Cognitive and Behavioral Considerations for TBI

Question 1

Describe the Rancho LOCF

Answer 1

• All task oriented, PNF, NDT based treatment approaches are applicable for treating TBI
• Severe TBI patients undergo changes in cognitive & behavioral patterns as they recover form injury
• Interventions depend on the collection of physical, cognitive, & behavioral status as they recover
• Rancho has 10 cognitive/behavioral levels

Question 2

Levels of consciousness as TBI patients recover

Answer 2

• Coma: lowest level, rarely lasts >4 wks
• Wakeful post comatose unawareness (aka pvs): might open their eyes, return of sleep/wake cycle, no tracking/fixing of gaze, no purposeful movements or communication, lasts >4 wks
• Minimal conscious state: can track objects visually, inconsistent ability to follow commands, simple communication (yes/no gestures)
• Confused state: disorientation, memory deficits, may become restless, agitated, experience sleep disturbances, delusions/hallucinations

Question 3

What must occur to determine one has overcome minimal conscious state

Answer 3

• once they can communicate consistently & follow instructions

Question 4

Describe cognitive/behavioral deficits after return of full consciousness

Answer 4

• Cognitive: variable degrees of attention, problem solving, mental flexibility (task switching), poor speed/increased reaction time, language deficits (name/word finding) may remain
• Behavioral: excessive/disinhibited, inappropriate societal & sexual behaviors, mood disturbances, irritability, rage, involuntary laughing/crying

Question 5

Describe Rancho level I

Answer 5

• No response, dependent/total assist
• Deep sleep & does not wake up (coma or vegetative state)
• May be in ICU & may be attached to a mechanical ventilator

Question 6

Interventions/considerations for Rancho level I

Answer 6

• Positioning, education to staff & family regarding PROM
• Conversation with family about bringing pictures/personal items, say who you are each time you see the pt, tell them the day, date, & time, use calm voice, use pictures to talk about their house/friends/family

Question 7

Describe Rancho level II

Answer 7

• Generalized response, dependent/total assist
• Generalized response to painful stimuli, eyes might open, return of sleep/wake cycle, generalized gross body movement, responses may be the same regardless of type/location of stimulation and may be significantly delayed

Question 8

Interventions/considerations for Rancho level II

Answer 8

• Mobilize to sitting EOB or passive standing (verticalization is known to improve awareness/arousal), ROM exercises, positioning
• Begin orientation with people/place/time, address amnesia, use family pictures to help recall, short Tx time

Question 9

Describe Rancho level III

Answer 9

• Localized response, dependent/total assist
• Withdrawn from or vocalization to painful stimuli, turns toward or away from auditory stimuli, blinks with strong light, follows moving object that passes within visual field, responds inconsistently to simple commands (yes/no), may show delayed responses

Question 10

Interventions/considerations for Rancho level III

Answer 10

• mobilize, visual tracking exercises, continue mobilization to EOB to work ons seated balance, attempt/progress to transfer training & progress as able to standing balance
• Avoid overstimulation, improve pt’s response to one step commands, work on orientation/memory, start a simple routine, consider having the patient participate in activity, talk to them about their daily routine

Question 11

Describe Rancho level IV

Answer 11

• Confused/agitated, MAX A (mostly due to risky behavior)
• Alert, heightened state of activity, agitated, extremely confused, purposeful attempts to remove restraints, very brief divided attention, may cry out/scream.swear to stimuli even after removal, may be aggressive/flight behavior, unable to cooperate with treatment efforts

Question 12

Interventions/considerations for Rancho level IV

Answer 12

• Consider ADLs or other functional mobility tasks to increase mobility level
• Work in quiet environment, calm voice, if agitated stay with pt until they calm down and try telling them gently what is accurate but DON’T argue, attempt redirection, end therapy & try again later, short sessions, maintain routine, expect no/limited carryover. from skills training

Question 13

Strategies to manage agitated behavior

Answer 13

• Calm behavior: pt may model
• Redirect: come prepared with multiple types of activities in mind
• Consistency: establish a routine
• Keep patient safe: provide safe choices
• Appropriate. environment: closed environment with limited distractions

Question 14

Describe Rancho level V

Answer 14

• Confused, inappropriate, non agitated, Max A
• Confused but not agitated, behaviorally inappropriate, short attention span, impaired divided attention, impaired recent memory with confusion of past & present, absence of problem solving, able to respond appropriately to simple commands fairly consistently with external structures & cues, confabulatory & pt may presevere when external structure & cues are not provided

Question 15

Interventions/considerations for Rancho level V

Answer 15

• Promote routine, lots of structure & routine & cues during treatment sessions, pt will need cognitive & physical rest breaks, begin dual tasking
• Recognize confabulations & perseverations & attempt to redirect to task at hand

Question 16

Describe the Moss Attention Rating Scale (MARS)

Answer 16

• Appropriate for Rancho IV or higher
• Higher score indicates better attention
• Items could be used to characterize patient responses during PT. activities when task complexity is increased

Question 17

Strategies to address attention deficits

Answer 17

• Quiet environment to work, less distractions & clutter
• Small pieces of instructions
• Maintain eye contact
• Ask to repeat instructions
• Use all types of cueing to provide structure
• Provide ample time to respond, avoid interrupting

Question 18

Metacognitive skills training (MST) strategies

Answer 18

• Metacognition: awareness and understanding of one’s own thought process
• We all need metacognitive skills for learning and problem-solving in daily lives.
• MST training helpful during ‘confused states’ of TBI. Internal confusion leads to deficits in metacognitive abilities
• MST can be used to improve cognitive skills, and is helpful for problem recognition, problem solving, planning and executive decision-making during tasks
• For problem recognition: watching videos of someone else doing the task at hand, and demonstrating how they overcame their failures
• For problem solving: Self-reflection activities, self-prediction of performance prior to performance and self-evaluation following performance
• For decision making: allow for errors safely -> self-recognition of errors (if not happening, provide timely feedback) -> encourage to develop self correction strategies for future use -> practice with multiple reps -> generalize strategies for similar tasks

Question 19

Describe Rancho level VI

Answer 19

• Confused, appropriate, Mod A
• Emerging awareness of appropriate response, able to problem solve task with less assistance, memory & attention are still impaired but able to attend to familiar tasks in somewhat distracting environment, carry over for relearned familiar tasks

Question 20

Interventions/considerations for Rancho level VI

Answer 20

• More open environments, keep sessions up to 30 min, keep pt in routine with slight progressions depending on pt’s level of success
• Consider use of a memory book, recall events of the day, dual task training with gait & balance type functional activities, more success at this level with dual task training

Question 21

Describe Rancho level VII

Answer 21

• Automatic, appropriate, Min A
• Minimal/no confusion, consistently oriented to person & place, automatic & appropriate responses but flat affect, initiates & carries out steps, Abel to monitor accuracy correct errors & completeness of tasks, still uncomfortable with learning new tasks but demo carryover of new learning, emergence of executive function abilities but deficits in reasoning, problem solving, & judgements

Question 22

Interventions/considerations for Rancho level VII

Answer 22

• Full sessions in therapy gyms/hallway, task specific interventions
• Continue working in open environments, routine sessions but add new tasks & stimulations, pt is able to use some memory strategies, patient should be more independent with basic self care activities

Question 23

Describe Rancho level VIII

Answer 23

• Purposeful, appropriate, SBA
• Consistently oriented to person/place/time, good attention span, independently completes familiar tasks in distracting environment, able to recall & integrate past & percent events, may need assistive memory devices, aware of impairments, thinks about consequences, acknowledges others’ needs

Question 24

Interventions/considerations for Rancho level VIII

Answer 24

• May be in OP therapy, potentially ready for programs for re-entry into community, driver retraining
• Treat patient as an adult, no need for simple cues, may benefit from neuropsychology consult

Question 25

Describe Rancho level IX

Answer 25

• Purposeful, appropriate, SBA on request
• Likely in home health or OP therapy, may already have started going to work/school & may be participating in social actives

Question 26

Interventions/considerations for Rancho level IX

Answer 26

• Continue training functional mobility in home, may require & tolerate longer PT sessions
• Can independently shift back & forth b/w skills independently for hours, may rely on AD to manage memory impairments, may show frustration, pt should be independent to manage familiar housework/work/personal matters/leisure activities

Question 27

Describe Rancho level X

Answer 27

• Purposeful, appropriate, Mod independent
• Consider need for increased time, work/school accommodations
• Patient may have a low frustration threshold
• May continue to require a memory device
• May have periodic depression
• Patient should be able to multi-task independently with both physical & cognitive tasks