lecture 6: PT management for indivisials with disordes of consciousness

Question 1

what is “An injury to the brain, which is not hereditary, congenital, degenerative, or induced by birth trauma. An injury to the brain that has occurred after birth.”

Answer 1

acquired brain injury

Question 2

what is “an insult to the brain, not of degenerative or congenital nature, but caused by an external physical force that may produce a diminished or altered state
of consciousness, which results in impairment of cognitive abilities or physical
functioning”

Answer 2

traumatic brain injury

Question 3

what does the Glasgow Coma Scale measure

Answer 3

levels of consciousness

Question 4

what score on the glasgow coma scale is considered severe , moderate and mild

Answer 4

3-8 severe
9-12 moderate
13-15 mild

Question 5

what is a tool to describe patient’s level of cognitive functioning across continuum of recovery

Answer 5

rancho los amigos level of cognitive functioning

Question 6

what foes rancho levels correlate with ? (3)

Answer 6

24 hour GCS score , length of coma , duration of posttraumatic amnesia

Question 7

what is rancho levels 1

Answer 7

no response

unresponsive to any stimulus (in a coma)

Question 8

what is ranchos level 2

Answer 8

generalized response

Question 9

◦ Limited, inconsistent, non-purposeful, generalized reflex response often to pain only
◦ Responses may be physiological, gross body movements, non-purposeful vocalizations

what ranchos level would this be

Answer 9

level 2: generalized response

Question 10

what is ranchos level 3

Answer 10

localized response

Question 11

◦ Increased movements and reacts more specifically to stimuli (may turn towards sound, withdraw from pain, watch someone move around the room)
◦ May begin to inconsistently respond to commands and yes/no questions

what ranchos level is this

Answer 11

stage 3: localized response

Question 12

what stage of rancho los amgios and score for glasgow coma scale would a severe TBI be defined as ( referring to patients with disorders of consciousness)

Answer 12

1-3 for ranchos

3-8 GCS

Question 13

what is the difference between arousal vs awareness

Answer 13

arousal is the state of being alert and awake

but

awareness is the state of being able to understand and reflect on decisions

Question 14

what is a collective term describing conditions where consciousness or arousal have been affected by brain damage.

Answer 14

disorders of consciousness

Question 15

what are the main differences between coma , vegetative state , and minimal conscious state

Answer 15

coma is when someone is full unconscious and does not respond to external stimuli

vegetative state is when a person has sleep wake cycles but lacks any interaction

MCI is when a patient has a severe altered consciousness but has more awareness and purposeful behavior

Question 16

what is o Complete paralysis of cerebral function or state of unresponsiveness

Answer 16

coma

Question 17

o “Unresponsive Wakefulness Syndrome”
o A wakeful, reduced responsiveness with no evident cerebral cortical function

what does this describe

Answer 17

vegetative state

Question 18

Consciousness severely altered but there are signs demonstrating self or environmental awareness

what is this

Answer 18

MCS

Question 19

what is emergence from minimally conscious state

Answer 19

• awake most of the time but still confused
• functional object use
  -functional accurate communication

Question 20

if a patient has no arousal and no awareness then what is this diagnosis prob

Answer 20

coma sleep anesthesia

Question 21

if a patient has a high arousal and a low awareness then what state are they in

Answer 21

vegetative state q

Question 22

if a patient has a normal arousal but a up and down type of awareness what state are they in

Answer 22

minimally conscious state

Question 23

if a patient has high arousal; and high awareness but they can’t move and can only move their eyes up and down.. what is it called

Answer 23

locked in syndrome

Question 24

what is damaged for locked in syndrome

Answer 24

damage to bilateral ventral pons usually due to basilar thrombosis

Question 25

what is spared and what is impaired in locked in syndrome

Answer 25

spared:  Reticular activating system/reticular formation
 Vertical gaze centers from midbrain

impaired : B corticospinal tracts (paralysis below head)
B corticobulbar tracts (paralysis to facial mm ,chewing and talking)
B abducens (CN VI) nerve nuclei (cant more eyes side to side)

Question 26

what are the communication primary impoatiments after a brain injury

Answer 26

◦ Dysarthria
◦ Aphasia
◦ Impaired reading/writing
◦ Auditory deficits

Question 27

what are the Sensory and Perceptual primary impairments after a brain injury

Answer 27

◦ Decreased somatosensation
◦ Decreased light touch/
proprioception
◦ Visual and perceptual deficits
◦ Vestibular dysfunction

Question 28

◦ Agitation
◦ Aggression
◦ Irritability
◦ Disinhibition
◦ Impulsiveness
◦ Lack of concern
◦ Perseveration
◦ Decreased judgment
◦ Reduced insight of deficits

these are all what kind of primary impairments after a brain injury

Answer 28

behavior and personality

Question 29

what are MSK secondary impairments after a brain injury

Answer 29

◦ Contractures
◦ *Heterotropic Ossification (HO)
◦ Pain
◦ Decrease bone mineral density
◦ Decreased muscular strength

Question 30

what is sympathetic storming

Answer 30

autonomic instability following a TBI

Question 31

what is autonomic instability following a TBI

Answer 31

dysfunction of autonomic centers in the diencephalon or their connections to cortical , subcortical , and brainstem loci that mediate autonomic function

Question 32

what are S&S of sympathetic storming (8)

Answer 32

• agitation
• diaphoresis
• hyperthermia
• HTN
• tachycardia
• tachypnea
• posturing
• pupillary dilation

Question 33

what may trigger storming in patients post TBI

Answer 33

noxious stimuli

Question 34

what is the difference between anoxia and hypoxia

Answer 34

anoxia is when there is no oxygen reaching the tissue and hypoxia is when there is a decrease amount of O2 reaching the tissue

Question 35

◦ Arousal/Consciousness
◦ Cognition/communication ability
◦ Responses observed
◦ Eye responses
◦ Painful stimulus
◦ Tactile stimulus
◦ Auditory stimulus
◦ Visual Stimulus

◦ Vitals
◦ Cranial nerve examination
◦ Reflex integrity
◦ Tone, posturing
◦ Pain
◦ ROM
◦ Muscle performance
◦ Posture

all of these fall under what test and measures domain

Answer 35

body functions and structures

Question 36

◦ Movement Analysis/Functional
Assessment
◦ Bed mobility
◦ Transfers
◦ OOB to chair tolerance/upright
tolerance
◦ Balance /head and trunk control/
◦ Gait

these fall under what domain for tests and measures

Answer 36

activity

Question 37

◦ Prior life roles?
◦ Job, school
◦ Hobbies
◦ Sport

what domain for tests and measures does these fall into

Answer 37

participation

Question 38

what is the outcome measure for TBI that belongs in the participation domain

Answer 38

disability rating scale

Question 39

◦ Functional Assessment Measure (FAM)
◦ FIM

these 2 outcome measures fall under what domain for TBI

Answer 39

activity

Question 40

what are the 5 body function and strucutre outcome measures for TBI

Answer 40

◦ Glasgow Como Scale (GCS)
◦ Rancho Level of Cognitive Functioning
◦ Disorders of Consciousness Scale (DOCS)
◦ JFK Coma Recovery Scale-Revised (CRS-R)
◦ Modified Ashworth Scale (MAS)

Question 41

what scale is developed to track an individual from coma to community

Answer 41

disability rating scale

Question 42

what is the scoring for the disability rating scale

Answer 42

0 (no disability) - 29 (extreme vegetative state)

Question 43

what additional areas are addressed in the functional assessment measure (FAM) rather then in the FIM

Answer 43

◦ Cognitive
◦ Communication
◦ Community function
◦ Behavioral

Question 44

what scale measures neurobehavioral function during coma recovery

Answer 44

disorders of consciousness scale

Question 45

what is the purpose of the JFK coma recovery scale

Answer 45

assist in differential dx, prognostic assessment , treatment planning in pts with disorders of consciousness

Question 46

what scale asses the consciousness in pts with disorders of consciousness

Answer 46

JFK Coma Recovery Scale –Revised

Question 47

what is teh administration of the coma recovery scale (JFK)

Answer 47

observe for 1 minute and record observations

• determine level of arousal
• differentiate between volitional from coincidental movement
  -resting position of extermiees , eye opening status and tracking

Question 48

if u want to assess a patient with the JFK CRS and their eyes do not open then what do i perform

Answer 48

the arousal facilitation protocol

Question 49

what is the the arousal facilitation protocol

Answer 49

deep pressure to face , neck , shoulders, arm , hand , chest , back , leg , foot and toes

Question 50

what is the scoring for the CRS
◦ Communication:
◦ Visual:
◦ Motor
◦ Auditory:
◦ Oromotor:

Answer 50

◦ Communication: 1
◦ Visual: 2
◦ Motor: 3
◦ Auditory: 3
◦ Oromotor: 3

Question 51

when does the CRS what are indicators of emergence )eMCS)

Answer 51

• ◦ Motor Scale: Functional object use
  ◦ Functional accurate communication

Question 52

Change of positions, weight bearing, PROM

this is what kind of mode for sensory stimulation for patients to increase responsiveness

Answer 52

kinesthetic

Question 53

Head turns, rolling, changing head position

this is what kind of mode for sensory stimulation for patients to increase responsiveness

Answer 53

vestibular

Question 54

pressure, light touch, noxious stimulation, temperature

this is what kind of mode for sensory stimulation for patients to increase responsiveness

Answer 54

tactile

Question 55

oral swabs, lollipop, popsicle, oral hygiene

this is what kind of mode for** sensory stimulation** for patients to increase responsiveness

Answer 55

gustatory

Question 56

what are 6 ways to mange spasticity

Answer 56

Prolonged stretching
Weight bearing
Encouraging active movement
Bed and wheelchair positioning
Casting/splinting
Medications

Question 57

what are preventions of pressure ulcers

Answer 57

◦ Positioning devices in bed
◦ Turning /positioning schedule
◦ Boots for pressure relief off of heel

Question 58

what are ways to educate the familiy of a person in rancho levels 1, 2 and 3

Answer 58

◦ Keep room calm and quiet
◦ Use short, simple commands/questions with calm tone of voice

◦ 2-3 visitors in room at a time
◦ Allow patient extra time to respond (sometimes won’t respond at all)-give rest breaks
◦ Orient the patient
◦ Bring pictures of family members, favorite belongings
◦ Engage the person in familiar activities