final exam mild TBI Flashcards
do you need to have a bleed or positive imaging to have a severe or moderate TBI?
no!
traumatic injury that affects the brain induced by biomechanical forces transmitted to the head by a direct blow to or forces exerted on the body but that does not result in an extended period of unconsciousness, amnesia, or other significant neurological signs indicative of a more severe brain injury
concussion aka mild TBI
a combination of what 5 things differentiates the state of a TBI?
LOC
AOC
GCS
imaging
PTA
mild, moderate or severe TBI?
- LOC: 0-30 minutes
- AOC: brief-24 hours
- PTA: 0-1 day
- GCS: 13-15
- neuroimaging: normal
mild TBI
mild, moderate or severe TBI?
- LOC: >30 minutes and < 24 hours
- AOC: > 24 hours
- PTA: > 1 and < 7 days
- GCS: 9-12
- neuroimaging: normal or abnormal
moderate
what are the 3 major categories on the Glasgow Coma Scale?
eye opening
best motor response
verbal response
which Rancho level?
No response. deep sleep, unresponsive
I
which Rancho level?
Generalize response. inconsistent, non-purposeful response to stimuli
II
which Rancho level?
localized response. inconsistent localized response to a stimulus
III
which settings will you most likely see Rancho levels I-III?
ICU and LTACH
which Rancho level?
Heightened state of activity, non-purposeful, confused, hard to learn
IV: confused agitated
which Rancho level?
can follow simple commands inconsistently, minimal attention, inappropriate verbalizations
V: confused inappropriate
which Rancho level?
can show goal directed behavior, but need external cuing, follows simple directions consistently, some learning
VI: confused appropriate
which levels are more related to mild TBI stages?
Rancho VII: automatic appropriate - can get through daily activities, but robotically and needs routine
VIII: purposeful appropriate - responsive to environment, has carryover for new learning
what is post-traumatic amnesia (PTA)?
- what do you measure it with?
duration of memory loss post injury
measured with: O Log and Galvaston orientation and amnesia test (GOAT)
what’s the most likely reason an older person would be hospitalized from a TBI?
falls
what are the two main mechanism of injury for mTBI?
- blow to head –> direct trauma
- forces exerted on the body –> pressure, movement of the brain inside a closed system
can you get a concussion without hitting your head?
yes
Coup/contrecoup forces (acceleration/deceleration)
example: whiplash
injury to cells or structure itself. sagittal, frontal, rotational, angular
what are the 5 subtypes of concussion?
anxiety/mood
cognitive
migraine -> headache is the first highest symptom
ocular
vestibular –> dizziness is 2nd highest symptom
what are 2 other under represented subtypes?
cervical
sleep disturbances
is concussion an isolated problem or is it electrical and metabolic problems too?
electrical and metabolic
can affect multiple systems
depolarization leads to:
glutamate influx
increased Na and Ca2+
decreased potassium (K+)
decreased cerebral blood flow –> this impacts the function of mitochondria
decreased cerebral blood flow leads to:
energy crisis
decreased ability to produce ATP –> we need to bring more O2 to the area
there is decreased ATP due to (3)
lack of glucose
decreased mitochondria function
decreased cerebral blood flow and oxygen
if the force was applied in the sagittal plane, what structures are involved?
frontal lobe - functional execution
occipital lobe - vision
brainstem area - CN involvement
if the force was applied in the frontal plane, what structures are involved?
temporal parietal lobe - strength, sensation, speech
TRUE OR FALSE. sheer forces and rotational injuries would not happen with mild TBI?
false - both can also be involved
it takes ____ days to recover from metabolic cascade.
___% resolved in 1 week
symptom resolution for collegiate athletes is ____ days. why?
7-10 days
60%
28 days - have higher return to function
if symptoms do not resolve in 1-3 months what could be the case?
PCS - post concussion syndrome
diagnosis for PCS:
cognitive deficits in attention and memory AND at least 3 of the following symptoms:
fatigue
sleep disturbance
dizziness
irritability
affective disturbance
apathy or personality changes that persist 3+ months
what three things do you need to make sure to ask in your subjective history for mTBI?
mechanism of injury
baseline levels (any history of concussion)
questions surrounding subtypes
in order to conduct a more efficient screening of mTBI, what is one thing you should work to identify?
the subtype of concussion
what are the 4 major categories to eval concussion per the CPG?
cervical/MSK
vestibular/oculomotor
autonomic/exertional tolerance
motor function: balance and gait
vestibular/oculomotor exam should include:
ocular alignment
smooth pursuits
saccades
vergence and accommodation
gaze stability
dynamic visual acuity
visual motion sensitivity
vertigo caused by BPPV
light-headedness due to orthostatic hypotension
balance/gait exam should include:
static and dynamic balance
motor coordination and control
dual/multitasking tests
what are 4 outcome measures specific to concussion
SCAT 6 (sports concussion assessment tool)
HiMAT (high level mobility assessment tool)
BCTT (buffalo concussion treadmill test)
BESS (balance error scoring system)
how should you base your interventions for concussion?
specific to subtype and individual
CPG
within symptom tolerance –> you CAN push them too hard & make them worse
which subtype is there best evidence for?
vestibular-ocular subtype
consider head turns with vestibular rehab –> slow these down to 1Hz due to MOI
what are things you need to educate your patient on post-concussion?
self management of symptoms
importance of relative rest
importance of sleep
gradual progressive return to activities with pacing strategies
signs and symptoms that warrant further follow up care
POC and expected time to recovery
what are two things PTs need to factor in when making interventions for concussion?
irritability of patient
Self-management ability of the patient
in the past, we were told not to sleep after a concussion. why?
what are we told is best now?
past: don’t sleep bc we are worried about brain bleeds
now: relative rest, NOT strict rest. strict rest prolongs recovery
what is stimulation schedules? why is this found to be the best now?
scheduled times with decreased stimulation (can sleep, don’t have to) followed by times with stimulation (light activity)
we still need sleep, just not all day and don’t stay up all night
what are return to sport protocol rules?
must have full 24 hours between each stage –> this is why it often takes ~ 1 week to return post-concussion
must be completely symptom free to move to next stage
need physician approval to initiate protocol, initiate full contact, & return to competition
what are the 6 stages that must be met to return to sport?
- back to regular activity
- recovery - back to light aerobic activity
- increase heart rate - moderate activity
- add movement - heavy, non-contact activity
- exercise, coordination, cognitive load - practice and full contact
- restore confidence and assess functional skills by coaching staff - competition
who is part of the healthcare team with concussion?
PT
SLP
OT
Athletic trainer
Physician
Neuropsychologist
what settings will concussion show up in?
sports –> on field
military
outpatient (ortho, neuro, geriatrics, peds, sports)
ED
acute care
acute rehab (secondary injuries most likely)
