TBI Flashcards
What are the areas of assessment and intervention for traumatic brain injury?
Areas of Assessment & Intervention- a lot slower; slow processing
- Physical
- Visual
- Perceptual
- Cognitive
- Psychosocial
- ADL, IADL
- Community Reintegration
- Return to work, leisure, school
- Return to driving
Interventions:
- Rehabilitative
- Compensatory
- Adaptive
- Modifying
What are the similarities and differences between evaluation and intervention of the individual in the lower-level stages of brain injury and the individual in the intermediate to higher-levels of brain injury?
What evaluation and the tools used?
What intervention?
What is sensory stimulation intervention?
Evaluation of the Lower-Level Individual- Rancho 1-3
- Are they alert/ RAS/ coming out of coma
- Can they alert with eyes?
- Level of Arousal and Cognition
- Vision
- Sensation
- Joint ROM
- Motor Control
- Dysphagia
- Emotional and Behavioral Factors (levels 3-5)
Tools:
- Goniometer
- Muscle and tone testing (ROM/ gross motor testing)
- Neurological screening
- Glasgow Coma Scale- very general
- Rancho Los Amigos Levels of Cognitive Functioning Scale
Intervention of the Lower-Level Individual
- Score determines level of TBI
- 3-4 is severe
- Sensory Stimulation
- Wheelchair Positioning
- Bed Positioning
- Splinting and Casting- for tone and spasticity
- Dysphagia- want off tube
- Behavioral and Cognition
- Family and Caregiver Education
Sensory Stimulation: Intervention
- Goal: Increase level of awareness by trying to increase arousal with controlled sensory input
- Sensory Regulation: increases neurological signals to the reticular activating system
- Visual- pictures
- Auditory
- Olfactory
- Gustatory
- Tactile-
- Kinesthetic- ROM
- Theoretical aim of functional sensory stimulation:
- Reactivate highly processed neural pathways established prior to injury
- Favorite music, tap into whatever they like, things familiar, smells – anything familiar, family members voices
- During all activity, observe for any of the following changes: These are VERY simple- 5 sec. 30 sec
- Visual tracking
- Turning of head
- Physical responses
- Vocalizations
- Ability to follow verbal commands
Physical Status: Neuromuscular Impairments
- Decorticate Posturing
- Cerebrospinal tract
- Spastic hemiplegia (CVA)
- Decerebrate Posturing
- Upper brainstem
Lower- Level Stage: Identify areas of intervention for wheelchair positioning and discuss the clinical reasoning for the various interventions.
Wheelchair Positioning: Intervention
•Goal: Allow interaction with immediate environment (people and objects) in an upright, midline posture
- Facilitate head and trunk control- how long can they tolerate wheelchair
- Prevents skin breakdown and joint contractures
- Facilitate normal muscle tone- sitting will help break up high tone
- Inhibit primitive reflexes
- Increase sitting tolerance
- Enhance respiration and swallowing function
- Promote function
Effective seating and positioning:
- Stable base of support
- Maintenance of trunk in midline
- Facilitation of head in upright, midline position
- Frees UE for use
- Allows client to visually scan environment
- Handle secretions
- Safer swallowing trials
- Pelvis
- Pelvis- ALWAYS check for skin breakdown
- Sling seat vs. Solid Seat Insert
- Lumbar support
- Wedged seat
- Seatbelt
- Trunk
- Solid Back Insert or Firm Contoured Back
- Lateral Trunk Supports
- Chest Strap
- Lower Extremities
- Abductor Wedge- to prevent internal rotation & abduction
- Knees at 90 degrees
- Feet on Foot Plates
- •Upper Extremities
- Scapulae in neutral
- Shoulders slightly externally rotated and abducted
- Lap Tray- considered a restraint (if can’t get out)
- Full
- Half flip away
- Elbows in neutral position of slight flexion and forearm pronation
- Wrists and digits in a functional position
- Head
- Contoured Head Rest
- Forehead Strap
- Reclining wheelchair 10 to 15 degrees
- Reevaluate seating and positioning
- Modify Devices
- Schedule
Lower-Level Injury
Identify areas of intervention for bed positioning and discuss the clinical reasoning for the various interventions.
Bed Positioning: Intervention
- Critical due to increased time in bed
- Prevents pressure sores
- Facilitates normal muscle tone
Difficult to maintain optimal positioning due to:
- Spasticity and abnormal posturing
- Casts
- Splints
- IVs
- NG Tubes
- Fractures
- Medical precautions
Bed Positioning: Intervention- vail beds- used for behavioral problems- you must zip back up
Abnormal tone or posturing:
- Side-lying or semi-prone to normalize tone and provide sensory input
- Supine may facilitate tonic labyrinthine reflex extensor tone, and ATNR
- Pillows, foam wedges, and splints facilitates normal position and prevents abnormal postures
Lower-Level Injury
Identify areas of intervention for splinting and casting and discuss the clinical reasoning for the various interventions.
Indicated when:
- Spasticity interferes with functional movement and ADL Independence
- Joint ROM limitations present
- Soft-tissue contractures are possible
- Splints provide elongation and inhibition by positioning the joint in a static position with the muscles and the soft tissues on stretch
- Splinting of the elbows, wrists, and hands often implemented to maintain a functional position at rest and to reduce tone
Splinting and casting
- Reduce contractures
- Increase ROM
- Prevent skin breakdown- esp open hand
- Resting or functional position splint
- Cone splints See Photos
- Anti-spasticity splints
- Serial casting
- More aggressive
- Increases ROM in joints when contractures have formed or spasticity is present (or both)
- Serial Casting Program
- Moderate to severe spasticity that cannot be managed by splints
- Wearing schedule 5-7 days for each cast
- Most common are Elbow and Wrist-Hand
- Can be done in conjunction with motor point, nerve blocks or Botulinum toxin injections
- Indicators for completion of a casting program:
1) Obtaining functional ROM or plateauing
2) Improvement in ROM achieved and goal met
3) Bivalve (cut in half & velcro) cast to maintain functional position
4) Develop wearing schedule
Lower-Level Injury
What does dysphagia intervention consist of for the individual in the lower-level stages of brain injury?
Dysphagia: Intervention
- When emerging from coma, client is fed through NG tube or G-tube
- Once client is alert and oriented, the physician decides when the dysphagia evaluation is indicated
- Usually at intermediate- to advanced -level stages of rehab
Lower-Level Injury
What are the specific areas of behavioral and cognitive intervention for the individual in the lower-level stages of brain injury?
Document changes and progress in the following areas:
- Level of arousal and awareness
- Visual attention
- Visual tracking
- Ability to follow commands
- Attempts to establish communication
- Communicate wants and needs
Lower-Level Injury
What are some areas that can be addressed for family and caregiver education for the individual in the lower-level stages of brain injury?
- Sensory regulation program
- Items from home
- Positioning
- ROM
intermediate to higher-level brain injury
Identify areas for evaluation and intervention of the individual with an intermediate to higher-level brain injury.
Evaluation of the Intermediate- to Higher- Level Individual
- Physical Status
- Cognition
- Perception
- Vision
- Dysphagia
- Psychosocial and Behavioral Factors
- ADL, Work Re-entry, & Community Re-entry
Intermediate -higher level
What are the areas for evaluation, tools used for assessment, and interventions for the physical and neuromuscular status of individual with an intermediate to higher-level brain injury?
Intervention of Intermediate- to Higher-Level Individual:
- Physical Status:
- Joint ROM
- Muscular Strength
- Sensation
- Proprioception
- Kinesthesia
- Fine and Gross Motor Control
- Total Body Control
- Physical Status: Assessment
- Physical Status Limitations:
- Abnormal Tone
- Spasticity
- Muscle Weakness without abnormal tone
- Heterotopic Ossification
- Fractures
- Soft-tissue contractures
- Peripheral Nerve Compression
- Tools to Measure Physical Status:
- Goniometers
- Dynamometers
- Manual muscle testing
- Clinical Observation
- Standard Assessments:
- Jebsen Hand Function Test
- Minnesota Rate of Manipulation Test
- Minnesota Manal Dexterity Test
- Purdue Pegboard
Intermediate-higher level
What are the neuromuscular impairments? Interventions? Assessments?
Neuromuscular Impairments
- Spasticity
- Rigidity
- Soft-tissue contractures
- Primitive reflexes
- Diminished or lost postural reactions
- Muscular weakness
- Impaired sensation
Neuromuscular Intervention
- Facilitate control of muscle groups, progressing proximally to distally
- Encourage symmetrical posture
- Facilitate integration o f both sides of body into activities
- Encourage bilateral weight-bearing
- Introduce a normal sensory experience
Neuromuscular Intervention
Rehabilitation Techniques:
- Neurodevelopmental Treatment (NDT)
- Proprioceptive Neuromuscular Facilitation (PNF)
- Myofascial Release
- Rood techniques
- Physical Agent Modalities
- Facilitate trunk alignment
- Stimulate reciprocal trunk muscle activity
- Shift weight from a stable posture into all directions
- Move the lower trunk on a stable upper trunk; Move the upper trunk on a stable lower trunk
- Upper extremity intervention
What are the areas for intervention for ataxia for the individual with an intermediate to higher-level brain injury?
Ataxia: Intervention
- Motor dysfunction from damage to cerebellum
- Rehab methods ineffective
- Compensatory approach
What are the areas for evaluation, tools used for assessment, and interventions for the cognitive status of an individual with an intermediate to higher-level brain injury?
Cognition: Assessment
•Assessed within functional tasks
- Counting the number of errors and correct responses
- Assessing the amount of assistance or cueing required.
- Determining the percentage of the task that was completed correctly.
- Executive Function Performance Test (EFPT)
- Kitchen Task Assessment (KTA)
- Toglia’s Contextual Memory Test (CMT)
- Rancho Los Amigos Levels of Cognitive Function: http://www.rancho.org
- Rivermead Behavioral Memory Test
- Kohlman Evaluation of Living Skills
Other Factors that Affect Cognitive Performance:
- Language Barriers
- Aphasia
- Visual-perceptual Deficits
- Effects of Medication
- Educational and Cultural Background
- Previous experience with task
Cognition: Intervention
- Intervention implemented through ADL and IADL
- Attention and concentration
- Memory
- Initiation and termination of activities
- Safety awareness and judgement
- Processing of information
- Executive function and abstract thought
- Generalization
What are the areas for evaluation, tools used for assessment, and interventions for the perceptual status of an individual with an intermediate to higher-level brain injury?
Perceptual Function
- Right-Left Discrimination
- Form Constancy
- Position in Space
- Topographical Orientation
- Naming of Objects
Perceptual Motor Function
- Ideational Praxis
- Ideomotor Praxis
- Three-Dimensional Constructional Praxis
- Body Scheme Praxis
Perceptual Assessment
- Hooper Visual Organization Test
- Motor-Free Visual Perception Test-Revised
- Rivermead Perceptual Assessment Battery
- Loewenstein Occupational Therapy Cognitive Assessment
Perception: Intervention
- Rehabilitative and Compensatory
- Figure-ground – locating items on a similar background vs. facilitate identification
- Apraxia – hand-over-hand vs. Following sequential steps on picture cards
- Neglect syndrome – using neglected side vs. rearranging environment.
