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PHTY3140 Additional > L26-27: Rehabilitation management following TBI > Flashcards

L26-27: Rehabilitation management following TBI Flashcards

1
Q

What are 3 characteristics of acquired brain injury?

A
  1. Malignancy eg SOL (tumour)
  2. Mechanical eg haemorrhage, embolus, aneurysm or arteriovenous malformation (cardiovascular)
  3. Trauma eg MVA, assault, sporting accident, falls, falls from and kicks from horses (TBI)
    • Associated with hypoxic episodes, swelling and raised inter-cranial pressure, altered biochemistry, speed of impact if accident, multi-trauma or multi-diagnoses eg LBP or arthritis
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2
Q

What are 5 characteristics of the nature of traumatic brain injury?

A
  1. Increasing incidence, survival due to better quality, faster retrieval and improved ICU management
  2. Young males between 18 and 35 years old
  3. MVA/ MBA/ bicycle/ skateboard etc
  4. Sports injury/ assault/ falls
  5. Usually high speed impact –> shearing force –> diffuse axonal injury ® global dysfunction
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3
Q

What is TBI?

A

TBI is an acute brain injury resulting from mechanical energy to the head from external physical forces.

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4
Q

What are 5 operational criteria for clinical identification?

A
  1. loss of consciousness
  2. post-traumatic amnesia
  3. other neurological abnormalities, such as focal neurological signs, seizure and/or intracranial lesion.
  4. These manifestations of TBI must not be due to drugs, alcohol or medications, caused by other injuries or
  5. treatment for other injuries (eg, systemic injuries, facial injuries or intubation), or caused by other problems (eg, psychological trauma, language barrier or co-existing medical conditions).
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5
Q

______ can occur in the context of penetrating cranio-cerebral injuries but in this situation, focal neurological deficits are generally more important than any diffuse element.

A

TBI

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6
Q

What is primary injury VS secondary injury?

A
  1. Primary injury
  2. Secondary injury: as a result of swelling, movement of brain in skull…etc (symptoms)
    • Tearing and stretching entry points or pressure (eg. where nerves pass through)
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7
Q

What is the the problem with foramen magnum (brainstem)?

A

Pressure through this area = life threatening

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8
Q

When assessing neurological disorders, a clear understanding of the presenting _____can be gained by comparing the functional role of each area of the _____ with the blood supply to that area

A

symptoms; CNS

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9
Q

What are 9 areas of the brain?

A
  1. Middle cerebral artery
  2. Anterior cerebral artery
  3. Posterior cerebral artery
  4. Frontal lobe
    • Planning/organising personality
  5. Temporal lobe
    • Smell and sound R) visual memory L) verbal memory
  6. Occipital lobe
    • Visual information
  7. Parietal lobe
    • Sensation- touch pressure R) Visuo-spatial L) language
  8. Brainstem
    • Cranial nerves- survival and arousal
  9. Cerebrellum
    • Co-ordination
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10
Q

What are 8 primary brain injuries?

A
  1. Skull fractures
  2. Contusion, laceration, haemorrhage
  3. Shearing / tearing of neuronal structures
  4. Loss of autoregulation
  5. Change in efficiency of BBB
  6. Damage to other structures - cranial nerves, pituitary, hypothalamus, blood vessels
  7. Depressed skull #s - push on cortex causing contusion and laceration
  8. # temporal bone - can tear middle meningeal artery - EDH
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11
Q

What are signs of Base of Skull fractures?

A

Raccoon eyes, Battle’s sign (bruising behind ear).

  • Often missed in scan –> implications for potential treatments (eg. suction due to airway pressure)
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12
Q

What are 4 cranial nerves that are most often damaged?

A

contused or torn –> Shearing pressure

  1. Olfactory
  2. Optic
  3. Facial
  4. Auditory.
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13
Q

What is the injury with blood vessels?

A

eg, tearing of middle meningeal artery (EDH), tearing of internal carotid (Carotico -Cavernous fistula)

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14
Q

What is Pituitary / Hypothalamus malfunction?

A

A

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15
Q

What are 3 characteristics of secondary brain injury?

A
  1. any neurological damage that increases morbidity or mortality - that occurs after the primary injury
  2. delayed cerebral haemorrhage, cerebral oedema, hypercapnia, hypoxia, hypotension, sustained raised ICP, infections, respiratory. Complications
  3. Neurons are torn or ruptured leaking out toxic neurotransmitters glutamate,chloride,potassium and sodium

Main goal = keep blood going to brain (can influence treatment choices)

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16
Q

What are 7 purposes of CSF?

A
  1. Fluid pathway for the delivery of substances to the brain cells
  2. Elimination of by-products of brain metabolism
  3. Transport of hormones from their site of origin to their peripheral sites of action
  4. Cushioning of brain tissue within the fixed bony ridges of the skull
  5. Ability to respond to pressure changes
  6. pH of CSF influences pulmonary drive
  7. Clear colourless fluid normal, circulating between the space between the arachnoid and pia mater and into the spinal canal. Produced in the choroid plexus at a rate of around 500mL/day
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17
Q

What re 4 characteristics of CO2 and cerebro spinal fluid (CSF)?

A
  1. Chemoreceptors within the floor of 4th ventricle detect changes in pH of CSF
  2. pH of CSF becomes more acidic with increasing levels of CO2
  3. Hyperventilation to maintain homeostasis
    • Do not want CFS to dilate out (run at lower CO2 = will usually hyperventilate to avoid this)
  4. pH of CSF influences pulmonary drive and cerebral blood flow

Keep oxygen to cerebral tissue (keep blood following through)

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18
Q

What are 2 types of Intracranial Pressure?

A
  1. Raised Intracranial Pressure (ICP)
  2. Cerebral Perfusion Pressure (CPP)

ICP is the pressure exerted by the cerebrospinal fluid within the ventricles

  • Normal ICP - 0 to 15mmHg (or 80mm to 180mm of water

No area to compensate in the skull (bone- not able to increase the area= rigid) = very dangerous to have an increase in pressure as this will cause problems with brain (more malleable than bone)

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19
Q

What are the 2 characteristics of doctrine of relative displacement?

A
  1. the skull is filled to capacity with essentially non-compressible components. If any one component increases in volume, another component must decrease, for overall volume to remain constant
  2. Components are - Brain (80%), Blood (10%), CSF (10%)
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20
Q

What are 4 characteristics of central perfusion pressure?

A
  1. CPP is the blood pressure gradient across the brain
  2. Is an estimate of the adequacy of cerebral circulation
  3. Calculated by the equation:
    • CPP = Mean SAP - ICP
    • * therefore - ICP and CPP are dependent on each other *
  4. Normal CPP is 80 to 100 mmHg
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21
Q

What are 4 secondary injuries?

A
  1. Loss of Autoregulation ->loss of tone in arterioles ->increased CBF ->mov’t of fluid into extracellular space (vasogenic)
  2. BBB inefficiency ->large molecules leak into extracellular space drawing H2O with them ->vasogenic C.O.
  3. Dec. perfusion ->failure of Na pump
  4. ->Na & H20 accumulate in cell (cytotoxic)
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22
Q

What are 2 characteristics of hyperthermia?

A
  1. May be due to systemic infections or to dysfunction of the hypothalamus as a result of the head injury
  2. An increase in body temperature will increase the basal metabolic rate and increase oxygen and glucose consumption
    • Eg. ICE therapy

Increase O2 demand

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23
Q

What does primary and secondary injury look like?

A
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24
Q

What are 4 managements of hypotension?

A
  1. Powerful predictor of outcome
  2. Cerebral oxygenation is threatened by systemic hypotension
  3. Inotropic Support (dopamine, phenylephrine, norepinephrine, epinephrine, dobutamine)
  4. Fluid resucitation (consider effects on other systems)
  • Compromise CPP –> decreases blood pressure
  • Management will help to increase blood pressure
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25
Q

What is Diffuse Axonal Injury?

A

Diffuse Axonal Injury (DAI)- previously known as

‘shearing injury’

  • immediate loss of consciousness without any focal lesion seen. May be widespread neurological dysfunction, diffuse white matter degeneration and diffuse cerebral swelling.
  • May be graded I to IV
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26
Q

What is an Extradural Haemorrhage?

A

usually arterial in origin, most assoc. with #s of temp/parietal bone resulting in injury to middle meningeal artery; however can sometimes be of venous origin

  • If arterial in origin can act as a rapidly developing SOL, leading to herniation and death if not evacuated urgently
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27
Q

What is an acute Subdural Haemorrhage?

A

occur within 72hrs of injury, and are usually assoc. with a large degree of underlying brain damage from the injury & consequently carry the poorest prognosis

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28
Q

What is a chronic Subdural Haemorrhage?

A

can occur up to 3 weeks post injury, more prevalent in pts. with cerebral atrophy (alcoholics, elderly)

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29
Q

What are 6 characteristics of a Subarchnoid Haemorrhage?

A
  1. Bleed into the subarachnoid space
  2. Often accompanies other types of traumatic haemorrhage
  3. Associated with poorer outcome
  4. Associated with hydrocephalus
  5. Can be traumatic or spontaneous (resulting from aneurysmal or arteriovenous malformation leakage or rupture)
  6. Symptoms may include headache and photophobia
    • Can be left undetected
    • Once pressure overrides the artery wall –> rupture –> symptoms will show
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30
Q

What is the Grades World Federation of Neurological Surgeons (WFNS)- Glasgow Coma Score (GCS)?

A
  1. Grade 1 – Glasgow Coma Score (GCS) of 15, motor deficit absent
  2. Grade 2 – GCS of 13-14, motor deficit absent
  3. Grade 3 – GCS of 13-14, motor deficit present
  4. Grade 4 – GCS of 7-12, motor deficit absent or present
  5. Grade 5 – GCS of 3-6, motor deficit absent or present
31
Q

What is the The Fischer scale (CT scan appearance)?

A
  1. Group 1 – No blood detected
  2. Group 2 – Diffuse deposition of subarachnoid blood, no clots, and no layers of blood greater than 1 mm
  3. Group 3 – Localized clots and/or vertical layers of blood 1 mm or greater in thickness
  4. Group 4 – Diffuse or no subarachnoid blood, but intracerebral or intraventricular clots are present
32
Q

What is an Intercerebral Haemorrhage?

A

large traumatic ICH are not common, most traumatic ICH are seen as small multiple petechial haemorrhages, or contusions, and are assoc. with diffuse axonal injury

33
Q

What are the 3 stages of rehabilitation?

A
  1. Primary – ICU, acute wards and In-patient Rehabilitation Units
  2. Secondary - Outpatient and Transitional Living Programs
  3. Tertiary - Community Integration, return to work or long-term support
34
Q

What are the 6 assessments for primary rehabilitation?

A
  1. EFFECTIVE MANAGEMENT OF UNCONSCIOUS PATIENTS
  2. NEUROLOGICAL FOCUS
  3. ASSESSMENT
  4. TREATMENT AIMS
  5. TREATMENT PRINCIPLES
  6. STRATEGIES FOR OPTIMISING INPUT
35
Q

What are 4 ways to obtain subjective information?

A

Information already gained from diagnosis – charts ,relevant past history,

Tests- x-ray,Biochemistry,CT scan

  1. Medication
  2. Social background
  3. Family members
  4. Nursing staff
36
Q

What are 7 initial observations for brain injuries?

A
  1. Conscious Level – GCS
  2. Appearance
  3. Posture / Alignment / Deformities
  4. Colour / skin condition / oedema
  5. Movement – spontaneous / purposeful
  6. Facial symmetry / expression
  7. Respiration
37
Q

What is the Glasgow Coma Scale?

A

The Glasgow Coma Scale is a standardized system used to assess the degree of brain impairment and to identify the seriousness of injury in relation to outcome.

38
Q

What are 3 determinants for the Glasgow Coma Scale?

A
  1. eye opening,
  2. verbal responses
  3. motor response (movement)
39
Q

What are the 3 scores of the GCS?

A
  1. MILD - GCS 13 to 15
  2. MODERATE - GCS 9 to 12
  3. SEVERE - GCS 8 or below

Less than 8 = 50% mortality rate

Affects Tx/Mx –> they might be better in morning or afternoon
Aim to increase or maintain GCS

40
Q

What are 5 characteristics of —-?

A
  1. Airway - prevent hypoxia / hypercapnia, when ventilating aim for CO2 of 30 – 35 –sensitive cerebral vasoconstrictor
  2. Avoid hyperthermia – increases use of oxygen
  3. Avoid clustering of cares
  4. Ascertain whether maintaining own airway – trachy, O2 needs, sats
  5. Cranial nerve damage
    • Loss of swallow
    • Loss of cough
41
Q

What are 6 characteristics of acute/ICU positioning?

A
  1. Optimum position for cerebral perfusion is head up 15-30° with the neck in a midline, neutral position
    • Optimal position to manage pressure gradient
  2. Allows venous drainage without compromising SBP thereby maximising CPP
  3. Changing position may not be an option for treatment if ICP is high, need to know how has reacted to previous position changes
  4. Changing position may cause an increase in O2 consumption (consider pre-oxygenation prior to turns)
  5. Head down position is contraindicated due to effect on ICP
  6. Do not lay on bone flap defect- Optimal position to manage pressure gradient
  7. Draining CFS if they have a high CCP (can be an open system where it can be turned on and off??)
42
Q

What are 4 characteristics of muscle strength?

A
  1. MRC grades
  2. debate re: accuracy/relevance for UMNL
  3. document:
    1. MRC grade
    2. and/or ROM in particular position
  4. Often assessment of spontaneous movement noted – likely not to be able to move to command
    1. Unable to follow commands
43
Q

What are 3 characteristics of the neurological assessment?

A
  1. Sensation
  2. Proprioception
  3. Co-ordination

Unable to formally assess – therefore need to gain from objective movements, position, response to touch movement.

44
Q

What are 5 problems with decreased consciousness?

A
  1. DECREASED MOVEMENT
  2. DECREASED SOMATO-SENSORY AND VESTIBULAR INPUT
  3. DECREASED WEIGHT BEARING
  4. DECREASE CHANGES BETWEEN MULTIPLE POSTURES / PERCEPTION OF MOVEMENT
  5. DECREASED INFLUENCE OF GRAVITY
45
Q

What are 7 aims of treatment for brain injuries?

A
  1. OPTIMISE RESPIRATORY FUNCTION AND PREVENT COMPLICATIONS
  2. DECREASE EFFECTS OF TONAL PRESENTATIONS
  3. OPTIMAL MUSCULOSKELETAL ALIGNMENT
  4. PREVENT ADAPTIVE MUSCLE SHORTENING
  5. PROVIDE NORMAL POSTURE AND MOVEMENT EXPERIENCES – MINIMISING THE EFECTS OF STATIC POSTURING AND INACTIVITY
  6. FACILITATE ALERTNESSS AND AWARENESS OF NORMAL POSTURAL ALIGNMENT.
  7. DETERMINE THE POTENTIAL FOR REHABILITATION
46
Q

What are 9 characteristics of sensory stimulus?

A
  1. Proprioceptive,cutaneous,vestibular,visual,auditory
  2. Handling – provide movement control guide normal movement – provide input
  3. Weight bearing stimulation –compression, approximation, weights, bandaging
  4. Traction
  5. Stretch
    • facilitatory , sweep tapping
    • Inhibitory , prolonged, slow lengthening
  6. Stroking / Brushing – variable textures
  7. Thermal –warmth – ICE – facilitary – inhibitory
  8. Vestibular – position changes, rocking, swaying, rolling
  9. Auditory – verbal cueing – talking through what you are doing ,what you want them to do, vary tone
47
Q

What are 4 characteristics of postural control?

A
  1. Choice of posture
  2. Use of gravity
  3. Size of base of support
  4. Key points for movement – stability
48
Q

What are 4 movement strategies for brain injury?

A

Make sure to speak to patient as you are doing you Tx

  1. HEAD ON BODY AND BODY ON BODY PERCEPTIONS – CERVICAL /THORAX/ PELVIS MOBILITY / BED MOBILITY
  2. BEGINNING CHALLENGES AGAINST GRAVITY TO FACILITATE MUSCLE ACTIVITY
  3. SPECIFIC ROM TECHNIQUES – INHIBITORY MOBILISATION, ROTATION, DISTRACTION, FUNCTIONAL PATTERNS OF MOVEMENT.
  4. MUSCLE ELONGATION / MOBILISATION OF MUSCLE BELLY / LETTING GO INSTEAD OF PASSIVE STRETCH / CONTRACT – RELAX
  • Vibration, compression
  • Unable to give grades for MMT but can give some subjective notes (e. spontaneous muscle contraction and ability to contract against gravity)
  • Soft splint (if they are in a hard splint –> more likely to oppose force and pull into the position you don’t want)
49
Q

What are 8 solutions of brain injuries?

A
  1. Give patient time to process request
  2. Use signs eg thumb up/down, eye movement
  3. Use humour
  4. Look closely for signs of recognition/understanding
  5. Pick up on non-verbals
  6. Clear concise instructions/explanations
  7. Try to imagine what is going on in patient’s mind
  8. We are unsure about how much a patient can hear when semi/unconscious –but in view of the above we MUST assume everything even if processing is slowed and/or muddled.
50
Q

What is an acute condition/storming?

A
51
Q

What are 6 features of acute conditions/storming?

A

Malfunction of autonomic system –> going into fight flight mode in response to minimal stimulation

  1. Symptoms – increased HR, increased BP, increased temperature, rigidity and posturing, daiphoresis
  2. Occurs in 10-30 % DAI
  3. Cause
  4. sympathetic storming, neurostorming, acute midbrain syndrome, central dysregulation
  5. Implications – associated with a poorer neurological recovery, increased energy expenditure up to 250%, elevation of catecholamines
  6. a release of the diencephalon and brainstem from cortical control
  7. due to impaired autonomic function with abnormal reflex responses to muscle mechanoreceptors or chemoreceptors during hypertonia
52
Q

What is dysautonomia?

A
  1. Occurs in 10-30 % DAI
  2. Aka sympathetic storming, neurostorming, acute midbrain syndrome, central dysregulation
  3. Occurs in patients without obvious structural lesions of the central autonomic regions ( hypothalamus) or raised intracranial pressure.
  4. Baguley found it to be associated with diffuse axonal injury, pre-admission hypoxia, younger age and brainstem injury
53
Q

What are 4 symptoms of dysautonomia?

A
  1. increased HR, increased BP, increased temperature, rigidity and posturing, daiphoresis
54
Q

What are 3 implications of dysautonomia?

A
  1. associated with a poorer neurological recovery
  2. increased energy expenditure up to 250%
  3. elevation of catecholamines
55
Q

What are the 3 phases of the dysautonomia?

A
  1. Phase one: 0 – 1 week little difference between patients with dysautonomia and those without
  2. Phase two: 1 – cessation of sweating onset of physiological changes of dysautonomia
  3. Phase three: paroxysmal episodes have burnt out, residual dystonia and spasticity of varying degrees
56
Q

What is the aim of treatment in dysautonomia? What are 7 medications?

A

minimize secondary cerebral injury due to physiological effects of autonomic dysfunction

  1. Morphine: narcotic analgesic
  2. Bromocriptine: pituitary hormone
  3. Dantrolene sodium: muscle relaxant
  4. Propranolol: beta adrenergic blocking agent
  5. Diazepam: antianxiety agent
  6. Clonazepam: anticonvulsant
  7. Cholorpromazine: antipsychotic
57
Q

What are the 5 implications for physio for dysautonomia?

A
  1. Caution with tactile and auditory input
  2. Limit therapy, cease if provoked
  3. Maintain flexed posture as much as possible
  4. Prevention of secondary musculoskeletal complications as best able
  5. Extra caution with splints and plasters
58
Q

What are 4 outcomes for dysautonomia?

A
  1. Longer rehabilitation and length of stay
  2. ICU admission no longer than for patients without dysautonomia
  3. Longer duration of PTA
  4. Worse outcome at discharge from rehabilitation
59
Q

What are 5 stages of the primary rehabilitation?

A
  1. Active initial rehab or preventative management as able
  2. BIRU rehab, Jasmine unit or Jacana (slow stream rehab),
  3. OPD physio to achieve defined goals
  4. NAB clinic / TRS program
  5. Gym program, more physio later

Not linear, can skip a stage, or return to active rehab when ready

60
Q

What are 5 overviews for brain injury?

A
  1. Specific TBI problems
  2. Non physical problems
    • Cognitive/memory,
    • psycho-social, emotional, social & behavioural
    • communication
  3. Physio specific problems
  4. Outcome measures
  5. Physio terminology
61
Q

What are 4 characteristics of cognition and memory?

A
  1. Attention & Concentration
    • problems with sustained, selective or sequential focus on a task
  2. Memory
    • problems with input, storage or retrieval of information
  3. High Level Skills
    • planning, problem solving, mental flexibility, insight and judgement problems
  4. Neuro psychology and Occ Therapy input required
62
Q

What is occupational therapy?

A
  • Assessment and monitoring of functional cognition: standardised tools (e.g., Westmead PTA scale, Cognitive Assessment of Minnesota [CAM]) in conjunction with functional assessment (task analysis) to determine the presence of cognitive/perceptual deficits and the impact upon occupational performance;
  • Assessing memory and other cognitive processes and then providing training in use of specific compensatory strategies (e.g., routine use of a diary, calendar or lists);
63
Q

What are 6 types of communication problems?

A
  1. Aphasia
  2. Dysarthria: Weakness of muscles associated with the speech mechanism. Speech may be slurred or the voice may be soft, monotone or hoarse.
  3. Dyspraxia: Motor programming deficit with no muscle weakness i.e. the person may make searching movements with the mouth and tongue in an attempt to find the right position.Speech can sound ‘jumbled’, effortful and be difficult to understand.
  4. Dysphasia
  5. Receptive Language: Problems understanding spoken or written words
  6. Expressive Language: Difficulty producing words/sentences or problems writing (dysgraphia)
64
Q

What are 9 pragmatic deficits?

A
  1. poor eye contact
  2. inability to take turns in conversation
  3. speaking too much (verbosity)
  4. getting stuck on a topic (perseveration)
    • Prompt them that they just asked the question, do you understand what I said?
  5. invading personal space
    • Inappropriate topics
  6. Limited facial expression.
  7. Reduced ability to initiate a conversation.
  8. Reduced awareness of personal space. Eg may sit too close to the other person.
  9. Reduced awareness of these changed behaviours and interactions

Social communication problems

65
Q

What are 5 psychosocial problems of brain injuries?

A
  1. Decreased drive and motivation
  2. Dis-inhibition and low frustration tolerance
  3. Emotional extremes
  4. Poor insight and unrealistic expectations
  5. Self-centred
66
Q

What are 6 treatment effects of brain injury?

A
  1. Quiet gym
  2. Set program time
  3. Short session
  4. Written exercise sheets
  5. Short direct commands
  6. Limit behaviour
67
Q

What is the severity of injury and prognosis?

A
  1. Short-term - GCS
  2. Long-term
    • Length of Post Traumatic Amnesia (PTA)
      1. <5minutes - very mild
      2. 5-60min - mild
      3. 1-24hours - moderate
      4. 1-7days - severe
      5. 1-4weeks - very severe
      6. >4weeks - extremely severe
      7. >6months - ongoing memory problems
68
Q

What are 7 characteristics of the length of Post Traumatic Amnesia (PTA) in severity of injury and prognosis?

A
  1. <5minutes - very mild
  2. 5-60min - mild
  3. 1-24hours - moderate
  4. 1-7days - severe
  5. 1-4weeks - very severe
  6. >4weeks - extremely severe
  7. >6months - ongoing memory problems
69
Q

What are 4 characteristics of mild GCS -13 to 15 (of a maximum 15)?

A
70
Q

What are 4 characteristics of Post traumatic amnesia - PTA?

A
  1. 12 questions daily
  2. Orientation to name, place, time and short and long memory
  3. must get 12/12 for 3 days with the 3 memory cards changing each day
  4. Then you are said to have “emerged from PTA” and the time from injury is the length of PTA
71
Q

What are 5 important strategies for primaru rehabilitation?

A
  1. short sessions
  2. frequent task changes
  3. simple and functional activities
  4. manual handling
  5. limit setting for behaviour
72
Q

What are 7 guides of addition of therapy for any type of TBI?

A
  1. Arousal
    • Change in position, rolling, sitting, TT etc…
    • Sensory stimulation
  2. Progressively load postural system
  3. Motor control
    • Re-establish head / trunk control as a basis for motor tasks (roll-over / prone on elbows / sitting / TT stand)
    • Establish eye follow & integrate eye / hand coordination
  4. Establish focal gaze (GS)
    • Integrate with head movement
    • Use a range of positions (supine /sitting / prone on elbows)
  5. Develop gradual habituation / tolerance to gravitational demand (sitting/ standing - tilt table) , movement (rotational)
  6. Improve orofacial control (minimise aspiration pneumonia++)
  7. Use strategies that consider the behavioural / cognitive ability of each patient
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PHTY3140 Additional (1 decks)

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