovery of impaired neural circuits
adaptability
individual’s capacity to change behaviors in order to adapt to changes in their natural or external environment
compensatory cog tx goal
designed to minimize the effect of deficits and to recover a degree of function
compensatory tx consists of
development of internal and external environmental strategies that make use of residual, intact abilities and relative strengths`
Factors affecting duration of psychiatric symptoms
unique to the individual
- genetic bias concerning mental illness
- effects on the brain
- stressors related to living with a disability
- individual’s psychological resiliency
- quality of the person’s support network
