Intervention of TBI Flashcards
What is the cognitive recovery process (pyramid)
Wakefulness -> Awareness: arousal, attention, purpose -> Perception and recognition of information -> Speed of information processing -> Memory -> Reasoning and problem-solving -> Executive functioning
What should not impact your functional goals?
Cognition - augment your approach
What is included in the observation of an exam for a TBI patient?
Varies depending on clinical setting and patient
- Surveying the room
- Identifying and documenting lines/monitors and vitals, surgical incisions, and obvious trauma
- Patient response when you enter the room or talk (e.g., no response, turn head, conversant)
What should be included in the history of an exam for a TBI patient?
Mechanism of injury
Acuity of injury
Prognosis/goal setting
May find out new PMH information if not in patient chart
Previous neurologic insults?
Clarify any precautions (WB, helmet or bracing, drains)
Diagnostic imaging/CT/MRI
Orthopedic injuries
What should be included in the social history of an exam for a TBI patient?
Social supports and home setup
- Social supports may dictate disposition upon d/c
- With social supports: home/rehab
- Without social supports: SNF
Life roles and interests
- May change significantly after TBI
- Get full/realistic picture of daily activities
- Principle of salience
What should be included in the systems review of an exam for a TBI patient?
Cognition
Cardiovascular:
Vitals and/or Impaired upright tolerance
Integumentary:
Effects of trauma and or surgical sites
Bony prominences if immobile
Implications of increased tone
Increased pressure in certain areas
Musculoskeletal:
Orthopedic precautions or fractures
ROM restrictions
Pain
Neuromuscular:
Gross coordination of movements/motor control
Spontaneous vs to command
Muscle overactivity
What are some resources to decided which outcome measures to use for patients with TBIs?
TBI EDGE
Rehabilitation Measures Database
COMBI website
What is the core set of outcome measures for patients with neurological conditions?
Berg Balance Scale
Functional Gait Assessment
Activities-Specific Balance Confidence Scale
10-Meter Walk Test
6-Minute Walk Test
5 Times Sit-to-Stand Test
TBI EDGE recommended outcome measures for acute care
Agitated behavior scale
COMA recovery scale-revised
Moss attention rating scale
Rancho levels of cognitive function
Ambulation issues include:
Functional Assessment Measure
FIM
TBI EDGE recommended outcome measures for inpatient only?
COMA recovery scale-revised
Moss attention rating scale
TBI EDGE recommended outcome measures for outpatient only?
High level mobility assessment
What is the typical timeline to emerge from a coma?
2-4 weeks
Many are slow to recover consciousness from that point forward
Why would patients get denied admission to an IRF after waking up from a coma?
Deemed to have limited active participation in rehab and if documentation fails to detect progress beyond VS and MCS
What is a level 1 responsiveness?
Complete absence of observable change in
behavior when presented visual, auditory, tactile,
proprioceptive, vestibular or painful stimuli
What is a coma responsiveness?
Complete failure of the arousal system with NO
spontaneous eye opening and inability to be awakened by application of vigorous sensory stimulation
What is a level II responsiveness?
“generalized response”
Demonstrates generalized reflex response to painful stimuli
Responds to repeated auditory stimuli with increased or decreased activity
Responds to external stimuli with physiological changes generalized, gross body movement, and/or not purposeful vocalization
Responses noted above may be same, regardless of type and location of stimulation
Responses may be significantly delayed
What is the criteria for Vegetative State/Unresponsive Wakefulness Syndrome?
All of the following criteria must be met:
1. No evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile or noxious stimuli
2. No evidence of language comprehension or expression
3. Intermittent wakefulness manifested by the presence of sleep–wake cycles
4. Sufficient preservation of autonomic functions to permit survival with adequate medical care
5. Bowel/bladder incontinence
6. Variable preservation of cranial nerves and spinal reflexes
What is a level III responsiveness?
Demonstrates withdrawal or vocalization to painful stimuli
Turns toward or away from auditory stimuli
Blinks when strong light crosses visual field
Follows moving object passed within visual field
Responds to discomfort by pulling tubes or restraints
Responds inconsistently to simple commands
Responses directly related to type of stimulus
May respond to some persons (especially family and friends) but not to others
What is the criteria for Minimally Conscious State?
Occasionally demonstrates clear-cut signs of self or environmental awareness
Diagnosis requires clearly discernible and reproducible evidence of one or more of the following:
1. Simple command following (e.g., mouth opening when instructed)
2. Gestural or verbal “yes/no” responses
3. Intelligible verbalizations
4. Movements or affective behaviors that occur in contingent relation to relevant environmental stimuli
What are some examples of contingent behavioral responses?
-Crying, smiling, or laughter in response to the linguistic or visual content of emotional, but not neutral topics or stimuli
- Vocalizations or gestures that occur in direct response to the linguistic content of comments or questions
- Reaching for objects that demonstrates a clear relationship between object location and direction of reach
- Touching or holding objects in a manner that accommodates the size and shape of object
- Pursuit eye movements or sustained fixation that occurs in direct response to moving or salient stimuli
What is the criteria for Emergence From MCS?
Diagnosis requires return of reliable and consistent interactive (functional) communication or functional object use
What is functional communication?
Requires accurate “yes/no” responses to six of six basic situational orientation questions on two consecutive evaluations (e.g., situational orientation: “Am I touching my ear?”, “Am I clapping my hands?”)
What is functional object use?
Requires generally appropriate use of at least two different objects on two consecutive evaluations
What is the gold standard for assessing recovery of consciousness?
Coma Recovery Scale (CRSR)
Administered by multiple domains over days
What is included in the JFK coma recovery scale (within the CRSR)?
Auditory
Visual
Motor
Oromotor/verbal
Communication
Arousal
What is another method of assessing recovery of consciousness?
Individualized Quantitative Behavioral Assessment (IQBA)
What is the Individualized Quantitative Behavioral Assessment (IQBA)
Applies principles of single-subject experimental design
Identify two movements patient may be able to perform
Give commands in random order to perform those movements
Record movement response (or not) on each trial
Use stats to determine if a relationship exists between the command and the patient’s responses
Why would you use the IQBA and the CRSR
IQBA may actually be able to identify command following earlier and more consistently than the CRSR in some patients.
So using both assessment methods is important so that we capture all the ability levels, all the possible awareness that exists across these patients and try to combat the issue of misdiagnosis and discharge to inappropriate places
What are some primary PT goals for level II-III patients?
Initiate early mobilization as soon as possible
Increase level of arousal and awareness
Increase motor control/postural control
Increase activity tolerance
Prevent/minimize secondary complications (e.g., joint mobility/contractures, DVTs, decubiti, pneumonia)
Family (and patient) education
What is the most important intervention you can provide?
In every session:
Talk to your patient and orient them, even if they do not seem to respond!
Ask questions as if you are expecting a conversation
What are some positioning interventions you can provide for a level II-III patient?
Neutral positioning in recliner wheelchair or tilt in-space chair (pressure-relieving cushion)
Positioning in bed (neutral head/neck, hips/knees slightly flexed, PRAFO-type boot, splints)
Post positioning signs (include time intervals) near bed as needed for family, nursing, patient care assistants/techs
Serial inhibitive casting for excessive tone (ROM maintenance and improvement)
What are some mobility interventions you can provide for a level II-III patient?
You will need another set of hands
General functional mobility (OOB, sitting balance, etc.)
Tilt table, standing frame, bodyweight support harness for standing
Gait—yes! (e.g., BWS system/Lokomat)
Think “outside the box”—safely
ROM (Educate family on safe ROM techniques)
What are some sensory stimulation interventions you can provide for a level II-III patient?
Visual, tactile, auditory, etc.
Vestibular stim (rocking, rotation)
Educate family on strategies to elicit responses/command following
Combine strategies (e.g., standing and sensory stim
What should you avoid with any treatment? and how can you tell it is occurring?
Overstimulation
Closing eyes (appearing to “tune out”)
Stops responding to commands which s/he responded to earlier
Diaphoresis
Flushing of the skin
Breathing more quickly
Seizure-like activity
Abnormal “posturing” or increased muscle tone
What is a level IV responsiveness?
“Confused and agitated”
Alert and in heightened state of activity
Purposeful attempts to remove restraints or tubes or crawl out of bed
May perform motor activities such as sitting, reaching, and walking but without any apparent purpose or upon another’s request
Very brief and usually nonpurposeful moments of sustained alternatives and divided attention
Absent short-term memory
May cry out or scream out of proportion to stimulus even after its removal
May exhibit aggressive or flight behavior
Mood may swing from euphoric to hostile with no apparent relationship to environmental events
Unable to cooperate with treatment efforts
Verbalizations are frequently incoherent and/or inappropriate to activity or environment
What is a level V responsiveness?
“still confused and inappropriate but not agitated”
Alert, not agitated but may wander randomly or with a vague intention of going home
May become agitated in response to external stimulation, and/or lack of environmental structure
Not oriented to person, place or time
Frequent brief periods, nonpurposeful sustained attention
Severely impaired recent memory, with confusion of past and present in reaction to ongoing activity
Absent goal-directed, problem-solving, self monitoring behavior
Often demonstrates inappropriate use of objects without external direction
May be able to perform previously learned tasks when structured and cues provided
Unable to learn new information
Able to respond appropriately to simple commands fairly consistently with external structures and cues
Responses to simple commands without external structure are random and nonpurposeful in relation to command
Can patients fluctuate between levels?
Yes!
What is a level VI responsiveness and assistance level?
“inconsistently oriented to person, time, and place but more appropriate”
Moderate assistance
Inconsistently oriented to person, time, and place
Able to attend to highly familiar tasks in nondistracting environment for 30 minutes with moderate redirection
Remote memory has more depth and detail than recent memory
Vague recognition of some staff
Able to use assistive memory aide with maximal assistance
Emerging awareness of appropriate response to self, family, and basic needs
Moderate assist to problem solve barriers to task completion
Supervised for old learning (e.g., self-care)
Shows carryover for relearned familiar tasks (e.g., self-care)
Maximal assistance for new learning with little or no carry over
Unaware of impairments, disabilities, and safety risks
Consistently follows simple directions
Verbal expressions are appropriate in highly familiar and structured situations
What levels require maximum assistance?
Levels I-IV
How can we structure the environment for level IV-V patients?
Important to avoid overstimulation and to maximize functional performance in the physical rehab interventions that follow
Consider who is in the room, noise level, visual distractions, need for private space
Your calm demeanor, and redirection at times, can make all the difference, especially in RLA IV
How can we maximize ROM for level IV-V patients?
Stretching program
Consider serial/delta casting
Static positioning for prolonged stretch
- Prone lying for hip flexors
- Passive standing for plantar flexors
- Leg extended on bolster with weight for hamstrings
Phenol blocks, Botox
How can we maximize force production for level IV-V patients?
Functional strengthening
- Body weight vs. resisted
- Cuff weights on limbs during mobility
- Thera-band resistance during swing phase
Address focal strength deficits
- Outside of functional mobility
Bilateral vs. unilateral tasks
- Moveo Table
How can we maximize core/proximal muscle activation for level IV-V patients?
Tall kneeling: Mini-squats, forward or lateral walking
Half kneeling
Quadruped: Single limb, alternate UE/LE
Add dynamic UE activity: Bean bag toss, balloon taps, Reaching
How can we maximize ambulation with or without
BWS for level IV-V patients?
Unlike severe TBI, not generally passive
Same devices, different settings/clinician assist levels: Lite Gait, Rifton, Lokomat, GEO, Ekso
Body weight support: Intensity, Decreased demands on therapist
Robotics as adjunct to traditional treatment
Consider 2020 CPG recommendations if higher gait capacity
What is a level VII responsiveness and assistance level?
“automatic and appropriate in their responses - consistently oriented”
Minimal Assistance for Daily Living Skills
Consistently oriented to person and place within highly familiar environments
Moderate assistance for orientation to time
Able to attend to highly familiar tasks in a nondistraction environment for at least 30 minutes with minimal assist to complete tasks
Minimal supervision for new learning
Demonstrates carry over of new learning
Initiates and carries out steps to complete familiar personal and household routine but has shallow recall of what they have been doing
Able to monitor accuracy and completeness of each step in routine personal and household ADLs and modify plan with minimal assistance
Superficial awareness of his/her condition but unaware of specific impairments and disabilities and the limits they place on his/her ability to safely, accurately and completely carry out his/her household, community, work, and leisure ADLs
Minimal supervision for safety in routine home and community activities
Unrealistic planning for the future
Unable to think about consequences of a decision or action
Overestimates abilities
Unaware of others’ needs and feelings
Oppositional/uncooperative
What is a level VIII responsiveness and assistance level?
Standby Assistance
Consistently oriented to person, place, and time
Independently attends to and completes familiar tasks for one hour in distracting environments
Able to recall and integrate past and recent events
Uses assistive memory devices to recall daily schedule, “to do” lists, and record critical information for later use with standby assistance
Initiates and carries out steps to complete familiar personal, household, community, work, and leisure routines with standby assistance and can modify the plan when needed with minimal assistance
Requires no assistance once new tasks/activities are learned
Aware of and acknowledges impairments and disabilities when they interfere with task completion but requires standby assistance to take appropriate corrective action
Thinks about consequences of a decision or action with minimal assistance
Overestimates or underestimates abilities
What is the assistance levels for IX and X?
Level IX: Standby Assistance on Request
Level X: Modified Independent
Big picture takeaways for level XII and higher interventions
Cognitive deficits can outweigh physical deficits
Keep the patient’s goals in mind
Hold the patient accountable
Consider insight and ability to safely execute their program at home
Be creative!
You will wear many hats
How can we gait train for level XII and higher?
Challenge patients with no risk of fall
Solo-Step: static
SafeGait: dynamic
Overground vs. treadmill
Allows error correction with therapist hands off
Ambulation with/without AD
Progress dynamic balance
How can we train for dynamic balance for level XII and higher?
Initiate new movement patterns—the list is endless!
- Agility ladder
- Line jumps
- Heel/toe walking
- Walking lunges
Mimic community environment
Challenge limits of stability
Anticipatory and reactionary balance
- Anticipatory: throw bean bags or balls onto treadmill
- Reactionary: perturbations
Vary surfaces and visual input
- Obstacle course
How can we provide strength/conditioning for level XII and higher?
Promote force production and muscular endurance
Closed chain vs. open chain
Circuit training: emphasize core, UE, LE
Quadruped, tall kneel, half kneel for core stability
Increased repetition, progressive resistance, timed intervals
Transition to community gym program
How can we provide intensive cardiovascular exercise for level XII and higher?
Patients with varied abilities/limitations (UE, LE)
Optimize motor learning
Change speed, direction, incline, variable stepping over obstacles
How do we monitor? HR, Borg
How can we provide cognitive challenge w/ mobility for level XII and higher?
Dual tasking
- Cognitive and physical duals tasks
- Progress complexity of secondary task
Route finding
- To familiar and unfamiliar locations
- Problem-solving using environmental cues
Scavenger hunts
- Working memory
- Environmental attention
- Executive function
