TBI Flashcards
Objectives
- Identify physical, cognitive and behavioral deficits common to Traumatic Brain Injured (TBI) patients.
- Explain the role of an interdisciplinary team for rehabilitation of the TBI patient.
- Discuss various clinical rating scales used with TBI patients.
fyi
Resistance of a muscle to passive elongation or stretch
Tone
Hypertonic motor disorder characterized by velocity-dependent resistance to passive stretch; often the result of an upper motor neuron lesion
Spasticity
Hypertonic state characterized by uniform resistance that persists the whole range of motion and is independent of the velocity of the movement; seen in disorders of the basal ganglia (leadpipe)
Rigidity
TBI
Patient care:
- Wide continuum of care; ICU, acute hospitalization, rehab center, community reentry, outpatient, schools, voc rehab, assisted living
- Need strong team concept
- Leading cause of death and disability in young adults
- 50,000 will die due to a TBI each year
- 230,000 will be hospitalized
- 80,000 to 90,0000 people will develop intellectual, behavioral and/or physical disabilities
- MVA: ½ of all TBI, ¼ falls, 15% assaults and violence, 10% sports and recreation
- Men more often than women
- Average: age 15-24
TBI-Epidemiology
- Can have a variety of mechanisms, as mentioned -external forces act on brain tissue
- Acceleration, deceleration and rotational forces of brain relative to bony skull
- Forces can be compression, strain, shearing and displacement
TBI- Pathophysiology
- Local injury to area of brain under site of impact
- Multiple types of injuries: hematoma, edema, contusion. Laceration
- Can have coup-countercoup injury: the brain “bounces”
- Common sites of focal brain injury: anterior-inferior temporal lobes and prefrontal lobes
TBI- Focal injury
- caused by acceleration, deceleration and rotational forces
- Results in shearing and retraction of damaged axons
- Diffuse axonal injury can cause coma
Diffuse axonal injury
- Result from lack of oxygenated blood flow to brain tissue
- Caused by systemic hypotension, anoxia or damage to specific vascular areas of the brain
- Can see global damage
- Associated with poor cognitive function
Hypoxal-Ischemic injuries
If brain swells or fluids increase; what happens to the brain?
- Increased intracranial pressure
- Hematoma
- Mild increase in ICP can cause increased morbidity
- Can see secondary cell death: when there is tissue damage there can be cellular events that follow that create cell death
- MRI and CT
- Also, PET (positron emission tomography) SPECT (single photon emission computerized tomograpy) and fMRI (functional MRI)
- MRI better than CT in terms of soft tissue injuries
- PET, SPECT, fMRI: detect regional blood flow
TBI- Diagnosis
Wide range of neuromuscular, cognitive and behavioral impairments: lead to functional limitations and disability
Sequelae of TBI
- Can present with abnormal tone
- Primitive postures: decorticate and decerebrate rigidity
- Decorticate: UE flexed, LE extended: upper brainstem injury
- Decerebrate: UE and LE extended: lesion in brainstem between vestibular nucleus and superior colliculus
- Will see spasticity
TBI-Neuromuscular Impairments
UE flexed, LE extended: upper brainstem injury
DECORTICATE OR DECEREBRATE
DECORTICATE
UE and LE extended: lesion in brainstem between vestibular nucleus and superior colliculus
DECORTICATE OR DECEREBRATE
Decerebrate
Change in light touch, pain, deep pressure, temperature
Proprioception and kinesthesia may be impaired
Alteration in sensations from Neuromuscular Impairments
- Altered level of consciousness: occurs with acceleration-deceleration injuries and some focal injuries
- COMA: can’t obey commands, can’t utter words, can’t open eyes
- Glasgow Coma Scale: help to identify coma
- Scores < 8 is severe brain injury
- 9-12 moderate brain injury
- 13-15 mild brain injury
- Rancho Los Amigos Levels of Cognitive Functioning
Cognitive impairments of Neuromuscular Impairments
I am able to respond to your simple commands. When my mother walked in the room, I was easily distracted and then began to ramble about something that appeared off subject. I could not remember what you had just instructed me to do.
what level of RLA
Rancho Los Amigos
5
confused- inappropriate
I am responsive to speech; I follow most motor commands and I attempt to talk though my speech is confusing and not well put together. My score = ??
Glasgow coma scale - you’ll need to look up
take a look
- Severely altered consciousness
- Minimal self or environmental awareness
- Will localize noxious stimuli
- Will reach for objects
- Altered LOC
Minimally conscious state of TBI
unresponsive state: pt can be aroused for brief periods of time
Stupor
sleeps often, when aroused exhibits decreased alertness and interest in environment with delayed reactions
Obtunded
- Retrograde amnesia
- Anterograde amnesia
- Posttraumatic amnesia:
TBI Memory
time between injury and time when pt is able to remember ongoing events
Posttraumatic amnesia
recall facts and previous events
Used to explicitly learn
Declarative memory
- How to do motor tasks
- Implicit learning
Procedural memory
- Habits
- Don’t require a lot of conscious thought
- Learn by lots of practice
Implicit learning OF TBI
- Problems with hyperactivity, impulsiveness
- Unable to focus, easy to distract
- Difficult for pt to attain functional skills
- Poor safety awareness
- Executive function cognitive skills may be impaired: volition, planning, purposive action, effective performance
Patient with TBI- Difficulty with attention
- Can be most socially debilitating
- Sexual disinhibition, low frustration tolerance, emotional disinhibition, apathy, aggressive tendencies, depression
- Neuropsychologists treat behavioral disorders
Behavioral Impairments
Can have multiple deficits: reading, writing, aphasia, language skills, dysarthria
Communication Impairments
- Cranial nerve or occipital lobe damage
- Hemianopsia or cortical blindness
- Spatial neglect (inability to report, respond, or orient to stimuli), apraxia (loss of the ability to execute or carry out learned purposeful movements)
Visual-perceptual
Dysphagia
Swallowing impairments
Indirect impairments OF TBI
- Contractures
- Skin breakdown
- DVT
- Heterotropic ossification
- Decreased bone density
- Muscle atrophy
- Decreased endurance
- Infection
- Pneumonia
Galveston Orientation and Amnesia Test
Measures posttraumatic amnesia (PTA)
Ask standardized questions
Score 76-100 is normal
DONT NEED TO KNOW JUST FYI
FYI
Rappaport’s Disability Rating Scale
Classify disability: death to no disability
Tracks progress well (coma to community)
Score: 0-29 (30= death)
DONT NEED TO KNOW -FYI
FYI
measure functional mobility
FIM
measures areas in stroke and TBI
FAM
- Difficult to determine
- Severity of injury, duration of coma and length of PTA are important predictors
- Coma > 2 weeks: moderate to severe disability
- PTA > 12 weeks: moderate to severe disability
OUTCOMES OF TBI
- Early treatment is important in outcomes
- Use Glasgow early: helps determine level of severity
- Monitoring of intracranial pressure
- Can have many complications which interfere with rehab
- Pay attention to medications being used and possible side effects
Medical management OF TBI
- Range of facilities depending on recovery: minimally conscious or coma, those who are beginning to recover: nursing home, acute, in-pt rehab, skilled nursing, long term care, community based
- Work with interdisciplinary team: share skills, findings with team members
Rehabilitation FOR TBI
- Pt and family
- Need to know family dynamics, what pts hobbies, likes and dislikes are, what does the pt do (school, work)
- Educate family on process
- Educate on HEP and process that will occur with motor function
- Physician
Physiatrist and/or neurologist
neuropharmacology
- *
The team FOR TBI REHAB
Treats communication, swallowing and cognitive impairments
Instrumental in determining best way to communicate with patient
Speech-language Pathologist
- Evaluates ability to perform ADL, visual perceptual impairments, UE functional loss, sensory integration
- Co-treat with PT
Occupational Therapist
- Medications dispensing and monitoring
- Bowel and bladder retraining
- Monitor medical stability
- Assess skin
- Carry through with team plan: to include splinting schedules, positioning
Rehab Nurse
- Directs team, schedules family conferences, acts as liaison
- Constant communication with family
- Helps coordinate insurance benefits
Case Manager
- Support family with counseling and education
- Can help provide counseling through entire process
Medical Social Worker
- Performs neuropsych testing
- Help determine behavioral management program
Neuropsychologist
Involved if pt requires ventilator support
Respiratory therapist
assist pt to return to activities enjoyed prior to injury
many times not reimbursed
Recreational therapist
JUST BE AWARE
- Stages of recovery
- Level I: unresponsive to stimuli
- Level II: response to stimuli is inconsistent
- response may be same no matter what the stimuli is
- Level III: localized response that is related to type of stimuli presented
- Will see/ evaluate pt at all of these stages; probably acute care hospital or inpatient rehab
Physical Therapy Ranchos Los Amigos Level s I, II, III
PT evaluation and continued treatment
- Therapist will do thorough chart review
- Important to pay attention to changes: monitoring o f ICP, WB precautions, wounds, etc
- Always talk to primary nurse before starting treatment
Continually watch for changes;
posture pt is in, eyes open or closed, track auditory or visual stim, vocalize, active movement, tactile/painful stimuli, change in vital signs
WHAT SHOULD BE Observed during txs
- Change in mm tone/spasticity
- Watch for contractures
- Decorticate, decerebrate rigidity
- Modified Ashworth scale for grading spasticity
- If your patient displays difficulty with passive movement throughout the range, what grade might that be?
- Watch for changes over time
- *Evaluation will take several sessions
POC
- Will be developed according to findings including pt status and prognosis
- Remember that not all pts will progress, especially if in minimally conscious state
- General goals: level of alertness increase, decrease risk of secondary impairments, improve motor control, mange affects of tone, jt integrity and mobility are improved, pt and family education
treatment
- Select treatments that address several factors/ goals at one time
- PROM: jt mobility/integrity improved, decrease risk of secondary impairment, include sensory stimulation
- Positioning: need to be careful in bed and WC: are at increased risk for contractures, DVT, pneumonia, skin breakdown
Keep head in neutral
*
Positioning
- Bed: head in neutral
- Legs: hips and knees slightly bent
- Turn every 2 hours
- Use special air mattress
- Make sure that ROM is being done to avoid contractures
Wheelchair-Positioning
- Proper pelvic and head position
- Use reclining or tilt in space wheelchair
- May use splints
Exercise
- PROM
- Prevents contractures, decrease hypertonicity, provides sensory stimuli
- Mobilize scapula
- Watch joint mechanics at GH joint
- LE ROM: especially ankle and hip
- Do not do forceful motion: may increase risk of heterotopic ossification (other risk factors: trauma, increased muscular tone, paresis): abnormal formation of bone in mm and soft tissue, usually seen at more proximal joints
Improve arousal by??
- Sensory stim: used to increase level of arousal and elicit movement
- Attempting to increase stimulation in reticular activating system which will cause a general increase in arousal
- Usually structured: auditory, olfactory, gustatory, visual, tactile, kinesthetic, vestibular
- Monitor vital signs, watch for any motor response
- Some question whether this is helpful
Pt and family education
- Teach family about stages of recovery
- Family can help with ROM and train them in helping with positioning
Early sitting
- Should get into sitting as soon as is medically stable
- Into chair or wheelchair
- Support head
- Will probably be a max assist transfer
Documentation
- Look for little things
- Document tonal changes: pt neck is rotated to right with rt UE abducted
- Pt inconsistently tracks to right with auditory stimuli
- Pt exhibits nonpurposeful active movement of rt UE
- Pt withdraws to painful stimuli
- As emerge from coma: will have periods of agitation
- Can be combative, confused, disoriented, non-compliant
- May verbally, physically or sexually act out
- Decreased attention span
- Poor memory
- Difficult to evaluate skills at this point
RLA Level IV (confused-agitated)
- Can have pt standing at this point; make sure have help
- Strength, motor control, sensation and reflexes should be evaluated by PT
- Goals to work toward: increase endurance, maintain jt mobility and integrity, increase tolerance to activities
what level of RLA (LOCF)
Confused-agitated
AT THE Confused-agitated LEVEL what would the tx look like?
- At this level work on endurance more than implementing new, harder skills
- Work with neuropsychologist to work on appropriate behavior: points, redirection, medications
- Everyone should address inappropriate behavior in consistent manner
- Automatic skills may improve but will not see new skill development , will have poor recall day to day
- Model calm behavior, calm voice
- Pt will think only of himself….don’t argue it
- Watch for limited attention span, treat at appropriate age level.
- Give choices when it is appropriate
- May be a safety risk, do not leave the patient at all until you are sure they are not a risk
- Educate family: remind them that pt does not have control over behavior
Documentation
- Monitor/comment on ROM passively and actively
- Coordinated/uncoordinated
- Safety awareness
- Ability to follow command/outbursts
- Increase in tolerance for ex/ambulation
- If pt is unable to participate document why…ill, aggressive outbursts, etc
RLA level V, VI: confused-inappropriate and confused appropriate
- Confused, but can follow simple commands
- Therapist will be able to examine pt better
- Therapist might use berg balance scale or observational gait analysis, gait speed and endurance
- Motor control: tone, coordination, movement pattern, functional status
RLA level V, VI: confused-inappropriate and confused appropriate
Goals for therapy will usually include some of the following:
Improved functional mobility and ADL skills
Improvement in gait, mobility and balance
Improved motor and postural control
Improved strength and endurance
Safety with functional tasks
….and many others
RLA level V, VI: confused-inappropriate and confused appropriate
treatment
- Pts will still have some cognitive and behavioral deficits
- Try to maximize motor learning
- May get fatigued quickly: mentally and/or physically
- May become irritable, decreased attention, declined physical performance
- Rest periods
- Give simple feedback
RLA level V, VI: confused-inappropriate and confused appropriate
treatment……cont
- No studies identify which interventions are best
- Possibly task-specific interventions with a lot of practice
- Task specific intervention with lot of practice can be beneficial
- BWS locomotor training
- Constraint induced movement therapy: use for 90% of waking hours
- Safety awareness: pt is improving but usually not safe
- Family should learn how to assist pts with transfers, ambulation and wheelchair mobility
family education
Teach family how to assist with strengthening, ROM
Family needs to be taught good body mechanics
what do you document
- Ambulation: how far, closed environment or environment with more activity
- Transfers: WC to bed or in department onto mat; what assistance and VC due they need
- Changes in tone
- Safety awareness
- Fatigue/endurance
what RLA level
- Usually discharged by this time
- Want to get them into a less restricted environment
- Day treatment setting
- Goals of community re-entry, return to work/school, improve cognitive, behavioral and psychosocial issues
- Setting may be day program or residential program
ROL levels VII and VIII: appropriate response level of recovery
ROL levels VII and VIII: appropriate response level of recovery
tx
- Continuation of last level
- Help pt integrate cognitive, physical and emotional skills
- Able to perform ADLs, social skills and community skills
- Work toward independence in activities
- Have pt problem solve around their own disabilities
ROL levels VII and VIII: appropriate response level of recovery
documentation
- Should continue to show progression
- Requires less assist
- More community based activity: ambulation and transfers
ROL levels VII and VIII: appropriate response level of recovery
Special considerations
- Abnormal tone
- Many have spastic hypertonia
- Involuntary flexor and extensor spasms, babinski sign, velocity dependent increase in stretch reflexes
- Tone may be helpful in case of standing, however can interfere with dressing and other ADLs
how to tx Abnormal tone
Treatment: stretching and strengthening, functional retraining
PROM and strengthening of antagonist
Positioning
Serial casting: use with plantarflex or biceps contractures
Must be careful due to possibility of skin breakdown
Can improve ROM but not necessarily tone or function
Medications can reduce tone, but have side effects: fatigue, weakness, sedation, drowsiness
Rehab Technology
- Adaptive technology
- Advanced computer systems
- Wheelchairs
