Final: TBI Pt 1 Flashcards
When is TBI rehab started?
No set standard - is dependent on the pt
What two conditions allow for TBI rehab to be initiated?
- Normalization of ICP
- Hemodynamic stability
What value is considered normal ICP that indicates that the pt is safe to start rehab?
< 20 mmHg
What are the four categories of TBI impairments?
- Neuromuscular
- Communication
- Cognitive
- Behavioral
What are the 6 common neuromuscular impairments following TBI?
- Impaired motor control
- Impaired coordination
- Hemiparesis
- Hypertonicity - posturing
- Somatosensory
- Impaired postural control
What are common behavioral impairments following TBI?
Easily frustrated, agitation, mental inflexibility, impulsivity, disinhibition, emotional lability, irritability
What are common cognitive impairments following TBI?
Arousal, attention, concentration, memory, learning, executive function
What does PTA stand for when discussing TBI?
Post Traumatic Amnesia
What is post traumatic amneisa?
Pt is unable to form new memories. Determined by neuropsychologist
What must the pt have in tact in order to be diagnosed with post traumatic amnesia?
Able to identify date, time, place, and situation consistently
What are other impairments that may be present following TBI?
Communication (not aphasia), CN involvement, visual deficits, perceptual deficits, dysphagia, secondary impairments due to immobility or comorbidities
What three medications address tone following TBI?
- Baclofen
- Diazepam
- Dantrolene
What four medications are used to control seizures following TBI?
- Depakote
- Keppa
- Dilantin
- Cerebyx
How is attention addressed with medication following TBI?
Neurostimulants, dopamine
What medication is used to address arousal following TBI?
Amantadine - dopamine agonist
When is amantadine prescribed?
4-16 weeks after diagnosis
What two medications are used for heterotopic ossification?
NSAIDs, biphosphonates
What medication is most effective to control depression following TBI?
Nontricyclic medications
Practice Question: When do we start PT rehab after brain injury?
1) one week post brain injury
2) when GCS reaches above 9
3) vitals and ICP stability
4) when the patient emerges from consciousness
3) vitals and ICP stability
Practice Question: Which of the following impairments is common after brain injury?
1) amnesia
2) apathy
3) aphasia
4) hypotonicity
1) amnesia
Practice Question: Which of the following medications has been shown to address a secondary complication of seizures?
1) amantadine
2) baclofen
3) dopamine
4) keppra
4) keppra
What is the term for Rancho level I-III?
Low Level Patient
What is the term for Rancho level IV?
Confused/Agitated Patient
What is the term for Rancho levels V-VI?
The Confused Patient
What is the term for Rancho levels VII-VIII?
High Level Patient
What are acute care concerns for a low level patient?
Ventilator, ICP, weightbearing restrictions, cardiac precautions, wounds, surgical sites, dysautonomia
What are the 5 goals for a low level patient?
- Consistently assess LOC
- Increase arousal and functional mobility
- Improve tolerance to upright
- Reduce risk of secondary impairments
- Improve or retain joint integrity and ROM
What is the name for Rancho Level I?
Coma
What are the four characteristics of a coma?
- Unresponsive to any stimuli
- Arousal system not functioning
- Eyes closed, ventilator
- No auditory, visual, cognitive, communication function
What is the name for Rancho Level II?
Unresponsive wakefulness
Describe unresponsive wakefullness
Awake but not aware, basic brainstem functions only, spontaneous eye opening, sleep/wake cycles, startle response, not able to follow commands or communicate, reflexive expressions, withdraw or posture to noxious stimuli
What is the name for Rancho Level III?
Minimally conscious state
Describe minimally conscious state
Awake and partially aware, inconsistent behaviors that are different than reflexes
Pt’s need to do one or more of these things on a reproducible and sustained basis to be considered to be in a minimally conscious state?
- Follow simple commands
- Gestural or verbal yes/no response
- Intelligible verbalization
- Movement or emotional behavior that occur in relation to relevant stimuli, not attributable to reflexive activity
What does MCS stand for?
Minimally conscious state
What are examples of MCS?
Smiling or crying in response to verbal or visual emotional content, vocalization in direct response to comments or questions, visual fixations and tracking, localization to noxious stimuli
Is a MCS pt able to communicate thoughts and feelings?
Yes
The pt must demonstrate reliable and consistent demonstration of one or both of the following in order to be considered to be in emergence of MCS
- Accurate yes/no responses to 6/6 situational questions on 2 consecutive examinations
- Functional use of at least two different objects
What is the gold standard to assess levels of consciousness?
Coma Recovery Scale Revised (CRS-R)
What are the subscales of the CRS-R?
- Auditory
- Visual
- Motor
- Oromotor
- Communication
- Arousal
What does DOCS stand for?
Disorders of Consciousness Scale
What are the six subscales of the DOCS?
- Social knowledge
- Taste/swallowing
- Olfactory
- Proprioception
- Tactile sensation
- Auditory and visual function
What does SMART stand for?
Sensory Modality and Rehab Techniques
What are the components of SMART?
Sensory and behavioral observation
What does WNSSP stand for?
Western Neurosensory Stimulation Profile
What is the WNSSP?
Assessment of arousal/attention, expressive communication, response to stimuli. Relies on visual comprehension and tracking
What is the goal of multi-modal sensory stimulation programs?
Increase arousal and attention
What is the Reticular Activating System?
Cortical processing in multi-sensory, to better engagement of cortical function through lots of stimulation. Neuroplasticity occurs through environmental factors
What are the key aspects of providing stimuli?
- Controlled and structured
- Multi-sensory
- Balance of stimulation and rest
- Monitor pt response
- Assess with outcome measures
What is FAST (familiar auditory stimulation training)?
5 min story telling by pt’s relatives that involve autobiographical events
What are the results of FAST (familiar auditory stimulation training)?
Improvements in CRS and increased activation of language areas on fMRI
What are the results of music therapy in MCS?
More eye contact and smiles, improves BP, greater activation of auditory network and physical responses
What level of consciousness is multimodal stimulation more effective in?
It is more effective in MCS than VS or UWS
What are key things to be mindful of with multi-modal sensory stimulation programs?
Begin early, perform frequently, avoid overstimulating, non-distracting environment, allow time to respond
What are benefits of early mobilization?
Shorter length of stay, increase chance of discharging to home, decreased secondary complications, improve outcomes due to neuroplastic changes
What are the two contraindications for early mobilization?
- Unstable spine
- Increased or increasing ICP
What are the four precautions for early mobilization?
- WB restrictions
- Skin and joint integrity
- Autonomic instability
- CV status
What is the goal of early mobilization?
Increase alertness with stimulation in different positions and environments to improve level of consciousness, GI motility, ROM, CV response
What four secondary impairments are likely?
- Contractures
- Pressure sores
- Pneumonia
- DVT
What are the weight shifting parameters for positioning in a wheelchair?
Every 30 minutes for 2 minutes (tilt in space, cushion)
What are the parameters and conditions for positioning in bed?
Turn every two hours. Hips and knees should be slightly flexed
What interventions are indicated to manage muscle tightness and joint stiffness?
Stretching, weightbearing, splinting, serial casting
What are the four key concepts of family education and support?
- Maintain open communication
- Involve family in POC and decisions
- Educate on current evidence
- Provide realistic and consistent messages
What are guidelines for pt’s with severe disorders of consciousness?
Multidisciplinary, standardized outcomes, can still have a favorable prognosis after 28 days, be aware of medical complications
When can a MD prescribe amantadine, and what does it do?
4 weeks to increase arousal
What % is there to regain consciousness after being in an unresponsive wakefullness state for one month?
50%
What is the name for Ranchos Level IV?
Confused-Agitated
Describe a confused-agitated pt
Heightened state of activity, not purposeful behavior, bizarre, confusion, brief attention, memory impaired, aggression, unable to cooperate, unable to learn new info
What are the primary exam goals for a pt in a confused and agitated state?
- Identify behavioral and cognitive concerns
- Impairments and function
- Goal is not to progress function, use familiar activities and focus on participation and tolerance to session
What are challenges for working with a pt in a confused and agitated state?
Amnesia, confused, decreased attention, distracted, uncooperative, agitation, aggressive, impaired insight into deficits
What are environmental conditions for managing agitation?
Closed, allow for freedom of movement, low distraction, dim lighting
What are methods for maintaining consistency when managing agitation?
Address inappropriate behaviors in a consistent manner, re-orient, follow schedule, use daily charts, expect no carry over without new learning
Which is the first choice when dealing with an agitated pt, medical or behavior intervention?
Behavioral - restraints are last choice
What are examples of medications to use to control an agitated pt?
Propanolol, trazadone, SSRIs, tegretol, seroquel, ativan
What is the Agitated Behavior Scale?
Observation period in a set environment
What are the rehab goals for a confused agitated state?
Motor relearning, no new learning is possible, endurance, activity tolerance, improve attention, education, prevent agitation, behavior
