Neuromuscular Unit 3 Exam Flashcards
an alteration in brain function or evidence of brain pathology caused by external force
traumatic brain injury (TBI)
what are some common causes of TBI?
falls
firearm injuries
motor vehicle crashes
assaults
what is a common cause of TBI that accounts for nearly half of TBI related hospitalization?
falls
leading cause of injury related death and disability
TBI
TBI incidence is highest in older ______ followed by infants and young adults/adolescents
older adults (>75)
men are ______ as likely as women to be hospitalized following a TBI
2x
do men or women have a higher rate of TBI related deaths?
men
what is the pathophysiology of a TBI?
result of a high velocity or high impact hit to the head leading to brain tissue damage
2 categories of brain tissue damage
primary injury
secondary injury
what the two mechanisms of primary injuries of TBI?
direct contact with an object
rapid acceleration/deceleration
primary injury mechanism that leads to focal brain damage
direct contact
TBI due to direct contact is between what two things?
skull and penetrating object
what are the four common areas of primary injury that result from direct contact mechanisms?
anterior temporal poles
frontal poles
lateral inferior temporal cortices
orbital frontal cortices
primary injury mechanism that causes sheer, tensile, and compressive forces in the brain
rapid acceleration/deceleration
sheer, tensile, and compressive forces in the brain lead to what injury?
traumatic axonal injury (TAI)
what other injury can occur with a TAI that signifies a severe brain injury where not only the axons are damaged but also the functional regions of the cortex are disrupted, often leading to significant cognitive impairments and neurological deficits
cortical disruption
why are changes in the brain due to a TAI difficult to view on a MRI or CT scan?
they are microscopic
common areas of TAI occurrence in the brain
corpus callosum
internal capsule
cerebral peduncle
brainstem
cell death following brain tissue damage
secondary injury of TBI
what are some examples of secondary injuries of TBI?
hypoxemia
hypotension
ischemia
edema
elevated ICP
what is the pathophysiology of a secondary TBI injury?
brain tissue damage triggers a cellular cascade causing cell death
release of glutamate and other excitatory neurotransmitters lead to increased brain swelling and therefore increased _____
ICP
blood pooling in the brain following a head injury
hematoma
3 hematoma classifications
epidural
subdural
intracerebral
what causes ICP to elevate?
swelling in the brain is confined by the rigidity of the skull
injuries that result from lack of oxygen to the brain caused by anoxia, hypotension, and damage to vascular areas of the brain
hypoxic ischemic injuries
main goal of early medical management of a TBI
maintain blood flood and oxygen delivery to the brain to reduce the risk of secondary injury
normal systolic BP
> 90 mmHg
normal O2 sats
> 90%
______ spine stabilized until ligamentous and/or bony injury can be ruled out
cervical
normal cerebral perfusion pressure (CPP)
> 60 mmHg
normal intracranial pressure (ICP)
< 20 mmHg
3 ways to monitor ICP
external ventricular drain
subdural bolt
fiber optic catheter
ICP should be monitored for individuals with any of these four things
GCS < 8
acute findings on CT scan
systolic BP < 90 mmHg
> 40 years of age
way to treat elevated ICP pharmacologically?
sedating medications
(example: Barbituates)
ways to treat an elevated ICP
HOB at 30 degrees
hypothermia
medically induced coma
surgical decompression
shunt placement
osmotherapy
imaging used initially following a TBI because it is fastest
CT scan
imaging used 24-48 hours following a TBI for higher sensitivity OR if initial scan was negative
MRI
3 neurosurgeries that may be needed for subdural hematomas or other lesions for ICP management
craniotomy
craniectomy
burr holes
removal of part of the skull bone with immediate replacement during the same surgery
craniotomy
a portion of the skull bone is removed and not immediately replaced
craniectomy
replacement surgery of the skull using the patient’s or other material such as titanium
cranioplasty
small holes are drilled in the skull to relieve pressure on the brain
burr holes
continued overactivity of the sympathetic nervous system following a TBI
paroxysmal sympathetic hyperactivity (PSH)
paroxysmal sympathetic hyperactivity (PSH) is also known as what?
sympathetic storming
% incidence of PSH
30%
symptoms of PSH
elevated HR, RR, and BP
diaphoresis
decerebrate/decorticate posturing
hypertonia
teeth grinding
development of bone
osteogenesis
abnormal development of bone in areas of soft tissue
heterotrophic ossification (HO)
HO most often occurs in what two joints?
hip and knee
clinically significant HO occurs in what percentage range of adult patients with TBI?
10-20%
individuals with _______ are at an increased risk of developing HO
spasticity
early symptoms of HO
swelling
ROM limitations
joint pain
redness/warmth
low grade fever
how can HO be managed pharmacologically?
NSAIDs
what limitation is important to address with physical therapy for patients with HO?
range of motion
_______ may be indicated for HO patients in cases of severe activity limitations
surgery
timeframe of immediate posttraumatic seizures
< 24 hours following TBI
timeframe of early posttraumatic seizures
1 to 7 days following TBI
timeframe of late posttraumatic seizures
> 7 days following TBI
mild GCS score
8 or less
moderate GCS score
9 to 12
severe GCS score
13 to 15
3 disorders of consciousness
coma
unresponsive wakefulness
minimally conscious state
complete absence of arousal or awareness with no sleep/wake cycle, ventilator dependent
coma
arousable to external stimuli but no awareness of self or environment, reflexive movement may be present
unresponsive wakefulness
self or environment awareness with spontaneous eye opening, inconsistently localize to stimuli
minimally conscious state
refers to the time after a TBI where the patient exhibits disorientation, confusion, and memory loss
posttraumatic amnesia (PTA)
what is the duration of PTA?
the length of time from injury to when a patient can consistently remember ongoing events
PTA duration is predictive of what four things?
functional independence
employment
overall recovery
independent living 1 year post injury
true or false: patients in PTA cannot benefit from rehab
false
PTA timeframe of a mild TBI
0-1 day
PTA timeframe of a moderate TBI
more than a day but less than a week
PTA timeframe of a severe TBI
more than 7 days
outcome measure to assess for recall of events preceding and following the injury
the galveston orientation and amnesia test (GOAT)
scores below ___ on the GOAT indicate PTA
75
outcome measure consisting of 10 questions assessing time, place, and circumstances
orientation log (O-log)
scores of ____ or higher on the O-log are considered WNL
25 out of 30 or higher
scores below ___ on the O-log indicate PTA
25
4 negative pronostic factors
low GCS score
age
CT showing mass lesions
prolonged PTA
what 3 ICF domains are impacted following a TBI?
body function/structure impairments
activity limitations
participation restrictions
mental process of knowing and applying information
cognition
scale to address behavioral and cognitive recovery post brain injury
Ranchos Amigos Levels of Cognitive Functioning (LOCF)
which Ranchos Amigos LOCF? patient is in deep sleep and is unresponsive to any stimuli
level I: no response
which Ranchos Amigos LOCF? patient reacts inconsistently and non purposefully to stimuli in a non specific manner
level II: generalized response
which Ranchos Amigos LOCF? patient reacts specifically but inconsistently to stimuli, may follow simple commands in an inconsistent delayed manner
level III: localized response
which Ranchos Amigos LOCF? patient is unable to cooperate directly with treatment efforts, incoherent or inappropriate words, heightened activity and bizarre behavior, no selective attention, lacks short + long term recall, may confabulate
level IV: confused agitated
which Ranchos Amigos LOCF? patient can respond to simple commands consistently, random response to complex commands, has attention to environmental but lacks focused attention to a task, words are confabulatory or inappropriate, memory is impaired, inappropriate use of objects, can perform old learned tasks but unable to learn new information
level V: confused inappropriate
which Ranchos Amigos LOCF? patient can demonstrate goal directed behavior but needs external input or direction, shows carry over for relearned tasks, follows simple directions consistently, past memories are showing up more in depth than recent memories, may have wrong answer to questions but inappropriate in answers
level VI: confused appropriate
which Ranchos Amigos LOCF? patient has minimal to no confusion, oriented and demonstrates appropriate behavior in structured and familiar environments, able to go through structured routines automatically, shows carry over of new learning but requires additional time, able to participate in structured social and recreational activities, demonstrates impaired judgement
level VII: automatic appropriate
which Ranchos Amigos LOCF? patient demonstrates carry over of new learning, no supervision is required once task is learned, able to recall past and recent events, patient may have difficulty with abstract reasoning, tolerance to stress, and judgement in emergency or unusual circumstances in comparison to premorbid abilities
level VIII: purposeful appropriate
what two levels were added to the Ranchos Amigos LOCF to reflect higher levels of brain injury recovery?
level IX: purposeful appropriate with stand by assist on request
level X: purposeful appropriate modified independent
long term impact of TBI on health has correlations to what two types of diseases?
neurodegenerative and psychiatric
what are examples of neurodegenerative diseases that are correlated to TBI?
Parkinson’s disease
Alzheimer’s disease
frontotemporal disease
chronic traumatic encephalopathy (CTE)
what are examples of psychiatric diseases that are correlated to TBI?
depression and anxiety
what 3 things are used to diagnose TBI severity?
LOC
AOC
PTA
LOC duration for moderate TBI
> 30 minutes
< 24 hours
LOC duration for severe TBI
> 24 hours
AOC duration for moderate and severe TBIs
both > 24 hours
PTA duration for moderate TBI
1 to 7 days
PTA duration for severe TBI
> 7 days
possible signs of cognitive and physical fatigue
irritability
decreased attention
initiation delay
decreased focus
worsening physical skills
early mobilization < ___ hours after surgery is shown to reduce hospital stays and reduce the risk of secondary complications
< 72 hours
contraindications to early mobilization
spine instability
elevated ICP
low CPP
precautions to early mobilization
wounds
weight bearing restrictions
joint integrity
autonomic instability
fluctuating cardiovascular symptoms
upright posture encourages _________
alertness
with acute TBI, head of bed should not be lower than 30 degrees for what purpose?
ICP
true or false: early mobilization is beneficial for patients with disorders of consciousness
true
what are some possible progressions of early mobilization?
sitting EOB
wheelchair transfers
supported standing
tilt table
walking
______ can be medically managed with Amantadine
arousal
for patients with decreased alertness and arousal levels, should treatment be done in an open or closed environment?
closed
bed positioning should be changed every __ hours to prevent bed sores and off weight pressure areas
every 2 hours
maintaining range of motion prevents _________, which can occur due to immobility and spasticity
contractures
therapists may consider positioning static ______ to maintain range of motion
splints
what is serial casting?
immobilizing a joint at end range in a cast for 2 to 5 days at a time, further stretching is performed and a new cast is set with new end range of motion until significant gains in range of motion are made
serial casting is often indicated for _________ or _______ contractures due to spastic posturing
plantar flexors or biceps
injection for focal management of spasticity
botulinum toxin (botox)
how long does botox last?
3 to 4 months
how do botox and oral medications manage spasticity differently?
botox: local
oral: widespread
examples of oral medications that manage spasticity
Baclofen
Diazepam
Dantrolene
what is the side effect of oral medications when treating spasticity that is the opposite goal of physical therapy?
drowsiness (decreased arousal)
pump inserted in the abdomen that delivers medication directly into the spinal cord to manage severe spasticity
Baclofen pump
why might a baclofen pump be used over an injection?
allows for a higher dosage of
surgery for contracture management due to severe spasticity
musculotendinous surgery
type of wheelchair that is necessary for a patient with poor head + trunk control because it positions them upright, can also tilt for pressure relief
tilt in space wheelchair
how often should a patient change positions in a wheelchair?
every 15 minutes
wheelchair progression from a tilt in space wheelchair
K005 ultra light weight wheelchair
type of wheelchair that allows for customized trunk support and cushions based off sensation, ability to weight shift, and pelvic alignment
K005 ultra light weight wheelchair
poor ______ can place a patient at a risk for repeat head injury
balance
_____ ______ impairments can lead to decreased walking speeds and balance deficits
dual task
common vision problem post TBI that can contribute to worsening balance
diplopia
what sensory system commonly experiences dysfunction post TBI causing dizziness (BPPV)?
vestibular system
in regards to aerobic conditioning, what is the TBI population at high risk of?
deconditioning
ACSM guidelines for aerobic conditioning post stroke + TBI
3-5 days a week
40-70% of HRR
20-60 minutes/session
ACSM guidelines for resistance training post stroke + TBI
2 days/week
1-3 sets of 8-15 reps
50-70% of 1RM
_________ of healthcare providers, routine, family members, and of addressing inappropriate behaviors is important when treating confused and agitated patients
consistency
expect limited _________ in confused and agitated patients, meaning no new learning
carryover
in confused and agitated patients, focus on functional activities for ______ of tasks
automaticity
progressive autoimmune disease that has inflammation, demyelination, and gliosis characteristics (can be acute or chronic)
multiple sclerosis
approximately how many people in the US have multiple sclerosis?
400,000
true or false: multiple sclerosis is genetic
true (MS risk increases with an affected family member)
MS onset usually occurs between what years of age?
20-50 years
is MS more common in men or women?
women (2:1) > men (3:1)
true or false: MS is common in children
false
who has a worse prognosis: younger age or older age
older age
do men or women have a more progressive disease course and greater disability?
men
MS affected predominantly what race population?
white (also in asians and native americans)
what are the 3 geographical frequency categories of MS?
high frequency: farther from equator
medium frequency: closer to equator
low frequency: tropical areas
what is the pathophysiology of MS?
an abnormal immune-mediated response attacks the myelin nerve coating, the oligodendrocytes, and the nerve fibers themselves within the CNS
a disruption of myelin slows neural transmission and causes what to happen to the nerves?
fatigue more quickly
activation of immune cells that cross the blood brain barrier initiate an inflammatory cascade of events that contributes to overall fluctuations in function is called what?
relapse
as attacks continue, what happens to the anti-inflammatory process?
becomes less effective
MS disease course is highly variable and therefore _______
unpredictable
four clinical description subtypes of MS
relapsing remitting (RRMS)
secondary progressive (SPMS)
primary progressive (PPMS)
progressive relapsing (PRMS)
what is the worst form of MS?
progressive relapsing (PRMS)
what is the most common disease course of MS?
relapsing remitting (RRMS)
relapsing remitting MS affects approximately what % of patients with MS?
85-90%
what form of MS is characterized by discrete attacks or relapses followed by remissions?
relapsing remitting
most individuals with RRMS transition to what other form of MS?
secondary progressive (SPMS)
what form of MS begins with a relapsing remitting course followed by progression to steady and irreversible worsening of neurological function + accumulation of disability?
secondary progressive
what are some further classifications of SPMS?
active or not active
with progression or without progression
evidence of disease worsening on an objective measure of change over time, with or without relapse
progression
less common form of MS that occurs in 15% of cases, characterized by continuous worsening of the disease from the onset without distinct attacks
primary progressive
worst form of MS that is characterized by progressive accumulation of liability from onset with clear, acute clinical attacks occur
progressive relapsing
true or false: a patient with PRMS may or may not have a full recovery
true
new and recurrent MS symptoms lasting longer than 24 hours but generally of longer duration, unrelated to another etiology
exacerbation
what are some factors to avoid exacerbation?
deterioration of health
viral or bacterial infections
major organ disease symptoms
stress (minor + major)
what is a temporary worsening of MS symptoms that comes and goes very quickly (24 hours)
pseudoexacerbation
how does pseudoexacerbation resolve?
cooling off and/or fever resolution
pseudoexacerbations are commonly associated with what phenomenon?
uthoff’s phenomenon
what is the uthoff’s phenomenon?
adverse reaction to head that leads to dramatic reduction in function and increase in fatigue
