Exam 1: TBI Flashcards
1
Q
What are the categories of traumatic brain injuries (TBI)?
A
-Mild TBI/concussion
-Moderate TBI
-Severe TBI
2
Q
What is the definition of a concussion/mild TBI?
A
-Any period of observed or self-reported transient confusion, disorientation, impaired consciousness, dysfunction of memory around the time of injury, or loss of consciousness lasting less than 30 minutes
-Alteration of consciousness for 24 hours
3
Q
What is the Glasgow definition of mild TBI?
A
-Post traumatic amnesia for less than 24 hours
-Glasgow coma scale of 13-15 at 30 minutes
4
Q
What is the Glasgow Coma Scale (GCS)?
A
-Gold standard for head trauma
-Will always be documented after a TBI in the ER
-Tests eye response, motor response, and verbal response
5
Q
What are the structural differences between mild TBI and moderate to severe TBI?
A
-There is no structural brain changes with none to minimal cell death in mild TBI
-No medical intervention is typically required with mild TBI
-Moderate to severe TBI has structural brain injury with cell death and requires medical intervention or hospitalization
6
Q
What population has a higher chance for sports related concussions?
A
-Girls are at higher risk
7
Q
What is the etiology of concussions?
A
-Caused by a bump, blow, or jolt to the head or by a hit to the body that causes the brain to move rapidly back and forth
-This sudden movement can cause the brain to bounce or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells
-Combination of insult and chemical changes in the brain
8
Q
What will the results of an MRI or CT scan show with concussion?
A
The MRI or CT scans will often be normal in someone with a mild TBI
9
Q
What are the different causes of traumatic brain injuries?
A
-Direct impact injuries
-Acceleration-deceleration injuries (Coup counter coup)
-Blast injury (sound waves)
10
Q
What age groups show the greatest risk for concussions?
A
-10-17 years old
-Risk significantly increases again after 80 years old
11
Q
What are signs and symptoms to watch for after a concussion? What should you do if you see these symptoms?
A
-Problems may arise over the first 24-48 hours
-Worsening headache
-Very drowsy and cannot be awakened
-Have repeated vomiting
-Can’t recognize people or places
-Confused or very irritable
-Have seizures
-Weak or numb arm or legs
-Unsteadiness or slurred speech
-Take them to the ER!!!
12
Q
What are some red flags after concussion?
A
-Worsening dizziness or vertigo
-Worsening disequilibrium
-Worsening headache
-Double vision
-Loss of coordination
13
Q
What is the time frame for improvement of symptoms for mild TBI?
A
7-14 days but can last up to 3 weeks
14
Q
What behavioral symptoms are there with concussion?
A
-Irritability
-Anxiety
-Depression
-Inability to sleep
15
Q
What environmental symptoms are there with concussion?
A
Sensitivity to light and sounds, especially background noises
16
Q
What cognitive symptoms are there with concussion?
A
-Memory loss
-Concentration and attention problems
-Cognitive failure: reading/using computer
17
Q
What motor symptoms are there with concussion?
A
-Loss of dexterity, coordination, and speed
-Balance
-Impairments with vestibulo-ocular system
18
Q
When should someone seek medical care after sustaining a concussion?
A
If symptoms persist after 3 weeks
19
Q
What are the 4 major events that occur in the brain after a mild TBI? What do these 4 things lead to?
A
- Axonal damage due to axons getting stretched
- Neuroinflammation: microglia activation and excitotoxicity leads to cell damage or death
- Ionic dysfunction causes excess glutamate release which further contributes to inflammation and cell damage
- Energy crisis caused by hypermetabolism of glucose: mitochondrial dysfunction and oxidative stress
-Leads to susceptibility to repeat injuries
20
Q
What occurs due to increased metabolic activity in the brain after concussion? When are symptoms of this the most apparent?
A
-Reduced information processing efficiency
-Brain fatigue
-Dual task reductions
-Reduced divided attention
-Signs and symptoms increase with environmental interactions such as light, sound, reading, electronic devices, etc.
21
Q
Why are there frequently oculomotor and vestibular issues post concussion? What specific impairments are often seen?
A
-Because the ocular system has long axons that span the length of the brain which make it more susceptible to injury
-Oculomotor and vestibular systems undergo chemical disruptions
-Impairments in the VOR are often seen in 29-69% of patients
22
Q
What is vertigo?
A
Feels as if the world is spinning
23
Q
What is the medial vestibular pathway responsible for?
A
-Sends information to control cervical and thoracic musculature
-Helps generate muscle activity with movement of the head and ocular muscles
24
Q
What is the lateral vestibular pathway responsible for?
A
-Sends information to control LE motor units to control balance
-Extensor and flexor musculature
25
What is post concussion syndrome?
-Concussion signs and symptoms that last longer than 6 weeks caused by continued neuroinflammation and brain changes
-Affects 20% of people that have concussions
-Requires PT
-Higher risk of post concussion syndrome with repeated concussions
-Most common findings are headaches
26
What complications can occur from post concussion syndrome?
-Lower hippocampal volume (memory)
-Increased risk of cell death
-Smaller thalamus (unable to process sensory information)
-Risk of limbic atrophy
-Women are at higher risk
27
What is the difference between migraines and tension headaches?
-Tension: one side
-Migraine: bilateral
28
What vestibular signs and symptoms might someone have after a concussion?
-40-60% of individuals will experience vestibular issues
-BPPV
-Central problems: nausea, vomiting, nystagmus
29
Are most vestibular problems after a concussion peripheral or central?
Central
30
What are specific oculomotor deficiencies after a concussion?
-Initiation in saccades
-Loss of ballistic saccade accuracy
-Voluntary gaze movements has marked slower speeds
-Loss of visual motor symmetry
31
What are specific physical deficiencies after a concussion?
-Reductions in postural control
-Decreased response times to unanticipated changes in environment
-Unable to turn quickly
32
What are the autonomic nervous system changes that occur after a concussion?
-Loss of auto-regulation of blood pressure which leads to constriction of blood vessels, exercise intolerance, and headaches
-These can lead to anxiety and depression as well as sleep disturbances and confusion
33
What should be examined during a concussion evaluation?
-Saccades
-H test (smooth pursuit)
-Functional vision tasks
-Light sensitivity
-VOR
-Postural control
-Ask for patients symptoms after each test
-Cervical spine to rule out cervicogenic headaches that includes extension and rotation exam, facet eval, and palpation of cervical musculature
34
What questions should be included in the history for a concussion evaluation?
-Mechanims of injury
-Loss of consciousness
-Able to remember event/how long post traumatic amnesia
-Dizziness/confusion with loss of orientation to time, place, self
-Loss of function
-Questionnaires for symptoms
35
What is visual accommodation?
The ability of the eye to make adjustments of the lens to focus on objects at various distances
36
What is vergence?
Movement of the eyes synchronously and symmetrically to track objects
37
How do accommodation and vergence relate to each other?
They work synchronously to be able to focus clearly and quickly on objects at different distances
38
What is convergence?
The ability of the eyes to move medially, towards the nose, which allow for single vision of closer objects
39
How much of the brain's circuits does the visual system use?
Roughly half
40
What visual areas may have deficits after a concussion?
-Convergence
-Accommodation
-Ocular muscle balance
-Saccades
-Smooth pursuit
41
What can contribute to eye strain and pain after a concussion? What can this lead to?
-Since there is an injury, greater effort is required to move the eyes medially which results in eye strain and pain
-Caused by an injury to the neuromuscular connection to the extra-ocular muscles
-Leads to blurry vision, headaches with reading and computer use, and double vision
42
At what speed should the VOR be tested? What degree of head movements is required?
-180 bpm
-20 degrees
43
What outcome measures are used after concussions?
-Vestibular ocular motor screening (VOMS)
-The Rivermead Post Concussion symptoms questionnaire
-King Devick
-Graded exertional tolerance exam (treadmill or bike)
-Buffalo concussion treadmill test
-Balance error scoring system (BESS)
-mCTSIB
44
What does the VOMS test?
-Smooth pursuit
-Horizontal saccades
-Vertical saccades
-Convergence
-Horizontal VOR
-Vertical VOR
-Visual motion sensitivity test (VOR cancellation)
-Pt reports symptoms on a scale of 0 to 10 before the test and then after each item
45
What is a normal convergence distance?
< 5-6 cm
46
What does the Balance Error Scoring System (BESS) test?
-Double leg, single leg, and tandem stance on firm ground with eyes closed
-Double leg, single leg, and tandem stance on foam surface with eyes closed
-# of errors are counted
47
What is King-Devick Concussion Screening Test?
-A series of numbers that a pt must read off while it is timed
-# of errors are counted
-Requires a baseline time to determine if there is any change after a concussion
-Developed for athletes
-If the subject performs slower than his or her baseline or has increased errors, then they should be removed from play
48
What are the different medical definitions for moderate and severe traumatic brain injury (TBI)?
-Coup contra-coup
-Blunt trauma
-Diffuse axonal injury (DAI)
-Shaken baby syndrome
49
What are the causes of acquired brain injury (ABI)?
-Anoxic brain injury: complete occlusion of oxygen
-Hypoxic brain injury: insufficient oxygen saturation
50
What are the leading causes of TBI?
-Falls (40.5%)
-MVA (14.3%)
51
What is the primary damage from TBI's?
-Scalp laceration with or without skull fx
-Skull fracture
-Cerebral contusions
-Cerebral lacerations
-Intracranial hemorrhage
-Diffuse axonal injury
51
What are the secondary damage from TBI's?
-Ischemia
-Hypoxia
-Cerebral swelling
-Infection
52
What chemical brain changes do TBIs result in?
A cascade of biochemical, cellular, and molecular events that evolve over time due to the initial injury and injury-related hypoxia, edema, and elevated intracranial pressure (ICP)
53
What is diffuse axonal injury (DAI)?
-Shearing/stretching of the axons and myelin sheath
-Occurs from unequal deceleration, acceleration, or rotational injuries
-Most common type of primary lesion following a TBI
54
What are the grades of DAI?
-Grade 1: mildest form; microscopic changes in the white matter of the cerebral cortex, corpus callosum, brain stem, and cerebellum
-Grade 2: moderate DAI; grossly evident focal lesions isolated to corpus callosum
-Grade 3: severe DAI; additional and severe focal lesions on the brainstem
55
What are symptoms of a dural hematoma?
-Changing cognition
-Headache, pt might describe it as worst headache of their life
55
What percentage of TBI patients with DAI have good recoveries?
More than 50%
56
What is the difference between a epidural hematoma and a subdural hematoma? Which takes longer to heal?
-Epidural hematoma: skull fracture that tears the meningeal artery causing the dura to be peeled off the skull
-Subdural hematoma: tearing of the bridging veins in the superior sagittal sinus
-Subdural hematoma and vein tearing can take longer to heal
56
When does a midline shift of the corpus callosum occur? How serious is this?
-Can happen after a subdural hematoma
-Can be very deadly
57
What will diffuse axonal injury look like on an MRI?
Will show black specks/spots where white matter should be
58
What are the secondary complications that occur after TBI?
-Cerebral edema, hypoxia, ischemia, etc.
-Cell death
-Increased glutamate
-Mitochondrial dysfunction and impaired glucose metabolism
-BBB damage
-Excitotoxicity
-Complement activation, inflammation, and ROS generation
59
What does excessive glutamate lead to in the brain?
-Exictotoxicity
-Leads to increased Ca entry into cells which can cause cerebral edema and cell death
60
When does the blood brain barrier weaken after a TBI? What are some complications of a weakened BBB?
-Weakens the most when the brain is tired or fatigued
-Neutrophils and microglia can cross the BBB
-Can lead to meningitis as now things can cross the BBB
61
What occurs with the M1 (protective) and M2 (neurotoxic) microglia after a TBI? What does this cause?
-M1, protective microglia decrease activity & production
-M2, neurotoxic microglia increase activity and production
-This causes increased brain damage
-M2 can be activated for up to 1 month after
62
What disease is TBI highly correlated with? What clinical characteristics do they share?
-Repetitive mTBI and severe TBI's are associated with Alzheimer's disease
-Tau neurofibrillary tangles
-Amyloid beta plaques
-Variable chronic cognitive and neuropsychiatric impairments
63
What structural changes occur in the brain after a TBI?
-Fornix atrophy
-Enlargement of ventricles
-Brain atrophy
64
What brain structures are primarily involved with TBI?
-Hippocampus: learning and memory
-Prefrontal cortex: working memory, self control, decision making
-Amygdala: emotional regulation and fear response
-Brainstem and midbrain
-Cerebellum
-Cortex
-Basal ganglia
65
What are some neurocognitive changes that occur after TBI?
-Memory
-Judgement
-Language issues
-Sleep wake cycle problems
66
What behavioral problems occur after TBI?
-Impulsive, irrational behavior
-Behaviors out of context
-Personality changes
67
What motor symptoms does someone have after a TBI?
-Hemiparesis
-Ataxia (cerebellar)
-Synergistic movement
-Hypertonia
-Tremors
-Contractures
68
How is spasticity different in TBI patients than stroke patients?
-It is often much more severe in TBI patients
-Often results in contractures
-Needs to be treated in TBI compared to stroke
69
What is the reticular activating system (RAS)? What systems does it control?
-A network of neurons in the brainstem that controls sleep wake cycles, arousal, attention, and consciousness
-Sleep-wake cycle/Circadian rythm
-Sleeping
-Fight or flight responses
-Always involved in moderate to severe TBI
70
What is the reticular formation? What is it responsible for?
-A network of neurons in the brainstem that controls many vital functions
-Integration, relay, and coordination center for vital functions
-Circadian rhythm
-Coordination of somatic motor movements
-Cardiovascular and respiratory control
-Pain modulation
-Habituation
-Associated with cranial nerve nuclei
71
Why do a lot of TBI patients have difficulty sleeping after their injury?
-41% of patients with TBI have decreased melatonin levels at night
-TBI also disrupts pathways from the hypothalamus which helps in assisting circadian rhythms
72
What structure in the brain regulates the release of hormones that regulate circadian rhythm?
Suprachiasmatic nucleus
73
What memory disruptions occur in TBI? What complications can this lead to?
-mTBI and moderate can have short term memory loss
-Severe TBI will have long term memory loss due to disruptions in the connections between the hippocampus and prefrontal cortex
-Long term memory loss can lead to apraxia, inability to identify objects, spatial cognition/navigation
-Some patients will have to relearn how to do everyday tasks
74
What portions of memory is the hippocampus responsible for?
-Spatial info
-Identification
75
What portions of memory is the prefrontal cortex responsible for?
-Actions
-Everyday tasks
76
What areas of the brain are involved with memory? What type of memories does each control?
-Prefrontal cortex: working memory
-Amygdala: emotional memory
-Hippocampus: episodic memory
-Cerebellum: procedural memory
77
What hormones/factors does resistive and aerobic exercise help increase or decrease in TBI patients?
-BDNF which helps synapses reconnect
-Orexin A which is important for regulating sleep and wake cycles
-Helps to decrease inflammatory cytokines such as TNF alpha and IL-6 as well as neurotoxic microglia
-Increases neuroprotective microglia
78
What is intracranial pressure (ICP) associated with in TBI patients?
Increased ICP is associated with lower outcomes and higher mortality
79
What is normal ICP?
7-15 mm HG
80
What is acute hydrocephalus? What does it require to treat it?
-When blood accumulates in the ventricles
-Requires an external ventricular drain (EVD)
81
What must the EVD be kept in line with?
The tragus of the ear
82
What is the primary finding in the "GET-Up Trial" following a craniotomy?
There was better outcomes among patients who were in the early mobilization group
83
How is a brain oxygen monitor placed?
A hole is drilled into their skill and a rod is placed, and bolted in
84
What other treatment can be done for hydrocephalus or increased intracranial pressure?
-Decompressive craniotomy where they take a portion of the skull out to decrease the pressure
-They may or may not put the piece of the skull back in
85
What are medical considerations for TBI patients?
-ICP catheter device
-NG tube
-Compression stockings
-Foley catheter
-Central IV lines
-BP, HR, and pulse oximeter monitors
86
What should the ICP be kept under when treating TBI patients?
Must be under 20 mm Hg
87
What are the guidelines for mobilizing patients with EVDs?
-Patient position should not change while the drain is open
-EVD must be clamped before a patient is mobilized
-When out of bed, the EVD must be clamped until it is even with the tragus
88
What must central perfusion pressure be kept above?
Must be above 60 mm Hg
89
What is the medical definition of coma?
-Complete paralysis of cerebral function; state of unresponsiveness
-Eyes closed, no response to painful, auditory, or tactile stimulation
90
What is the medical definition of persistent vegitative state?
-Reduced responsiveness with no evidence of cerebral or cortical function
-Diffuse hypoxia and axonal white matter impact
91
What reflex shows a poor prognosis?
-Flexor withdrawal to painful stimuli
-If a patient does this every time, it is a poor prognosis as it is a primitive reflex because the signals are not being sent to the brain
92
What assessments are used for TBI patients?
-Glasgow coma scale
-LOC
-Rancho levels
-Disability rating scale
93
What is considered mild, moderate, and severe TBI based on the GCS?
-Mild: 13-15
-Moderate: 9-12
-Severe: < 9
94
What is considered mild, moderate, and severe TBI based on post traumatic amnesia (PTA)?
-Mild: < 1 day
-Moderate: 1-7 days
-Severe: > 7 days
95
What is considered mild, moderate, and severe TBI based on loss of consciousness (LOC)?
-Mild: 0-30 minutes
-Moderate: 30 minutes- 24 hours
-Severe: > 24 hours
96
When should someone go to the ER after a mTBI?
If their pupillary response is not intact
97
What are the three major areas that are measured by the Glasgow coma scale?
-Eyes opening
-Verbal response
-Motor response
98
What are the different subgroups of severe TBI?
-Coma
-Vegetative state
-Persistent vegetative state
-Minimally responsive state: responds to stimuli
-Locked-in syndrome
99
What are considerations for functional assessment in TBI?
-Bed mobility
-Transfers
-Upright stability
-Gait & AD use
100
What are environmental considerations for TBI?
-Light
-Noise/background noise
-People in the room
-Extraneous movement
101
What is a contributing factor in the pathophysiology of TBI?
Microvascular supply and metabolic demand
102
Which lobe is more susceptible to TBI?
Temporal lobe
103
What is the POC for a patient following a mTBI?
-Patients should rest for 24-48 hours and avoid activities that may cause re-injury
-After rest, pt should gradually resume activity as tolerated
-Pt education: reduce or avoid symptom provoking stimuli, adjust environment
-PT assesses if pt is ready for physical activity
104
What are some pt education tips for mTBI?
-Avoid: computer games, phone use, other cognitive activities
-Ask you doctor when it's safe to drive
-Take only the medications prescribed by the doctor
-Listen to your symptoms and rest when symptoms increase
105
What time frame are those with concussions most at risk for a subsequent injury?
The first 10 days
106
Who is at higher risk for being diagnosed with a concussion?
Athletes who have a history of 1 or more concussions
107
What parts of the vestibular system are affected with mTBI?
-VOR: deficits result in dizziness, inability to read, vertigo, unsteadiness, eye fatigue
-Vestibular postural system (VSR?) assists in postural stability and body orientation in space and assisting with postural tone
108
How is the VOR formulated?
-Oculomotor system connects with the medial longitudinal fasiculus (MLF) with several oculomotor and vestibular nuclei, semicircular canals to formulate the VOR
109
What is the unicinate fasiculus? How is it related to TBI?
-Fiber tract of axons that connect the lower frontal lobes
-Very vulnerable to injury when there is twisting of brain tissue
110
When does myelin production increase?
With aerobic exercise
111
What connects the visual cortex?
Superior longitudinal fasiculus
112
How can reaction time be tested with TBI or mTBI?
-Ruler drop test
-Cerebellar exams
113
What should be included in the exam for mTBI?
-VOR
-Balance
-Coordination and reaction time
-Endurance
-Gait with head movements
114
What is the Buffalo concussion stress test? When is the test stopped?
-Pt wear HR monitor and is given a RPE scale and VAS scale
-Participant walks on treadmill at brisk pace
-Speed and incline is gradually increased
-HR, RPE, and VAS is recorded each minute
-The test is stopped is the pt's VAS score increases by 3 or more, RPE is 17 or more, or participant appears faint or has stopped communicating
115
What are PT goals for concussion?
-Return to work, school, sports, etc.
-Based on symptoms
116
What are the otoliths responsible for?
Linear acceleration and acceleration in relation to gravity
117
How should ocular and VOR exercises be progressed? What should be started with first?
-Start with sitting
-Progress to standing
-Increase speed
-Start with just ocular exercises first such as saccades
-Add cognitive load
-Advance to VOR cancellation
-Unstable surfaces
-Gait and head movements
-Speed changes with gait
118
What are some dynamic postural interventions for consussion?
-Static balance: eyes open and closed, stable, unstable surface, tandem
-Dynamic balance: SLS, reaching, catching objects, figure 8 walking with head turns
119
What does graded aerobic exercise help with after TBI?
-Helps to increase recovery
-Start with walking or low levels and increase to submaximal target HR (70-80% of THR)
120
How does exercise help TBI patients?
-Increases neuroplasticity
-Decreases neuroinflammation
-Decreases apoptosis
-Increases neuroprotection and repair
-Modulates dopaminergic system
121
What exercise can be done to improve convergence?
Brock string exercise
122
What should always be considered during exercise with mTBI and TBI patients?
Blunted HR or BP responses
123
What is the episodic buffer? What areas of the brain are connected for this?
-Connection between prefrontal cortex, anterior cingulate cortex, and parietal lobe
-Helps with attention and perceptual processing
124
What is the phonological loop?
-Connection between the prefrontal cortex, Broca's, and Wernicke's areas
125
What is the connection between the prefrontal cortex and occipital lobe for? What is the best way to start improving executive function in moderate to severe TBI patients?
-Executive function
-Visuo-spatial tasks
-Start with the visual spatial tasks to improve executive function
126
What are perseverations?
When a pt repeats old activities when trying to move on to new ones
127
What should be included in the examination of moderate and severe TBI patients?
-Orientation
-Arousability
-Attention
-Environment
-Behaviors
-Neurological exam: motor, tone, CN, sensation
-Posture
-Function
128
What are common motor dysfunctions in moderate and severe TBI patients?
-Synergistic patterns
-Ataxia
-Poor motor planning
129
What kinds of activities should TBI patients do?
-Task based activities
-Based on everyday life or patient interests
-Add cognitive load
-Bed mobility
-Sit to stand
-Postural control
-Gait
130
What is the difference between task based and neuro developmental treatment? Why is task based better for TBI patients?
-Task based is pt guided
-NDT is therapist guided
-Task based engages the entire nervous system and more closely resembles the normal brain activation patterns
131
What are the top priorities of NDT with TBI patients?
1. Handling of the core, head, and trunk alignment
2. lower limb alignment and connection to trunk
3. motor learning with task
4. dual tasking
132
What should an aerobic exercise program look like post TBI?
-12 weeks
-3x/week for 30 minutes
-70-80% of THR
-Supervised
133
How much oxygen does the brain consume at rest?
20% of total oxygen
134
What are some tools to help TBI patients with sequencing, activities, and memory?
-Numbering the activity
-Providing a picture of the activity
-Memory notebook
-Calendars: crossing out dates
-Communication boards with pictures
135
What percentage of TBI patients experience irritability and outbursts?
29-71% of patients
136
What common themes arise in behavioral changes in TBI patients?
-Irritability comes from environmental distraction
-Inability to express oneself
-Communication break down
-Expectations or unable to reach goals
137
What are some ways that we can help patients reduce irritability?
-Remain calm, keep emotions low throughout treatment
-Know the triggers (auditory, visual, environmental)
-Give them rest breaks
-Establish stop cues before treatment: stop with hand signal or eye blinking
-No TV!!!
-Breathing
-Practice time out strategies
-Educate family
-Avoid sudden grabbing or touching the pt
-Formally end the interaction
-Provide choices
-Positive reinforcement
-Give patient time to process
138
What are some strategies to maximize therapy?
-Choose a time when the pt is well rested
-Complete treatment in quiet area
-Keep activities simple
-Do not provide constant verbal feedback
-Demonstrate
-Provide rest breaks
139
What exercises can be given to TBI patients that have lost their spatial awareness and navigation?
-Provide orientation by giving room map
-Tell them to go find an object
-Have the pt remember where they placed an object
-Have the pt practice navigating through these areas, such as finding their way back to their room
140
What are the different elements of spatial navigation?
-Anglar head velocity, linear velocity, and head direction cells provide input to stripe cells
-Stripe cells send info to grid cells
-Grid cells send info to place cells
141
What are some examples of planned movement?
-Reaching
-Pushing/pulling
-Lifting
-Sports
-Kicking
-Stairs
-Inclines
-Avoiding objects
142
What are some examples of automatic movement?
-Visual or auditory orientation
-Static balance
-Balance reaction to falls
-Sit to stand
-Gait
143
How does the motor system respond to stimuli? Where does this usually break down in TBI patients?
1. posterior sensory cortex provides information to the prefrontal cortex
2. prefrontal cortex plans movement
3. premotor cortex organizes movement sequences
4. motor cortex produces specific movements
-TBI patients usually have difficulty in steps 1-3 before movement occurs
144
What is the posterior parietal cortex? What is its function?
-Sensory association areas and intermodal integration of incoming sensory information
-Initiates planned movement that arises from the environment such as visual, auditory, and somatosensory input
145
What is the function of the superior colliculus? How is this affected in patient with TBI?
-Helps the brain respond to environmental stimuli by generating motor responses to turn toward visual stimuli by coordinating movement with CN XI and SCM
-Mediates consciousness awareness
-Decision making
-There can be injuries to the superior colliculus with DAI which makes it difficult to scan, impaired ability to quickly react to stimuli, and difficulty with spatial orientation of the head and eyes
146
What should be the first interventions when mobilizing patients with moderate to severe TBIs?
-Sitting patient up
-Work on head and trunk righting reactions
-Sitting endurance
-Utilize visual tracking to stimulate C/S muscles
-Progress to vision plus object recall
-Progress to two or three step activities
147
How do you involve the posterior parietal cortex in treatment?
-Add tasks that require more motor planning
-Provide choices so pt has to decide what to do
148
What are mirror neurons? Where are they located?
-A class of neuron that modulate their activity both when an individual executes a specific motor act and when they observe the same or similar act performed by another individual
-Located in the premotor cortex
149
What does stimulation of mirror neurons help with in TBI patients?
-Helps pt select and prepare for the movement
-Plans the correct mvoement
-Elicits more complex movements
-Activation of mirror neurons leads to recruitment of functionally interconnected cortical structures coupling action execution and observation
150
How does the premotor cortex learn with mirror neurons?
It learns to select a particular set of motions based on external events (visual and auditory)
151
Where do 10% of the corticospinal tracts originate from? What is the function of this area?
-Supplemental motor area
-Connects to the thalamus, cerebellum, and basal ganglia
-Deeply connected to primary motor cortex
-Helps with complex sequence of movements
152
When does the primary motor cortex activate? What is its function?
-Activates 5-100 ms before initiation of movement
-Encodes the force of the movement
-Encodes the direction of the movement
-Encodes the extent of the movement
-Encodes the speed of the movement
153
How should we incorporate evidence based practice while treating TBI patients?
-Choose activities that have meaning for the patient
-Demonstrate the task
-Provide a variety of sensory input
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What is task demand circuitry?
-Activation and sends to premotor cortex
-Corticospinal tract activated
-Motor program achieved via muscle spindle to cerebellum
-Cerebellum to somatosensory cortex on to the red nucleus
-Motor behavior
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What are the benefits of a tilt table for TBI patients?
-Prevention of contractures
-Verticality
-Weight bearing
-Increase load for bone density
-BP monitoring
-Verticality engages vestibular, somatosensory, and postural responses
