Neuromuscular Unit 11 TBI and Ataxia Flashcards
With Brain Injury, what are the 2 specific mechanisms?
- Anoxic Brain Injury: Oxygen deprivation to the brain (such as a stroke or heart attack)
- TBI: Brain injury caused by direct blunt trauma from external forces, rapid acceleration/decelertion, or from explosion
-Primary: direct tissue damange
-Secondary: subsequent event after inital truama
What is the Pathophysiology of TBI?
Primary Brain injury-damage occurs at the moment of impact, they may exhibit:
- Focal Brain Injury
–Coup-contrecoup injury
–Polar Brain Injury - Blast Injury
- Diffuse Axonal Injury (DAI)
With TBI, what is a Focal Brain Injury?
Coup-Contrecoup Vs Polar Brain injuries.
These injuries occur at the site of impact. Damage may take the form of a contusion or laceration or both.
- Coup-contrecoup: If the brain is hit hard enough, the brain will bounce and make contact with the skull at the opposite site of the local brain damage. (Coup=the injury that occurs within the first point of contact. Contrecoup= the injury on the opposite side)
- Polar Brain injury: Occurs in response to an acceleration, deceleration as well as rotational forces (Common in head on collisions), the frontal and temporal lobes are most susceptible to injury
One of the medical management for TBI is the monitoring of ICP. What is normal ICP and when is it a red flag or a danger?
- Normal ICP is 4-15 mmHG
- After TBI, 15-20 mmHG is expected
- > 25mmHG is a Red Flag and measures will be taken to reduce the pressure
- Danger >40mmHG because impaired blood flow to the brain can cause secondary injury
If ICP goes above 20mmHG notify the nurses &/or doctor and modify intervention
If ICP goes above 30mmHG immediately STOP all interventions and notify nurses and doctors
What are some of the Manifestations a TBI patient may present with?
- Motor and Sensory Impairment
- Cognitive Impairment
-Coma
-Vegitative state
-Minimally consious state - Behavioral changes
-Aggression/Agitation
-Emotional lability
-Apathy
TBI OM
What is the Glascow Coma Scale?
- A scale that looks at 3 responses: Motor, Verbal and Eye opening
- Score of < 8 are characterized as severe
- Low GCS scores have been associated with poor prognosis
Score betwenn 13-15 are characterized as Mild Injury
TBI OM
What is the Rancho Los Amigos (RLA)?
It assesses the Levels Of Cognitive Functioning (LOCF)
I. No response
II. Generalized Response
III. Localized Response
IV. Confused-Agitated
V. Confused-Inappropriate
VI. Confused-Appropriate
VII. Automatic-Appropriate
VIII. Purposeful-Appropriate
The first 3 are severe disorder of consciousness on the Coma Recovery Scale (coma, vegetative, MCS)
Multidisciplinary Management after TBI
What is the Physicans Role with TBI patients?
They manage meds. and important info regarding hormonal levels, BP regulations, etc
Multidisciplinary Management after TBI
What is the SLP Role with TBI patients?
They handle the responsibility of verbal and non-verbal communication, as well as comprehension and swallowing
Multidisciplinary Management after TBI
What is the OT Role with TBI patients?
They are concered with the patients return to activites that are necessary for normal everyday functioning, toileting, bowel and bladder management, dressing, eating, grooming, driving, a
Multidisciplinary Management after TBI
What is the Nurses Role with TBI patients?
With TBI patients, they can help with ICP difficulties, possible feeding abnormalites when the patient has a G-tube or a PEG.
Multidisciplinary Management after TBI
What is the Case Manager and Social Workers Role with TBI patients?
They will usually lead the team meetings and will coordinate the payments to insurance and other third party payers. They are also patient advocates that can assist in obtaining other means of compensation, counseling and finding opportunities for support groups
Multidisciplinary Management after TBI
What is the Neuropsychologist Role with TBI patients?
They are important to decide the ultimate ability for the patient to resume work or household related functions. From a cognitive and behavioral standpoint
Multidisciplinary Management after TBI
What is the Respiratory Therapist’s Role with TBI patients?
They are often an important player in the Acute stage as the patient may need assistance with breathing activities beyond a ventilatory or needs specific sectioning
- Also at times, if a fragile patient needs to be transferred for therapy and that patient is on a ventilator, the respiratory therapist may attend the beginning and end of the session
With PT Management, what must be done at the Evaluation?
- Thorough history and chart review
-Double check weight bearing status, vitals, orthostasis, co-morbidities (wounds), ICP
-Double check swallowing status - Normal evaluation components (ROM, strength, sensation, integumentary check, reflexes, mobility, etc)
With PT Management, what must be done at the Plan of Care?
- Set according to a multidisciplinary model of care
- Utilizing recovery vs. compensatory strategies
With PT Management, what must be done at the Interventions?
- Decreasing possibility of secondary complications
- Initiate mobility early (as tolerated by the patient from a safety standpoint)
- Environment
When designing Interventions with TBI patients, what must we consider?
- Motor learning/Motor control (Practice schedule/Feedback schedule)
- Motivation
- Recovery vs. Compensatory
- Task specific/Neuroplasticity
- Patient/Caregiver education
When designing Interventions Modifications may need to be made, what modifications may be made with Moderate to Severe Brain Injury?
- When the pt is not able to focus for a long period of time also they may emulate the behaviors of the therapist to find a normal, remaining calm will help provide a model of the behavior that is expected
- Try to remain consistent, frustration levels will increase if inconsistency occurs. This related to scheduling day-to-day interactions, this can also reduce anxiety
- Choices are good to engage with patients in order to allow them to have a small bit of control over a situation
- These patients will have limited carryover, setting expectations too high will undoubtedly frustrate your patient and lead to decreased participation during therpay
When designing Interventions Modifications may need to be made, what modifications may be made with Mild Brain Injury?
- These patient may respond to higher level interventions such as dual tasking or initial return to play intervnetions.
- Return to play interventions, however need to be approached with a strict precaution to avoid the reoccurrence of sx
TBI OM
What is the HiMAT OM?
This is an OM for those higher level functioning patients, that looks at high level balance and mobility
- The requirement for the HiMAT is independent ambulation of at least 20 meters
TBI OM
What is the Community Balance and Mobility Scale?
This is an OM used for higher level individuals
- Recommended by the TBI EDGE
- This OM unlike the HiMAT allows the individuals to wear orthotics, but also requires them to ambulate without any ADs
What is Community Re-Integration for TBI patients? What is the Community Integration Questionnaire?
These are facilities that focus on training individuals to return to their normal or near normal activities within the community
- The community Integration Questionnaire is an OM primarily in the outpatient or home health setting to grade the individuals ability to return to living an independent lifestyle
Disorders of Consciousness (DOC)
How will a patient in the Coma state of consciousness present?
This is also the 1st stage of the Rancho Los Amigos Level of Cognitive Functioing Scale
Disorders of Consciousness (DOC)
How will a patient in the Vegetative state of consciousness present?
This is also the 2nd stage of the Rancho Los Amigos Level of Cognitive Functioing Scale
Disorders of Consciousness (DOC)
How will a patient in the Minimally Conscious state of consciousness present?
This is also the 3rd stage of the Rancho Los Amigos Level of Cognitive Functioing Scale
Addressing pt with severe disorder of consciousness
With Disorders of Consciousness (DOC), what is The Coma Recovery Scale-Revised (CRS-R) OM?
This is a 23-item measure with 6 subscales
- Auditory, Visual, Motor, Oromotor, Communication and Arousal
- Score range from 0 - 23
- This is useful in distinguishing between different states of consciousness (Vegitative state, Minimally conscious state, and Emerging), determining the prognosis, and informing treatment planning
Wht is the Disorders of Consciousness Scale (DOCS) - DOC-23 & DOC-25 OM?
This is a scale designed to measure arousal and neurobehavioral recovery in patients with disorders of consciousness
- Consist of 23 or 25 items, which assess social knowledge, taste/swallowing, olfactory function, proprioception, tactile sensation, auditory function and visual function
- Scoring is based on the patients response and includes no response, generalized response or localized response
- The DOCS can be used to differentiate states of consciousness (vegitative state and minimally conscious state) and assist in determining prognosis for recovery
With Disorders of Consciousness (DOC), what is the PTs role and treatment for these patients?
Early Mobilization
- This will improve overall outcomes
** Treatment options**
- Out of bed activities: positioning in wheelchair; standing program (tilt table and standing frame); body weight support system (standing or gait)
- Postural control activites: sitting balance activities as edge of mat / bed
- Sensory stimulating activites: goal of challenging the Reticualr Activating System
Considerations
- Monitor vitals (patients stability)
- Use of C-Collar to assist with head control
- Co-treatment
With Disorders of Consciousness (DOC), what is the PTs role and treatment for these patients when it comes to preventing secondary impairments?
Secondary impairments include: contractures, decubiti, pneumonia, and DVTs
Treatment
- Proper positioing in bed and wheelchair
-Effective use of positioning devices (e.g., cushions, back rest)
-Turing schedules (Common turning schedules are 2 hours in bed and 15 min in a wheelchair)
-ROM activites, this includes all positions not just supine, we want to get them sidelying and/or prone if safe
-Splinting
-Serial Casting, for those with significant spasticity that allows for prolonged ROM for one to two days at a time (they can be removable)
With Disorders of Consciousness (DOC), what is the PTs role and treatment for these patients when it comes to Family Education?
- Discussion of prognosis - one/united interdisciplinary message
- Difference between purposeful and reflexive response
- ROM program
- Turning / Repositioning schedules
- Functional Mobility: Bed mobility and transfers
As the patient transitions out of Disorder of consciousness they will transition to the 4th level and up of the Rancho Los Amigos levels of consciousness? What S/S will they present with?
- Heightened state of activity
- Behavior is bizarre and nonpurposeful relative to immediate environment
- Does not discriminate among persons or objects
- Unable to cooperate directly with treatment efforts
- Verbalizations frequently are incoherent and/or inappropraite to the environment
- Confabulation may be present
- Restless
- Abusive
What are the characteristics of RLA level 4 (Confused/Agitated)
What are the characteristics of RLA level 5 (Confused, Inappropriate, Non-agitated)
What are the characteristics of RLA level 6 (Confused, appropriate)
How do we manage those in RLA 4-6?
- Safety, safety, safety (Not just with a gait belt)
- Creating a safe environent (physical)
- Behavioral management plans
What is the Agitated Behavior Scale (OM)?
This is an interdisciplinary tool that is utilized 24 hours a day with these patients
- When the patient shows any form of agitation we will document it
- 14 item, score 1 - 4
What is the Behavior Management Plan?
- Identification of trigger using Agitated Behavior Scale (ABS), (> 2 in any area)
- Interdisciplinary plan to prevent the triggers
- The primary focus of this conversation is to try to identify the triggers that are leading to agitation
With the Behavior Management Plan, what are ways to manage Acute Agitation?
- De-escalation
- Medical treatment (last resort)
-This leads to “snowing” of patient
-Slows neuroplastic changes
With the Behavior Management Plan, what must we consider when preparing our environment?
- The ability to call for assistance
- Managing distractions/triggers
- Dangerous object (that the pt. can grab and throw)
- Lock down units
What are the characteristics of RLA level 7 (Automatic, Appropriate)
What are the characteristics of RLA level 8 (Purposeful, Appropriate)
How do we manage those RLA patients in level 7 and 8?
- Start to break away from structure (pt might appear robotic in nature)
-practice changed to mass and variable - Can start to learn new things
- Challenge higher level balance / coordination / return to participation activities (with A)
- Demonstration of carryover with new tasks is overall goal
- Community re-intergration
With the Cerebellum, what does the Medial Zone do?
Afferent sensorimotor state of the limbs. Efferent output of posture, muscle tone, upright stance, locomotion and in gaze
With the Cerebellum, what does the Intermediate Zone do?
Controls coordination of agonist-antagonist muscle pairs during variety of movement - walking and limb control
With the Cerebellum, what does the Lateral Zone do?
Controls complex, mutlijoint voluntary limb movement, especially with visual guidance; planning of complex movements and error detection
What is the Normal Function of the Cerebellum?
- Responsible for the following function related to movement:
-Coordination of movement
-Adaptations of movement
-Vestibular
-Balance
-Motor learning - Connections to non-motor regions of the brain have been established
-Prefrontal cortex
-Impacts cognition - memory, emotional regulation, language processing
With Etiologies of Cerebellar Pathologies, what are examples of Acquired cerebellar damage?
With Etiologies of Cerebellar Pathologies, what are examples of Degenerative Non-Hereditary cerebellar damage?
With Etiologies of Cerebellar Pathologies, what are examples of Hereditary cerebellar damage?
What are the typical impairment from a Superior Cerebellar Stroke?
Dysmetria of ipsilateral arm, unsteady walking, dysathria, nystagmus
What are the typical impairment from a Anterior Inferior Cerebellar Stroke?
Dysmetria, Vestibular Signs, facial sensory loss
What are the typical impairment from a Posterior Inferior Cerebellar Stroke?
Vertigo, unsteadiness, walking ataxia
With Cerebellar Strokes, when is recovery best?
Recovery is best when the deep cerebellar nuclei are not involved
What are the characteristics of Cerebellar Brain Tumors?
- More common in children than adults
- Common location: Posterior Fossa
- Recovery of function and axatix movement: Children > Adults (Poorer prognosis in adults)
- Damage of the deep cerebellar nuclei may also predict recovery > age
With Hereditary Autosomal Dominant etiologies, what are Spinocerebellar Ataxias (SCA)?
- There are onset is mid-later life
- Genetic counseling needed before testing
- No pharmacological intervention
With Hereditary Autosomal Dominant etiologies, what are Episodic Ataxias?
- These are brief bouts of ataxia usually due to excitement, stress or exercise
- May respond to medications
- Episodes may last minutes to hours
What are the PT Examination Considerations when examining a patient with Cerebellar Ataxia?
Non-Progressive or Progressive
- Non-progressive: Recovery/Restorative
- Progressive: Health Promotion/Compensatory
What are the Motor and Non-Motor impairments present with Cerebellar Damage?
Ataxia is going to be the primary sign of damage; “Drunken gait”
- Rebound effect (aka Lack of check) is the inability to rapidly halt movement after isometric force is released
What is the classic presentation of Ataxic gait?
- Imbalanced - leads to falls backward or ipsilesional
- Shortened step
- Slow
- Irregular timing
- Unequal step length
- Wide BOS
What is the difference between Imbalance and Leg incoordination?
Both are critical elements of walking ➡️ stability during dynamic mobility while maintaining forward propulsion
- Imbalance has much greater impact on gait than leg coordination
- Patients with minimal balance deficits but (+) with leg incoordination present with less gait abnormalities
With the Examination, what should we check during the Systems Review?
- Fatigability: cerebellar damage leads to increased effort of movement
- Cardiovascular endurance: 2 or 6 min walk test, sustained aerobic workload monitoring vitals and RPE
- MSK endurance: Max repititions recorded of various muslce groups before reduced force or ROM observed
With the Examination, what are Key Differences with Body Structure and Function domain of ICF?
With the Examination, what may we find with Activity Limitations?
With Diagnosis Specific Cerebellar Ataxia OM, what is the International Cooperative Ataxia Rating Scale (ICARES)?
- Looks at activity on the ICF
- 19 task - 4 categories
-Postural limb
-Limb movements
-Speech
-Occulomotor - Ordinal scale (0-100)
- Reliable and valid for progressive and non-progressive ataxia
With Diagnosis Specific Cerebellar Ataxia OM, what is the Scale for the Assessment and Rating of Ataxia (SARA)?
- Looks at activity on the ICF
- Quantifies performance, not categorized
- 8 item (similar to CARES)
- Ordinal scale (0-40)
- Reliable and valid for SCAs
(SCAs: Spinocerebellar Ataxia)
What is the Prognosis for Non-Progressive Ataxia?
- 1st time ischemic cerebellar stroke = recovery is excellent
- 83% minimal to no residual deficit
What is the Prognosis for Progressive Ataxia?
- Progressively worsening clinical signs and symptoms
What does the evidence suggest to do for interventions when the treatment focus/approach is Gait and Balance Training?
What does the evidence suggest to do for interventions when the treatment focus/approach is Aerobic and Resistive Exercise?
What does the evidence suggest to do for interventions when the treatment focus/approach is Intensity and Duration of intervention - Longer?
What does the evidence suggest to do for interventions when the treatment focus/approach is Compensatory Strategies?
What does the evidence suggest to do for interventions when the treatment focus/approach is Biofeedback/EMG?
What does the evidence suggest to do for interventions when the treatment focus/approach is Transcranial Magnetic Stimulation / Direct Brain Stimulation?
What does the evidence suggest to do for interventions when the treatment focus/approach is Weighting?
What does the evidence suggest to do for interventions when the treatment focus/approach is Reducing upper limb tremor and ataxia?
What does the evidence suggest to do for interventions when the treatment focus/approach is Promote independence of mobility?
If the patiet has Poor Coordination and grading of Muscle Power, what sould the treatment focus be?
Reduce the degrees of freedom, external device, postural control
If the patient has reduced adaptability in environment, what should the treatment focus be?
Graded exposure, sensory cues, conscious attention
If the patient has reduced automaticity of walking, what should the treatment focus be?
Stepwise prompts, high reps, conscious attention
If the patient has Reduced postural control, tone, and tremor, what should the treatment focus be?
High intensity and conscious attension
If the patient has altered timing of stepping, what should the treatment focus be?
- Specific strength and balance, compensation, env cues, aids
- Avoid dual task, conscious attention to gait
What is the treatment focus with SCA?
Strength/balance, walking aids, cortically control walking, cues
What is the treatment focus with VCA?
Compensatory head fixing or retain VOR, strength/balance
What is the treatment focus with CCA?
Retrain gait in all functional environments, avoid obstacles
