lecture 6: PT management for indivisials with disordes of consciousness Flashcards
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.”
acquired brain injury
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”
traumatic brain injury
what does the Glasgow Coma Scale measure
levels of consciousness
what score on the glasgow coma scale is considered severe , moderate and mild
3-8 severe
9-12 moderate
13-15 mild
what is a tool to describe patient’s level of cognitive functioning across continuum of recovery
rancho los amigos level of cognitive functioning
what foes rancho levels correlate with ? (3)
24 hour GCS score , length of coma , duration of posttraumatic amnesia
what is rancho levels 1
no response
unresponsive to any stimulus (in a coma)
what is ranchos level 2
generalized response
◦ 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
level 2: generalized response
what is ranchos level 3
localized response
◦ 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
stage 3: localized response
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)
1-3 for ranchos
3-8 GCS
what is the difference between arousal vs awareness
arousal is the state of being alert and awake
but
awareness is the state of being able to understand and reflect on decisions
what is a collective term describing conditions where consciousness or arousal have been affected by brain damage.
disorders of consciousness
what are the main differences between coma , vegetative state , and minimal conscious state
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
what is o Complete paralysis of cerebral function or state of unresponsiveness
coma
o “Unresponsive Wakefulness Syndrome”
o A wakeful, reduced responsiveness with no evident cerebral cortical function
what does this describe
vegetative state
Consciousness severely altered but there are signs demonstrating self or environmental awareness
what is this
MCS
what is emergence from minimally conscious state
- awake most of the time but still confused
- functional object use
-functional accurate communication
if a patient has no arousal and no awareness then what is this diagnosis prob
coma sleep anesthesia
if a patient has a high arousal and a low awareness then what state are they in
vegetative state q
if a patient has a normal arousal but a up and down type of awareness what state are they in
minimally conscious state
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
locked in syndrome
what is damaged for locked in syndrome
damage to bilateral ventral pons usually due to basilar thrombosis
what is spared and what is impaired in locked in syndrome
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)
what are the communication primary impoatiments after a brain injury
◦ Dysarthria
◦ Aphasia
◦ Impaired reading/writing
◦ Auditory deficits
what are the Sensory and Perceptual primary impairments after a brain injury
◦ Decreased somatosensation
◦ Decreased light touch/
proprioception
◦ Visual and perceptual deficits
◦ Vestibular dysfunction
◦ 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
behavior and personality
what are MSK secondary impairments after a brain injury
◦ Contractures
◦ *Heterotropic Ossification (HO)
◦ Pain
◦ Decrease bone mineral density
◦ Decreased muscular strength
what is sympathetic storming
autonomic instability following a TBI
what is autonomic instability following a TBI
dysfunction of autonomic centers in the diencephalon or their connections to cortical , subcortical , and brainstem loci that mediate autonomic function
what are S&S of sympathetic storming (8)
• agitation
• diaphoresis
• hyperthermia
• HTN
• tachycardia
• tachypnea
• posturing
• pupillary dilation
what may trigger storming in patients post TBI
noxious stimuli
what is the difference between anoxia and hypoxia
anoxia is when there is no oxygen reaching the tissue and hypoxia is when there is a decrease amount of O2 reaching the tissue
◦ 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
body functions and structures
◦ 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
activity
◦ Prior life roles?
◦ Job, school
◦ Hobbies
◦ Sport
what domain for tests and measures does these fall into
participation
what is the outcome measure for TBI that belongs in the participation domain
disability rating scale
◦ Functional Assessment Measure (FAM)
◦ FIM
these 2 outcome measures fall under what domain for TBI
activity
what are the 5 body function and strucutre outcome measures for TBI
◦ 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)
what scale is developed to track an individual from coma to community
disability rating scale
what is the scoring for the disability rating scale
0 (no disability) - 29 (extreme vegetative state)
what additional areas are addressed in the functional assessment measure (FAM) rather then in the FIM
◦ Cognitive
◦ Communication
◦ Community function
◦ Behavioral
what scale measures neurobehavioral function during coma recovery
disorders of consciousness scale
what is the purpose of the JFK coma recovery scale
assist in differential dx, prognostic assessment , treatment planning in pts with disorders of consciousness
what scale asses the consciousness in pts with disorders of consciousness
JFK Coma Recovery Scale –Revised
what is teh administration of the coma recovery scale (JFK)
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
if u want to assess a patient with the JFK CRS and their eyes do not open then what do i perform
the arousal facilitation protocol
what is the the arousal facilitation protocol
deep pressure to face , neck , shoulders, arm , hand , chest , back , leg , foot and toes
what is the scoring for the CRS
◦ Communication:
◦ Visual:
◦ Motor
◦ Auditory:
◦ Oromotor:
◦ Communication: 1
◦ Visual: 2
◦ Motor: 3
◦ Auditory: 3
◦ Oromotor: 3
when does the CRS what are indicators of emergence )eMCS)
- ◦ Motor Scale: Functional object use
◦ Functional accurate communication
Change of positions, weight bearing, PROM
this is what kind of mode for sensory stimulation for patients to increase responsiveness
kinesthetic
Head turns, rolling, changing head position
this is what kind of mode for sensory stimulation for patients to increase responsiveness
vestibular
pressure, light touch, noxious stimulation, temperature
this is what kind of mode for sensory stimulation for patients to increase responsiveness
tactile
oral swabs, lollipop, popsicle, oral hygiene
this is what kind of mode for** sensory stimulation** for patients to increase responsiveness
gustatory
what are 6 ways to mange spasticity
Prolonged stretching
Weight bearing
Encouraging active movement
Bed and wheelchair positioning
Casting/splinting
Medications
what are preventions of pressure ulcers
◦ Positioning devices in bed
◦ Turning /positioning schedule
◦ Boots for pressure relief off of heel
what are ways to educate the familiy of a person in rancho levels 1, 2 and 3
◦ 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
