Neuro #5- Trauma & SCI pages 151- 158 Flashcards
1
Q
What is the mechanism of injury for TBI?
A
Contact forces to the skull and rotational acceleration forces, causing varying degrees of injury to the brain
2
Q
Pathophysiology of TBI - 3 areas
A
- Primary brain damage
- Secondary brain damage
- Concussion
3
Q
What types of injury are considered primary brain damage in TBI patients?
A
- Diffuse axonal injury
- Focal injury
- Coup-contracoup injury
- Closed or open injury
4
Q
What is Diffused Axonal Injury in TBI?
A
Disruption and tearing of axons and small blood vessels from shearing of angular acceleration; results in neuronal death and petechial hemorrhage
5
Q
What is Focal Injury in TBI?
A
Contusions, lacerations, mass effect from hemorrhage, and edema (hematoma)
6
Q
What is a Coup-contracoup injury in TBI?
A
Injury at a point of impact and opposite point of impact
7
Q
What types of injury are considered secondary brain damage in TBI patients?
A
- Hypoxic-ischemic injury
- Swelling/ Edema
- Electrolyte imbalance of damaging neurotransmittersand mass release
8
Q
What is Hypoxic-ischemic injury in TBI?
A
Results from systemic problems (respiratory or cardiovascular) that compromise cerebral circulation
9
Q
What is the effect of swelling/edema in TBI?
A
Results in mass effect, with increased intracranial pressure, brain herniation (uncal, central, tonsillar), and death.
10
Q
What is a concussion
A
Loss of consciousness, either temporary or permanent, resulting from injury or blow to the head, with impaired functioning of the brainstem reticular activating system (RAS); may see changes in HR,RR,BP
11
Q
What are the different ways Brain Damage can be categorized as mild, moderate, or severe? Table 2-14 pg 153
A
- Loss of consciousness
- Alteration of consciousness
- Posttraumatic Amnesia
- Glasgow Coma Scale
- Imaging
12
Q
How is a TBI categorized as mild?
A
Loss of Consciousness: 0-30 min Alteration of Consciousness: brief;>24 hours Posttraumatic Amnesia: <1 day Glasgow Coma Scale: 13-15 Imaging: normal
13
Q
How is a TBI categorized as moderate?
A
Loss of Consciousness: >30 min but <24 hours
Alteration of Consciousness: >24 hours
Posttraumatic Amnesia: >1 day but <7 days
Glasgow Coma Scale: 9-12
Imaging: normal or abnormal
14
Q
How is a TBI categorized as severe?
A
Loss of Consciousness: >24 hours Alteration of Consciousness: >24 hours Posttraumatic Amnesia: >7 days Glasgow Coma Scale: <9 Imaging: normal or abnormal
15
Q
What are the standardized tests and measures used to evaluate patients with TBI?
A
- Glasgow Coma Scale (GCS)
- Rancho Los Amigos Levels of Cognitive Functioning (LOCF)
- Rappaport’s Disability Rating Scale (DRS)
- Glasgow Outcome Scale (GOS)
- High Level Mobility Assessment Tool (HI-MAT)
- Functional Independence Measure / Functional Mobility Skills (FIM/FAM)
16
Q
Details of the Glasgow Coma Scale
A
Allows classification of TBI into Mild (score 13-15), Moderate (score 9-12), or severe (<8) head injury (coma)
17
Q
Details of Rancho Los Amigos Levels of Cognitive Functioning (LOCF)
A
It delineates eight general cognitive and behavioral levels
18
Q
What are the recovery stages from diffuse axonal injury? (6)
A
- Coma
- Unresponsive vigilance/ vegitative stage
- Mute responsiveness/ minimally responsive
- Confusional state
- Emerging independence
- Intellectual/Social Competence
Note that the patient can plateau at any stage or regress under conditions of stress or repetitive brain injury
19
Q
Define coma
A
A state of unconsciousness in which there is neither arousal nor awareness; eyes remain closed, no sleep/wake cycle
20
Q
Define Unresponsive vigilance / vegetative state
A
Marked by the return of sleep/wake cycles and normalization of vegetative functions (respiration, digestion, BP control); persistent vegetative state is determined if patient remains in vegetative state > 1 year after TBI
21
Q
Define Mute responsiveness/ minimally responsive stage
A
State in which pt is not vegetative and does show signs, even if intermittent, of fluctuating awareness
22
Q
Define Confusional state
A
Mainly a disturbance of attention mechanisms; all cognitive operations are affected, pt is unable to form new memories; may demonstrate either hypoarousal or hyperarousal
23
Q
Define Emerging Independence
A
Confusion in clearing and some memory is possible; significant cognitive problems and limited insight remain; frequently uninhibited social behaviors
24
Q
Define Intellectual/social competence
A
Increasing independence although cognitive difficulties (problem solving, reasoning) persist along with behavioral and social problems (enhancement of premorbid traits, mood swings)
25
What should PTs look for when examining a patient with TBI?
1. Generalized signs of increased intracranial pressure
2. LOC using (GCS), cognitive function (LOCF), Disorders of learning, Attention, Memory and complex information
3. Cranial N function
4. Behavioral changes- examine for appropriate physical, verbal, sexual behaviors; poor judgment; irritability, low frustration tolerance, and aggression; impulsivity and safety issues; depressed mood; restricted affect.
5. Speech and communication
6. Sensory deficits
7. Motor function: paresis, apraxia (dyspraxia), reflexive behaviors, balance deficits, ataxia and incoordination (cerebellar damage common)
8. Functional Mobility Skills (FMS, ADLs
9. Level of general deconditioning; after prolonged hospilization (comatose, vegetative, decreased response levels), patients experience severe deconditioning and effects of prolonged immobilization (dissuse atrophy, contractures and deformity, skin breakdown)
26
What are some PT goals, outcomes and interventions used for patients with TBI
1. Monitor changes associated with recovery and inactivity
2. Management based on decreased response levels (LOCF 1-111)
3. Management based on Mid-level recovery (LOCF IV-VI)
4. Management based on high-level recovery (LOCF VII-VIII
5. Provide emotional support, encourage socialization, behavioral control and motivation
- Reorient and reassure
- provide pt and family education
27
Management of TBI patients based on decreased response levels LOC 1-111
1. Maintain ROM, prevent contracture development: PROM, positioning, splinting and serial casting
2. Maintain skin intergrity; prevent development of decubitus ulcers through frequent position changes
3. maintain respiratory status, prevent complications: postural drainage, percussion, vibration, suctioning to keep airway clear.
4. Provide sensory stimulation for arousal and to elicit movement: environmental and direct stimulation (auditory, visual, olfactory, gustatory, tactile stimuli)
5. Promote early return of FMS: upright positioning for improved arousal, proper body alignment
28
Management of TBI patients based on decreased response levels LOC 1V-V1
1. Provide structure, prevent overstimulation for confused, agitation patient: closed, reduced stimulus environment, daily schedules and memory logs; relaxation techniques
2. Provide consistency: use team-determined behavioral modification techniques, give clear feedback, written contracts
3. Engage pt in task specific training; limit activities to familiar, well-liked ones; offer options; break down complex tasks into component parts
4. Provide verbal or physical assistance
5. Control rate of instruction; provide frequent orientation to time, place, your name, and task.
5. Emphasize safety, behavioral management techniques
6. Model calm, focused behavior
29
Management of TBI patients based on decreased response levels LOC VI1-V111
1. Allow for increasing independence: wean patient from structure (closed to open environments); involve pt in decision making
2. Assist pt in behavioral, cognitive, emotional reintegration: provide honest feedback, prepare for community reentry
3. Promote independence in functional tasks: FMS, ADLs, in real-life environments
4. Improve postural control, symmetry, and balance
5. Encourage active lifestyle, improved cardiovascular endurance
30
What is the etiology of Spinal Cord Injury (SCI)?
Partial or complete disruption of spinal cord resulting in paralysis, sensory loss, altered autonomic and reflex activities
31
Traumatic causes of SCI
- Motor vehicle accident
- Jumps and falls
- Diving
- Gunshot wounds
32
What are the Mechanisms of Injury (MOI) for SCI?
1. Flexion - most common lumbar injury (Some discrepency- Score Builders states most commonly cervical)
2. Flexion-Rotation- most common cervical injury
3. Compression
4. Hyperextension
33
What are the spinal ares of greatest frequency of injury?
1. C5
2. C7
3. T12
4. L1
34
What are some non-traumatic causes of SCI?
1. Disc prolapse
2. Vascular insult
3. Infections
35
Pathophysiology of SCI- Primary & Secondary
- Primary injury interruption of blood supply
| - Secondary sequele: ischemia, edema, demyelination, and necrosis of axons, progressing to scar tissue formation
36
How is SCI classified?
- Level of injury: UMN injury
- Degree of injury
- Clinical Syndromes
37
How is SCI classified using- Level of injury?
1. Lesion level indicates most distal uninvolved nerve root segment with normal functions; muscles must have a grade of at least 3+/5 or fair+ function
2. Tetraplegia (quadraplegia): injury occurs between C1-C8, involves all 4 extremities and trunk
3. Paraplegia: injury occurs between T1 and T12-L1, involves both LE and trunk (varying levels)
38
How is SCI classified using- Degree of Injury?
1. Complete: no sensory or motor function below the level of lesion
2. Incomplete: preservation of sensory or motor function below level of injury; spotty sensation, some muscle function (<3+/5 grades)
3. American Spinal Injury Association (ASIA) Impairment Scale
39
What are the components of the ASIA Impairment Scale?
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A
B
C
D
E
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40
How is SCI classified using- Clinical Syndrome?
1. Central Cord Syndrome
2. Brown-Sequard Syndrome
3. Anterior Cord Injury
4. Posterior Cord Syndrome
5. Cauda Equina
6. Sacral Sparing
41
What does Asia A represent on the ASIA impairment scale
Complete, no motor or sensory function is preserved in the sacral segments S4-5
42
What does Asia B represent on the ASIA impairment scale
Incomplete: sensory but not motor function is preserved below the neurological level and include sacral segments S4-5
43
What does Asia C represent on the ASIA impairment scale
Incomplete: motor function is preserved below the neurological level, and most key muscles below the neurological level have a muscle grad of <3
44
What does Asia D represent on the ASIA impairment scale
Incomplete: motor function is preserved below the neurological level, and most key muscles below the neurological level have a muscle grade of 3 or more.
45
What does Asia E represent on the ASIA impairment scale
Normal: motor & sensory function is normal
46
What is Central Cord Syndrome?
- Loss of more centrally located cervical tracts/arm function, with preservation of more peripherally located lumbar and sacral tracts/leg function- Typically caused by hyperextension injuries to the cervical spine.
- Cavitation ofcentral cord in cervical section
- Loss of spinothalamic tracts with BLE loss of pain and temp
- Loss of ventral horn with BLE loss of motor function: primarily UE
- Preservation of proprioception & discriminatory sensation
47
What is Brown-Sequard Syndrome?
Hemisection of spinal cord typically caused by penetration wounds (gunshot or knife) with asymmetrical symptoms
- Ipsilateral loss of dorsal columns with loss of tactile discrimination, pressure, vibration, & propriocepton
- Ipsilateral loss of corticospinal tracts with loss of motor function & spastic paralysis below the level of the lesion
- Contralateral loss of spinothalamic tract with loss of pain & temp below the level of lesion; at lesion level, bilateral loss of pain and temp
48
What is Anterior Cord Syndrome?
Damage is mainly in anterior cord, resulting in loss of motor function, pain & temp with preservation of light touch, proprioception & position sense.- Typically caused by flexion injuries of the cervical spine
- Loss of lateral corticospinal tracts with BLE loss of motor function, spastic paralysis below level of lesion
- Loss of spinothalamic tracts with BLE loss of pain & temp
- Preservation of dorsal columns: proprioception, kinesthesia, and vibratory sense
49
What is Posterior Cord Syndrome?
Loss of posterior columns with preservation of motor function, sense of pain and light touch; extremely rare
- BLE loss of proprioception, vibration, pressure, and picritic sensation (stereognosis, 2 point discrimination)
50
What is Cauda Equina Syndrome?
Injury below L1 results in injury to lumbar and sacral roots of the peripheral N (LMN) with sensory loss & paralysis and some capacity for regeneration; an LMN lesion with autonomous or nonreflex bladder
- Variable N root damage (motor & sensory signs); incomplete lesion common
- Flaccis paralysis with so spinal reflex activity
Flaccid paralysis of bowel and bladder
Potential for nerve regeneration; regeneration often incomplete, slow and stops after about 1 year
51
What is Sacral sparing?
Sparing of tracts to sacral segments, with preservation of perianal sensation, rectal sphincter tone or active toe flexion
52
What is complete cord lesion?
- Complete bilateral loss of all sensory modalities
- Bilateral loss of motor function with spastic paralysis below level of lesion
- Loss of bladder & bowel functions with spastic bladder and bowel
53
What areas do PTs have to include during examination of SCI patients? (7)
1. Vital signs
2. Respiratory function: action of diaphragm, respiratory muscles, intercostals; chest expansion, breathing pattern, cough, vital capacity; respiratory insufficiency of failure occurs in lesion type above C4 (phrenic N C3-5 innervates diaphragm)
3. Skin condition, integrity: check areas of high pressure
4. Muscle tone and DTRs
5. Sensation/spinal cord level of injury: check to see if sensory level corresponds to motor level of innervation (may differ in incomplete lesions)
6. Muscle strength (MMT/spinal cord level of injury: lowest segmental level of innervation includes muscle strength present at a fair+ grade (3+/5); use caution when doing MMT in acute phase with spinal immobilization
7. Functional status: full functional assessment possible only when pt is cleared for activity & active rehabilitation
54
What are the standardized test and measures used in the examinitation of SCI patients? (2)
1. FIM/FAM
2. Wheelchair skills test provides for measurement of functional & wheelchair management skills for the patient who uses the wheelchair for primary mobility
55
What are PT goals, outcomes & interventions for SCI patients?(14)
1. Monitor changes associated with SCI & recovery
2. Improve respiratory capacity
3. Maintain ROM & prevent contracture
4. Maintain skin integrity, free of decubitus ulcers and other injury
5. Improve strength
6. Reorient pt to vertical position
7. Promote early return to FMS and ADLs
8. Improve sitting tolerance, postural control, symmetry, and balance; standing balance as indicated
9. Appropriate wheelchair prescription
10. Promote wheelchair skills/independence
11. Locomotor training for pts with complete injuries
12. Improve cardiovascular endurance
13. Locomotor training for pts with incomplete injuries
14. Promote max independence & mobility in home and community environment; asst. pt in community reintegration; ordering of proper equipment, home modification
56
What are the changes associated with SCI that PTs need to monitor for?
1. Spinal shock
2. Spasticity/ spasms
3. Autonomic dysreflexia (hyperreflexia)
4. Heterotopic bone formation (ectopic bone)
5. DVT- check LE for edema & tenderness
57
What changes do PTs look for when examining for spinal shock in SCI patients?
Transient period of reflex depression & flaccidity; may last several hours or up to 24 hours
58
What changes do PTs look for when examining for Spasticity/Spasms in SCI patients?
Determine location & degree of tone. Examine for nociceptive stimuli that may trigger inc. tone (e.g. blocked catheter, tight clothing or straps, body position, environmental temp, infection, decubitus ulcers
59
What changes do PTs look for when examining for Autonomic dysreflexia in SCI patients?
An emergency situation in which a noxious stimulus precipitates a pathological autonomic reflex with symptoms of paroxysmal hypertension, bradycardia, headache, diaphoresis (sweating), flushing, diplopia, or convulsions; examine for irritating stimuli; treat as a medical emergency, elevate head, check and empty catheter first.
60
What changes do Pts look for when examining for Heterotopic bone formation (ectopic bone) in SCI patients?
Abnormal bone growth in soft tissues; examine for early changes - soft tissue swelling, pain, erythema, generally near large joint; late changes-calcification, initial signs of ankylosis
61
What types of treatment should PTs implement with SCI patients to improve their respiratory capacity?
Deep breathing exercises, Strengthening exercises to respiratory muscles; assisted coughing, respiratory hygiene (postural drainage, percussion, vibration, suctioning) as needed to keep airway clear; abdominal support.
62
What types of treatment should PTs implement with SCI patients to maintain ROM and prevent contracture?
- PROM
- Positioning
- Splinting
- Selective stretching to preserve function e.g.
tenodesis grasp
63
What types of treatment should PTs implement with SCI patients to maintain skin integrity free of decubitus ulcers and other injury?
- Positioning program
- Pressure-relieving devices e.g. cushion, gel cushion,
ankle booth
- Patient education: pressure relief activities (e.g.
pushups) and skin inspection; provide prompt
treatment of pressure sores
64
What types of treatment should PTs implemento with SCI patients to Improve strength?
Strengthen all remaining innervated muscles; use selective strengthening during acute phase to reduce stress on spinal segments; resistive training to hypertrophy muscles.
65
What types of treatment should PTs implement with SCI patients to reorient pt to vertical position?
Tilt table, wheelchair; use of abdominal binder, elastic LE wraps to dec. venous pooling; examine for S&S of OH (lightheadedness, syncopy, mental or visual blurring, sense of weakness)
66
What types of treatment should PTs implement with SCI patients to promote early return to FMS & ADLs
Emphasis on independent rolling & bed mobility, assumption of sitting, transfers, sit-to-stand, & ambulation as indicated
67
What are the appropriate wheelchair prescription for patients with SCI? Think cervical levels (6)
1. Pts with high cervical lesions (C1-C4): require electric wheelchair with tilt in space seating or reclining seat back; microswitch or puff-and-sip controls; portable respirator may be attached
2. Pts with cervical lesions, shoulder function, elbow flexion (C5): can use manual wheelchair with propulsion aids e.g. projections; independent for short distances on smooth flat surfaces; may choose electric WC for distance and energy conservation
3. Pts with cervical lesions, radial wrist extensors (C6): manual WC with friction surface hand rims; independent
4. Pts with cervical lesions, triceps (C7): same as for C6, but with inc. propulsion
5. Pts with hand function (C8-T1 and below): manual WC, standard hand rims
6. Significant changes in lighter, more durable, sports-oriented chairs
68
What types of treatment should PTs do with SCI patients to promote WC skills/independence
Management of WC parts, turns, propulsion on all surfaces indoors and outdoors, safe fall out of and return to WC
69
What types of treatment should PTs do to improve locomotion for pts with complete SCI injuries with Mid-thoracic lesions (T6-T9) ?
Supervised ambulation for short distances (physiological, limited household amb); requires BLE KAFOs & crutches, swing -to gait pattern; requires assistance; may prefer standing devices/standing WC for physiological standing
70
What types of treatment should PTs do to improve locomotion for pts with complete SCI injuries with- High lumbar lesions (T12-L3):
Can be independent in ambulation on all surfaces and stairs; using a swing-through or 4 point gait pattern and BLE KAFOs & crutches. Pts may also use reciprocating gait orthosis with walker, with or without FES system. Typically independent household ambulators; WC use for community amb.
71
What types of treatment should PTs do to improve locomotion for pts with complete SCI injuries with Low Lumbar Lesions (L4-L5)?
Can be independent with BLE AFOs & crutches or canes. Typically independent community ambulators; may still use WC for activities with high endurance requirements
72
What types of interventions should PTs perform to improve cardiovascular endurance? when working with SCI patients
1. Monitor HR & BP during all exercise or progressive activity
2. Methods (complete injuries): arm crank ergometry; FES- leg cycle ergometry; hybrid: arm crank ergometry & FES- leg cycle ergometry; WC propulsion
3. Precautions: Ind. with tetraplegia & high-lesion paraplegia experience blunted tachycardia, lack of pressor response, & very low Vo2 peak, substantially higher variability of most responses.
4. Trunk stabilization and protection is important
5. vascular support may be needed- elastic stocking, ab binder.
73
What are the absolute contraindications to exercise testing and training of individuals with SCI
- Autonomic Dysreflexia
- Severe or infected skin on WB surfaces
- Sympathetic hypotension
- UTI
- Unstable Fx
- Uncontrolled hot & humid environments
- Insufficient ROM to perform exercise task
74
What types of locomotor training do PTs do for patients with incomplete SCI
1. treadmill training using body weight support
2. Progression: decrease BWS, increase treadmill speed, eliminate manual assistance
3. Progression to overground locomotor training for community amb.
75
Some details about treadmill training using BWS
- Indications: incomplete injuries- ASIA B,C & D
- Promotes spinal cord learning/activation of spinal locomotor pools
- Uses body harness to support weight; variable levels of loading from 35%, dec to 10%, to full loading
- During early training therapists manually assists with foot placement
- High frequency (4 days/ week); moderate duration (20-30 min); typically for 8-12 weeks
